STRATEGIES HEALTHCARE LEADERS USE TO IMPROVE PATIENT SATISFACTION

STRATEGIES HEALTHCARE LEADERS USE TO IMPROVE

PATIENT SATISFACTION

Section 1: Foundation of the Study

Patient satisfaction is a critical element in the delivery of healthcare. As

technology advances in healthcare, patients have become more knowledgeable about

individualized care and the role of patient satisfaction. Healthcare leaders are accountable

for patients’ experiences and satisfaction with the care received based on a patient’s

perception when patients complete a patient satisfaction survey, the Consumer

Assessment of Healthcare Providers and Systems (CAHPS), implemented by the Centers

for Medicare and Medicaid Services (CMS). In this qualitative single case study, I

explored strategies healthcare leaders use to improve patient satisfaction in a healthcare

organization.

Background of the Problem

The Patient Protection and Affordable Care Act (PPACA) of 2010 includes strong

recommendations for healthcare leaders to improve patients’ perceptions of healthcare.

The PPACA initiated the requirement for healthcare leaders to restructure or create

provisions that include improving patient satisfaction and quality of care (Pascual, 2021).

Hospital reimbursement is affected by patients’ perceptions of care and services received

(Pascual, 2021). It includes accountability measures to aid healthcare leaders in

maintaining fiscal viability (Pascual, 2021). In healthcare, lack of accountability

corresponds with poor customer service experiences (D. L. Leonard, 2017). As patient

satisfaction plays a significant role in healthcare, healthcare leaders are increasingly

accountable for ensuring patients are satisfied with the care received.

Many healthcare leaders have established patient satisfaction organizational goals

to ensure higher levels of care and service. Healthcare leaders who have not implemented

strategies to improve patients’ perceptions of care and service are at risk of market share

loss resulting in healthcare consolidation (DeVore & Champion, 2011; Vizzuso, 2015).

Nationally, many healthcare leaders have improved patient satisfaction; however, some

still lack strategies to make necessary adjustments (Mann et al., 2016). Patient

satisfaction is a vital component of the financial longevity of healthcare organizations,

requiring healthcare leaders to establish strategies to improve patient satisfaction. Greater

satisfaction, in turn, could increase inpatient referrals and insurance reimbursements.

Problem Statement

Healthcare leaders who fail to deliver quality patient experiences are under

pressure to improve patient satisfaction, placing them at financial risk (Mahoney et al.,

2017). In July 2017, 14% of U.S. healthcare leaders publicly reported patient satisfaction

scores through 3.1 million completed CAHPS surveys, while 86% of healthcare leaders

did not (CMS, n.d.). A decrease in patient satisfaction could negatively affect hospital

profitability by 25% (CMS, n.d.). In addition, the PPACA includes a core measure for the

reimbursement for services provided by healthcare providers based on patient satisfaction

(Pascual, 2021). The general business problem is poor patient satisfaction within

healthcare organizations puts hospitals in the U.S. at financial risk. The specific business

problem is some healthcare leaders lack strategies to improve patient satisfaction.

Purpose Statement

The purpose of the proposed qualitative single case study was to explore strategies

healthcare leaders used to improve patient satisfaction. The targeted population included

leaders of a healthcare organization located in metropolitan Detroit, Michigan who

successfully implemented strategies that improved patient satisfaction. Findings may

influence the ways healthcare leaders address patient satisfaction and how patients

perceive service quality, resulting in improved service outcomes for patients and their

families.

Nature of the Study

I selected a qualitative approach for the study. Researchers use qualitative

methods to study characteristics of a population through focus groups and interviews that

produce data reflecting personal experiences, perspectives, and cultural backgrounds

(Anyan, 2013). The qualitative method was appropriate for this study as I explored

participants’ perceptions. By contrast, researchers use quantitative methods to evaluate

studies using hypotheses, nonpurposeful sampling, measures, and randomization

standards in changing contexts of real-world settings (Balasubramanian et al., 2015). The

quantitative approach was not appropriate for this study because I did not examine

relationships or differences among variables in real-world settings. Another option was

the mixed methods approach, which researchers use to integrate qualitative and

quantitative research (Pluye & Hong, 2014). Mixed methods research was not appropriate

for this study because there were no quantitative components to the study.

Several qualitative designs are available to researchers, including case studies,

ethnography, and phenomenology. For this study, I used the case study design.

Researchers use the case study design for an empirical exploration of a phenomenon

within a real-world context bounded by a unit of analysis, generally time (Yin, 2018). The

case study design is appropriate for exploring the depth of a single phenomenon specified

over time. The ethnographic design, which researchers use to describe a culture or act to

understand another way of life (Spradley, 2016), was not appropriate for this study

because my intent was not to describe groups’ cultures or understand a way of life.

Researchers use the phenomenological design to describe, interpret, or embrace the

essence of lived experiences of a group of people involving a specific phenomenon

(Valentine et al., 2018). Exploring a specific phenomenon of a group of people was not

the goal of my study; the phenomenological design was therefore not appropriate.

Research Question

One central question guided this research: What strategies do healthcare leaders

use to improve patient satisfaction in healthcare?

Interview Questions

1. What strategies did you use to improve patient satisfaction?

2. What strategy did you find worked best to improve patient satisfaction?

3. How did you measure the success of the strategies used?

4. What were the key barriers to implementing the strategies for improving patient

satisfaction?

5. How did your organization address the critical barriers to improving patient

satisfaction?

6. How did patients respond to your strategies to improve patient satisfaction?

7. What else would you like to share that you did not address regarding the strategies

used to improve patient satisfaction?

Conceptual Framework

The conceptual framework for this study is Mayeroff’s theory of caring. The

theory of caring involves the process of relating to someone, understanding their needs,

and committing to their well-being (Houghton et al., 2014; Mayeroff, 1971). Mayeroff’s

(1971) theory of caring is the process of helping another grow and satisfy another

person’s needs to actualize oneself through transformational qualitative relationships. The

act of caring includes observing and assessing responses to needs and concerns of another

person as well as expressions of compassion, empathy, and respect (Smylie et al., 2016).

Caring is a crucial function in multiple institutions that affects the lives of those in need,

as well as human services enterprises such as healthcare (Smylie et al., 2016). Caring for

individuals is the primary function of healthcare and a significant aspect of ensuring the

wellbeing of patients through listening, responding, and empathizing with each patient.

The theory of caring has evolved. The tenets of this theory include knowing a

person’s needs, limitations, patience, honesty, humility, hope, and courage (McAfee,

2016). The theory of caring has become a core training method for nurses since 1991.

Such training accelerates and expands to clinical and nonclinical roles within healthcare

organizations (Watson & Smith, 2002). Researchers use the theory of caring to focus on

relationships and behaviors, demonstrating consideration for the needs of others

(McAfee, 2016). Individualized care for patients involves the provision of care based on

addressing each patient’s unique needs and problems (Cheraghi et al., 2017). Continued

training and education focusing on the theory of caring and how to provide care to

patients individually can effectively strengthen the overall perceptions of the healthcare

organizations from patients’ perspective.

Tenets of the theory of caring can facilitate healthcare leaders’ understanding of

patients’ needs to develop and deploy strategies. Mayeroff’s theory of caring requires a

commitment to wellbeing of others by supporting and encouraging specific behaviors

(Houghton et al., 2014). This was a suitable foundation for understanding strategies used

to improve patient satisfaction in healthcare.

Operational Definitions

Centers for Medicare and Medicaid Services (CMS): Is a U.S. government

division of the Department of Health and Human Services that administers Medicare and

Medicaid health insurance coverage for seniors, individuals with disabilities, children,

low-income adults, and pregnant women (CMS, n.d.).

Clinician and Group Consumer Assessment of Healthcare Providers and Systems

(CGCAHPS): This is a standardized healthcare survey tool used to measure patients’

perceptions of care provided by physicians in office settings (CMS, n.d.).

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS):

This was the first national standardized healthcare survey tool used to measure a patient’s

perception of hospital care (CMS, n.d.). Meaningful Use: Meaningful use requires

healthcare leaders to develop an electronic patient portal for improving patients’

healthcare (CMS, n.d.).

Patient Protection and Affordable Care Act of 2010 (PPACA): An act enacted by

the U.S. 111th Congress and signed into law by President Barak Obama on March 23,

2010, expanding healthcare coverage for all Americans and reducing the number of

uninsured American’s and healthcare costs (Healthcare.gov, n.d.).

Value-based healthcare: The healthcare payment and delivery model which

rewards value over quantity based on patients’ perceptions of care (CMS, n.d.).

Assumptions, Limitations, and Delimitations

Assumptions

Three assumptions guided this study. Assumptions are the researcher’s unproven

assertions necessary to conduct the investigation (Marshall & Rossman, 2016). The first

assumption was that healthcare leaders responded to interview questions truthfully by

sharing their expertise and specific details about strategies used to improve patient

satisfaction. Second, I assumed that expanding healthcare leaders’ knowledge of

improving patient satisfaction would lead to action that will improve patients’ perceptions

of care, thereby improving CGCAHPS and HCAHPS results and financial stability of the

healthcare organization. The third assumption was that strategies provided by participants

contributed to overall patient satisfaction ratings of the healthcare organization as

reported through the CGCAHPS and HCAHPS results.

Limitations

Limitations are constraints or weaknesses beyond the researcher’s control and

may affect the outcome of the study (Theofanidis & Fountouki, 2019). Limitations of the

study included potential biases of healthcare leaders during interviews and limited

documentation for data collection. During interviews, participants had the ability to limit

the amount of information shared or withdraw from the study. The study was focused on

a single healthcare organization. Therefore, strategies may not help all healthcare leaders.

The focus of the study was specific to strategies used to improve patient satisfaction.

With a qualitative single case methodological design, other researchers can duplicate and

test study results in different demographic and geographic locations where healthcare

leaders improved patient satisfaction.

Delimitations

Delimitations are boundaries or challenges of the researcher’s shortcomings in the

assumptions of a study forcing the researcher to better evaluate the assumptions

(Theofanidis & Fountouki, 2019). The first delimitation of the study was that the sample

population was limited to healthcare leaders who implemented and improved patient

satisfaction processes for a healthcare organization. The second delimitation of the study

was the sample population of healthcare leaders were delimited to one health system

located in metropolitan Detroit, Michigan. The third delimitation of the study was my

choice to interview healthcare leaders who implemented and improved patient

satisfaction within the healthcare organization; therefore, I did not interview healthcare

leaders who did not implement and improve patient satisfaction within the healthcare

organization.

Significance of the Study

The findings of this study offer potential value to healthcare leaders because

improving patient satisfaction has a strong influence on patients’ behavior and wellbeing.

Patients’ perceptions of the care and service provided within a healthcare organization

determines the patients’ satisfaction with the clinician and the healthcare employees (D.

L. Leonard, 2017). High patient satisfaction scores as resulted through the CGCAHPS

and HCAHPS, are associated with increased reimbursement rates from insurers (Shirley

& Sanders, 2013); in turn, financial performance is a critical success indicator for

healthcare organization leaders (Akingbola & van den Berg, 2015). According to

Anderson and Wilson (2011), the results of the CGCAHPS and HCAHPS allow insurers

to provide up to 30% in reimbursements or deductions for services rendered based on

patients’ experience, and up to 70% reimbursement or deduction based on clinical care

patients receive within healthcare organizations. In addition to reimbursement rates tied

to patient satisfaction, the PPACA includes a core measure for the evaluation and pay of

healthcare providers based on patients’ perceptions of quality of care and services

received (Tsai et al., 2015). Healthcare leaders who create processes focused on patient

improvements and perceptions may have higher reimbursement rates, compared to the

previous year, based on patients’ feelings regarding the care received within the

healthcare organization.

Contribution to Business Practice

This study may contribute to healthcare leaders’ improvement of business

practices. Healthcare leaders seek alternative methods to ensure patients are satisfied with

services received by healthcare employees. Patient satisfaction may aid leaders in

creating effective ways to empower and create innovative process improvements in

healthcare organizations. Further, improved patient satisfaction may aid in terms of

organizational sustainability and improved patient health outcomes.

Implications for Social Change

Improving patient satisfaction in healthcare can directly affect positive social

change by contributing to overall patient wellbeing. U.S. Government leaders set forth

quality standards outlined in the PPACA that include strategies needed to achieve positive

patient experiences. Healthcare leaders who implement effective communication

practices within healthcare organizations can improve patients’ health, safety, and overall

satisfaction (Burgener, 2020). Study results may contribute to positive social change.

Revisions to patient satisfaction through patient-centered and respectful and responsive

care is necessary to achieve universal healthcare for all (Larson et al., 2019). Improving

quality of care from patients’ perspectives may promote improved health outcomes and

wellbeing for patients regardless of age, demographics, race, or ethnicity.

A Review of the Professional and Academic Literature

This literature review includes strategies used by healthcare leaders to improve

patient satisfaction. I present the theory, research problem, and studies on the topic. The

literature review addresses five strategies to improve patient satisfaction in healthcare: (a)

applying the theory of caring, (b) sustaining a culture of patient-centered care, (c)

understanding patient needs, (d) ensuring compliance, and (e) employing dedicated

leadership skills.

Sources reviewed included journals, government sources, and websites that

provided detailed information to address the research problem as well as findings from

scholars who have studied similar concerns. I used the following databases: Google

Scholar, National Center for Biotechnology Information (NCBI), Science Direct,

PubMed, and EBSCOHost, to retrieve peer-reviewed articles published between 2017 and

2021. Keywords searched were patient satisfaction in healthcare, HCAHPS, PPACA,

CMS, CGCAHPS, theory of caring, hospital compare, press ganey, patient satisfaction,

CMS star rating, customer service in healthcare, value-based care, organizational

leadership, transformational leadership, and culture of caring. I reviewed prior

scholarship on patient satisfaction strategies and improving patients’ perception of care.

The literature review consisted of 92 sources, 74 of which came from peer-reviewed

journals, with 85% published between 2017 and 2021 (see Table 1).

Table 1

Literature Review Source Content

Reference Type

Total

<5 Years

(2017 to

2021)

>5 Years

(Prior to

2017)

%Total <5 Year

Peer-reviewed journals

85%

Books

Websites

Non-peer reviewed journals

100%

Total

87%

The purpose of the proposed qualitative single case study was to explore strategies

healthcare leaders used to improve patient satisfaction. I first discussed the conceptual

framework, which was the theory of caring. Next, I explained sustaining a culture of

patient-centered care, understanding patients’ needs, ensuring compliance, and employing

dedicated leadership skills. The strategies identified are among several that healthcare

leaders may consider implementing based on the needs of patient populations. The review

concludes with a consideration of healthcare leaders and improving patient satisfaction.

Theory of Caring

The conceptual framework for this study is Mayeroff’s theory of caring.

According to Mayeroff (1971), caring is the process of relating to someone to understand

the person’s needs while being fully committed to his or her wellbeing. Mayeroff’s theory

of caring is a foundation for understanding strategies to improve patient satisfaction.

Caring requires a commitment to the wellbeing of others through hope and courage

(Bagnall et al., 2018). Leaders who implement a culture of caring create healthcare

providers with caring attributes and behaviors (Wei et al., 2019). Establishing a healthcare

environment with a primary focus on caring for each patient leads to a culture of caring.

Healthcare providers who deliver care and support to their patients can create a

culture of caring by listening to patients’ needs and treating them with dignity and

respect. Caring is a natural phenomenon (Arman et al., 2015). The theory of caring

framework involves the context of caring for life with a commitment and devotion for

wellbeing (Létourneau et al., 2017). In healthcare, the theory of caring is fundamental in

terms of providing patients with the care they deserve and aiding each patient with

healing and improved outcomes.

Healthcare leaders who encourage the theory of caring build a thoughtful

environment focused on improving patient care and wellbeing by applying personalized

treatment and creating a shared approach to patient care. This approach allows patients to

take part in their healthcare and make decisions with care teams, creating a foundation for

individualized care (Bokhour et al., 2018). There are three tenets of the theory of caring:

(a) knowing and understanding another’s needs, (b) adjusting behaviors to reduce

mistakes, (c) patience with growth and development (Bagnall et al., 2018). The three

tenets of the theory of caring may enhance patient satisfaction, resulting in an overall

improvement in patient outcomes.

Practicing the tenets of the theory of caring allows healthcare teams to understand

patients’ needs and vulnerabilities. Proper training and education involving

compassionate care and theory of caring principles positively affects patient experiences

(Saab et al., 2019). Creating a patient-centered environment is the most critical factor for

healthcare leaders who emphasize value and care for every patient (Bruno et al., 2017).

Creating a healthcare environment that allows patients to feel cared for and respected

while developing higher standards of perceptions of care improves outcomes of patients

and healthcare organizations.

Helping patients grow and develop through support and encouragement is a

means of caring for another human (Houghton et al., 2014). Caring is a process that

provides meaning, creates harmony and order, and inspires individuals to heal and grow

(Bailey, 2009). Caring behaviors within healthcare organizations are about patient

satisfaction (Ellina et al., 2020). Through the theory of caring, healthcare leaders who

create environments built on caring for patients may improve patient satisfaction and

wellbeing.

The theory of caring is essential to the process of caring and improving the health

of others. Having skills and knowledge to implement the theory of caring allows

healthcare providers to focus on each patient as an individual, stimulating growth and

healing. The theory of caring provides the foundation for creating a comprehensive

approach to patient care, specifically in healthcare (Bailey, 2009). This holistic approach

focused on the health and care of each patient shows the importance of accountability

through caring. Fostering the tenets of the theory of caring and creating a patient-centered

culture enhances care provided through attention and education for all patients.

Theory of Caring and Related Theories

Ten theories fall within the context of Mayeroff’s theory of caring. The 10

theories are: (a) Watson’s transpersonal caring theory, (b) Swanson’s middle range theory

of caring, (c) Leininger’s theory of culture care, (d) Gaut’s theoretical description of

caring, (e) Knowlden’s communication of caring in nursing, (f) Halldorsdottir’s theory of

caring and uncaring encounters within nursing and healthcare, (g) Boykin and

Schoenhofer’s nursing as caring theory, (h) Ray’s theory of bureaucratic caring, (i) Sister

(Sr.) Roach’s human mode of being, and (j) the Geropalliative caring model. These

theories all pertain to aspects of caring for other human beings and provisions of care.

Of the 10 theories, three are most relevant to improving patient

satisfaction:

Halldorsdottir’s theory of caring and uncaring, Ray’s theory of bureaucratic caring, and

Roach’s theory of caring as the human mode of being. Each of these theories includes

tenets that improve patient satisfaction in healthcare organizations: communication with

patients and their families, care for whole patients physically, emotionally, and spiritually,

and responsibility for patients.

Halldorsdottir’s Theory of Caring and Uncaring

Applied to nursing and healthcare encounters, Halldorsdottir’s theory of caring

and uncaring emphasizes the importance of creating professional and caring relationships

with individuals who seek care. The tenets of Halldorsdottir’s theory include connecting

with patients by developing communication plans during episodes of care and reducing

lack of communication or negative communication toward patients. Communication and

building relationships are the foundation of patient-centered care (Söderman et al., 2018).

Theory of caring can assist in identifying subjective experiences of individuals who need

or receive care from clinicians (Halldorsdottir, 1996). Professional care and

communication between the clinician and the patient create a positive health outcome for

the patient

In healthcare, clinicians providing care to patients have a responsibility to ensure

that patients feel safe and cared for while under the care of healthcare providers. Patients

who have negative or unpleasant interactions in healthcare organizations may have

adverse health outcomes that prevent them from healing (Halldorsdottir, 2007). Caring

requires a commitment to the wellbeing of others by supporting and encouraging specific

behaviors (Houghton et al., 2014). The provision of care can positively or negatively

affect patients; Halldorsdottir’s theory of caring and uncaring involves identifying the

importance of caring for patients as individuals with respect and dignity. The

Halldorsdottir’s theory of caring and uncaring relates to this study through the theory of

caring and the importance of establishing relationships and open communication with

every patient.

Ray’s Theory of Bureaucratic Caring

Ray’s theory of bureaucratic caring centers on caring from a spiritual and ethical

perspective. The theory is associated with giving and charity specific to services for

homebound individuals who require well-trained and balanced clinicians to provide care,

comfort, and fulfillment (Johnson, 2015). Tenets of the theory of bureaucratic caring

include spiritual wellbeing and clinical education and social elements of care relative to

the patient population, such as access to medication (Bailey, 2009). Through Ray’s theory

of bureaucratic caring, clinicians can contribute to wellbeing through improved safety

measures and assurance of patients’ adherence to treatment plans.

Healthcare providers offer support to individuals who are homebound and need

medical assistance. Healthcare employees provide more resources for patients and their

families to ensure improved quality of life using technical aspects, such as educating the

patient about the details of the disease and care provided, legal aspects, such as access to

fair and equitable care, or economic aspects, such as access to affordable medication, of

patient care and wellbeing (Johnson, 2015). Individualized managed care allows patients

to participate in their treatment and play a supportive role in terms of quality of care

received.

According to Wagner et al. (2001), patient care is the responsibility of the entire

health team. In conjunction with the bureaucratic care model, the chronic care model

involves quality improvements for patients, clinicians, and healthcare leaders by

implementing quality measures allowing patients to rate the quality of care received from

healthcare teams (Wagner et al., 2001). Through these ratings, healthcare leaders gain

insight into what healthcare teams experience while caring for patients.

To improve healthcare outcomes, the healthcare effectiveness data information

set measures patient care outcomes, created by the National Quality Council (Potter &

Wilson, 2017). Healthcare effectiveness data tool supplies metrics focused primarily on

the patient’s behavior, thus placing some responsibility on the patient to improve

healthcare outcomes (Potter & Wilson, 2017). Through these measures, patients receive

education to maintain wellness plans in order to address individual responsibility of

quality of care.

The chronic care model functions through an organized delivery system

connecting resources of healthcare organizations to patients within the community,

creating pathways to equitable care. To effectively use the chronic care model, an

organized delivery system with valuable resources, such as pamphlets and educational

sessions, that the local community can use outside of healthcare organizations should

exist (Wagner et al., 2001). Healthcare leaders who use community outlets, such as

community centers and social service organizations, provide patient education as a

community partner, building bridges to patient education about chronic health conditions

and the available treatments within a health system (Wagner et al., 2001). The community

partners act as a coach, providing essential information to aid patients with quality care

and improving perceptions of care for healthcare organizations.

The chronic care model includes a framework to improve outcomes of patients

with chronic diseases. The chronic care model involves six elements of care that support

constructive feedback and planning from the perspective of the people within the

community, the patients’, and the leaders of the healthcare organization (Llewellyn,

2019). Components of the chronic care model include (a) community resources, (b)

selfcare management support, (c) organization of healthcare (OHC), (d) delivery system

design (DSD), (e) clinical decision support (CDS), and (f) computer information systems

(CIS) (Llewellyn, 2019). Chronic care model elements work together simultaneously to

achieve desired outcomes involving improvement of patients’ overall experience and

health (Llewellyn, 2019). Patients establish support and guidance within healthcare

organizations and communities, jointly fostering an environment of care.

Resource leaders advocate for healthcare organizations and patients by providing

available resources to patients. Resources include peer groups, counseling, and outreach

for specific research trials available to the local community (Llewellyn, 2019; Wagner et

al., 2001). Self-management support involves (a)collaborative goal setting, (b) routine

assessments of health management, and (c) problem-solving and planning of health

outcomes. Self-management provides education culturally tailored to the patient’s

lifestyle and disease (Llewellyn, 2019; Wagner et al., 2001). Self-management allows

patients to maintain independence and responsibility for their own wellness and care,

supporting patients to improve health outcomes.

The health system-organization of healthcare (OHC) is the third element of the

chronic care model. The OHC is a review of the culture within a healthcare organization.

Through the OHC, the mechanics and culture of health systems require senior leadership

intervention in terms of creating a top-down leadership approach for health system

changes and initiatives (Llewellyn, 2019). Through motivation and support of senior

leadership, healthcare leaders may improve chronic illness care improving patient

outcomes and preventions. The OHC reflects the need for support by senior leadership to

implement changes such as the culture and the mechanics of the healthcare organization

to improve patient satisfaction while engaging employees.

The delivery system design (DSD) is the fourth element of the chronic care

model. Using the DSD, leaders define roles of healthcare workers and create standards

and expectations to provide quality patient care (Wagner et al., 2001). Through these

standards, healthcare leaders can create a culture of caring focused primarily on patients

and improving health outcomes.

The fifth element of the chronic care model, the clinical decision support (CDS)

element, functions with patient-centered care guidelines that work to improve patient care

and outcomes. The CDS element is the most effective element, with established

patientcentered guidelines that define the goals and expectations of care (Wagner et al.,

2001). Creating a care plan for each patient and goals for patient care may play a key role

in patient-centered care and wellbeing of overall patients.

The sixth element of the chronic care model, the clinical information system

(CIS), the CIS element highlights the technological aspects of patient care. The CIS is an

electronic communication tool that healthcare providers use to ensure communication

between patients and providers. This involves collecting and organizing patient data,

including feedback and reminders for patients and providers (Llewellyn, 2019). The

elements of the chronic care model, combined with Ray’s bureaucratic care model, served

as a guide for healthcare organizations to improve patient outcomes centered around

better patient care.

Roach’s Theory of Caring, the Human Mode of Being

Roach’s theory of caring, the human mode of being, reviews the moral aspect of

caring for oneself and others. Roach’s theory of caring, the human mode of being, focuses

on the holistic way of caring for self and others as a moral endeavor for everyone

(Villeneuve et al., 2016). Roach developed a caring practice, defining six tenets that align

with the human mode of being on a spiritual level. The six tenets are (a) compassion, (b)

competence, (c) confidence, (d) conscience, (e) commitment, and (f) comportment offer

deeper moral reasoning for caring for another (Villeneuve et al., 2016). Through these

attributes, clinicians can create a culture of caring for every patient, enabling an

environment for patients to improve their health outcomes.

The first attribute, compassion, highlights the awareness of a relationship with all

living creatures. The second attribute reflects individuals who show competence by

providing their skills and expertise to deliver professional, responsible care to others

(Villeneuve et al., 2016). The third attribute indicates an individual who displays

confidence in fostering a quality relationship with another (Villeneuve et al., 2016). The

reflection of conscience, the fourth attribute of Roach’s theory, is when a person cares for

another; one must have a conscience that directs the behaviors and thoughts toward an

ethical outcome (Villeneuve et al., 2016). The fifth attribute is a commitment to provide

quality care for another regardless of whether the care is a choice or an obligation

(Villeneuve et al., 2016). The sixth attribute, comportment, entails accepting others and

their beliefs (Villeneuve et al., 2016). Roach’s theory has served as a model for the

transformation of caring in healthcare and the development of character among care

providers (Villeneuve et al., 2016). Practicing Roach’s theory of caring improves the

quality of care provided by the clinician and the patient’s perception of the care received.

Sustaining a Culture of Patient-Centered Care

Patient-centered care involves the patient and enhanced patient satisfaction. The

physician and the patient work together as a team for a better outcome for the patient’s

well-being, establish human-to-human caring, align with the theory of caring tenets and

create moments of caring with the patient (Delaney, 2018). Patient-centered care

increases the patient’s involvement in the care received to improve health outcomes, with

the physician honoring the patient’s wishes (Olson, 2019). Patient-centered care

empowers the patient to become involved with and responsible for improving health

outcomes, quality of life, and best practices to avoid recurring health issues.

Patient-centered care comprises five tenets. The tenets are: (a) the biopsychosocial

perspective when the doctor appreciates the entire health problem from a social,

psychological, and biomedical perspective; (b) the doctor as a human being, who

expresses sensitivity toward the patient and the health condition; (c) the patient as a

human being, where the doctor is concerned about the health condition and the patient;

(d) sharing power and responsibility, as the doctor and the patient are involved in the

decision-making process; and (e) therapeutic alliance, when the doctor and patient

establish a personal and professional relationship to enhance the patient’s experience and

improve the initial health condition (De Boer et al., 2013). Patient satisfaction is pivotal

to the existence of healthcare organizations (Ellina et al., 2020) and the development of

patient-centered care practices. Patient-centered care is an essential function in improving

patient outcomes and perceptions, as the care received focuses on the patients, making

them a part of the healthcare team.

Patient-centered care in healthcare organizations across the United States and

abroad is transitioning to the essential evolution of care, to establish best practices.

Providing patient-centered care under any caring theory requires a commitment by

clinicians to offer ethical, safe, and supportive treatment to patients and their families

(Lee, 2019). Clinicians are responsible for caring behaviors to meet patient-centered care

(Ellina et al., 2020). The commitment and responsibility of clinicians to provide

patientcentered care encompass the ability to address each patient’s unique needs,

providing care and education on an individual level.

To create a culture focused on patient-centered care, clinicians need to establish

and maintain a healthy, caring relationship with patients. Healthcare organizations with a

focus on patient centered care have the potential to create a tailored care experience for

individual patients (Kuipers et al., 2021). Caring is the factor that distinguishes clinicians

from other professionals because caring is the essence of a clinician’s daily regime

(Afaya et al., 2017). Caring occurs when the clinician attends to another and genuinely

wants to provide care (Nicholson & Kurucz, 2017). Patient-centered care enhances the

relationships between clinicians and patients (Nurse-Clarke et al., 2019). Being aware of

caring behaviors and providing personalized care to each person is the embodiment of

caring.

Caring for the whole person leads to relationships with the patient and the patient’s

family. It is critical for the healthcare provider to understand the experiences of the

patient and the patient’s family; to ensure that the care provided is patient and family

centered care (Sorra et al., 2021). The caring relationship creates a fundamental human

connection improving the perceived attitudes and activities (Nicholson & Kurucz,

2017).

Patient-centered care is intrinsically vital to the quality-of-care outcomes (Larson et al.,

2019). Through patient-centered care, the patient is the focal point, involved in the

services received at every step of the treatment plan.

The delivery of care has changed vastly as the U.S. population has begun to age

and become increasingly ill. The demand for high-quality, fundamental patient-centered

care is at the core of patient care and satisfaction (Ellina et al., 2020). The clinician can

only achieve patients’ cultural needs and requirements through understanding and

communication (Lee, 2019). Engaging in a relational and reflective process of education

through conversation supports the development of patient care and welfare and improves

the clinician’s, leaders, and other healthcare employees’ overall effectiveness (Nicholson

& Kurucz, 2017). Leaders who support patient-centered care value an environment that

encourages improved patient care and patient perception. With continued awareness and

leadership, providers can manage the health and well-being of the aging population

through personalized care for each patient.

Physicians and nurses who practice patient-centered and fundamental care can

influence a patient’s attitude toward the care provided. Including patients in co-creation,

sensitive care decisions with clinicians play a pivotal role in improving patient care and

satisfaction (Lee, 2019). As an approach to patient-centered care, clinicians focus on what

is of value and necessary to the patients and their families (Delaney, 2018).

Patientcentered care as a practice always puts the patient at the center of healthcare to

provide individualized treatment and improve as many outcomes as medically possible.

As healthcare leaders seek to implement a patient-centered care model to improve

patient care and organizational financial outcomes, leaders establish a culture that reflects

the theory of caring and influences patients’ perception of care (Afaya et al., 2017).

Building patient-centered care environments empower patient-provider relationships that

enhance the goals of patient health outcomes (Bokhour et al., 2018). Healthcare providers

who establish relationships with patients and the patient’s family build a foundation of

trust. Patient-centered care improves the patient’s satisfaction and drives improved patient

care and experiences and clinician accountability (Bokhour et al., 2018). Patient

involvement is increasingly important to ensure proper delivery of care that meets the

patients’ needs (Seeralan et al., 2021). Including the whole patient in the care provided

creates trust between the patient and the clinical team. Developing open communication

and involving the patient in decisions implies a culture of caring for the well-being of all

patients.

Establishing professional, caring relationships with patients allows the patient to

develop a bond and trust with the healthcare provider and the environment. Fostering

patient-centered care invites the patient to participate in the care provided, creating a

perception of caring and quality-driven healthcare (Boysen et al., 2017). Four elements of

accessing good care are (a) humanistic care, or empowering patients’ care, (b) relational

care, or providing patients with communication that the patient can understand, (c)

clinical care, or knowledge and skills required to provide clinical care; and (d) comforting

care or providing a respectful environment and listening to the patient’s needs (Kuis et al.,

2014). Patients perceive clinicians as caring, responsive individuals. Practicing the

elements of good care ensures the patient is the focus of the care given, guiding the

patient to an improved health outcome.

Mayeroff’s theory of caring provides the rationale for the conceptional framework

for the study. The theory of caring indicates the ideals of delivering patient satisfaction by

providing compassionate care to every patient. The theory of caring can empower

clinicians with the knowledge and legitimacy of practicing patient care (Lee, 2018).

Creating a culture of caring requires the clinicians to focus on the patient as an individual

when providing care (Awdish, 2017). Establishing a culture of patient-centered care built

on the foundation of the theory of caring within a healthcare organization improves

patient trust and meaningful care.

Understanding Patients’ Needs

Identifying and understanding the needs of patients through patient feedback is

the second strategy healthcare leaders use to improve patient satisfaction. Patient

satisfaction is a broad term that encompasses personal feelings relative to the care

received in a healthcare organization. The patient’s experience may positively or

negatively impact a healthcare organization based on the emotional consequences of a

patient’s perception of the care received (Arboleda et al., 2018). Negative patient

experiences affect the patient and the organization greater than the positive patient

experiences (Ling et al., 2021). According to Lee (2019), the measurement of patient

experiences is related to the interactions and communication with the clinician.

Compiling the individual feedback results regarding patient satisfaction with healthcare

experiences could indicate deficits in the services provided.

In healthcare organizations, HCAHPS and CGCAHPS serve as tools to identify

and address areas of concern as voiced by individual patients. Through the CAHPS,

patients provide feedback to healthcare leaders regarding the experiences encountered at

specific healthcare facilities (CMS, n.d.). The results of the CAHPS allow for

reimbursement or deduction for services rendered based on the patients’ experience

(Onukogu, 2018), which could have a negative financial impact on healthcare

organizations. With the changes in Medicare reimbursement policies, patient satisfaction

is a large portion of the reimbursement to healthcare organizations (Chen et al., 2020).

Implied in the use of CAHPS is that healthcare leaders will implement the 2appropriate

measures to ensure that every patient receives a satisfactory visit.

The PPACA outlines the requirements for healthcare leaders to create provisions

that include improved patient satisfaction and quality reporting. Measurement sets rely on

clinician communication, technology, type of care and services, and patients’

engagements with staff (Lee, 2019). Patient satisfaction ratings guide quality

improvement efforts by holding healthcare leaders accountable to the patients and

communities served (Larson et al., 2019). Patient experience measures and reporting give

patients a voice regarding the care received to improve patient and actionable physician

feedback (Golda et al., 2018). The CAHPS provides healthcare leaders with direct insight

into the patients’ experience and may offer recommendations to improve service, quality,

and care.

CAHPS, supplies feedback to leaders, usually related to service, quality, care, and

facility appearance. The CAHPS is a way to solicit patient involvement to make

improvements and keep a significant patient base. CMS originally developed the

HCAHPS, a national standardized patient satisfaction tool used to incentivize valuebased

care and patient satisfaction (Dottino et al., 2019). The CGCAHPS, created later,

measures the quality of healthcare from the patients’ perspective based on personal

experiences with the physicians and clinical staff (CMS, n.d.). The CAHPS follows

principles that reliably access patient experiences based on standardized questions and

protocols to ensure that data are comparable across diverse healthcare settings. The

CAHPS is CMS’s effort to improve healthcare in the U.S., and healthcare leaders use the

data to ensure a better quality of care from the moment the patient enters the healthcare

organization.

CMS uses the CAHPS to survey patients about a recent healthcare experience,

randomly. Patient’s perception of care influences reimbursement for clinicians (Lindsay,

2017). Clinicians who demonstrate high patient satisfaction through patient-centered care

receive reimbursement from CMS at a higher rate for improved performance (Lindsay,

2017), making healthcare more patient-centered with a value-based, incentivized

performance for physicians. Through the CAHPS, healthcare leaders can facilitate

reflections and opportunities to improve patient care in addition to reinforce behavior

changes amongst healthcare employees and physicians (Spinnewijn et al., in press). To

practice healthcare transparency, to increase patients’ participation by making the best

decision for care, CMS publicly shares patient ratings of healthcare organizations and

clinicians.

Through the CAHPS, patients now have a voice in healthcare to impose change

and become active in the care received. Since the implementation of the Hospital

ValueBased Purchasing (VBP) program, quality of care and patient satisfaction helps to

determine reimbursement rates based upon using the results of the CAHPS (Lindsay,

2017). The CGCAHPS monitors patient satisfaction with healthcare visits (Adhikary et

al., 2018), allowing individuals to rate the level of service received. Healthcare leaders

and physicians seek the most efficient way to deliver quality care and patient satisfaction

and improve outcomes to remain competitive (Lee, 2019). Poor patient satisfaction may

create financial risk for healthcare leaders, increasing the need to improve patient

satisfaction.

CAHPS are patient-reported outcomes, measured by experiences or perceptions

toward the care and concern received. Many healthcare leaders have altered the

organization’s culture to supports individualized patient care and patient participation in

care (Lee, 2019). Providing patient-centered care is essential to a high-quality healthcare

system; therefore, establishing strategies that enhance patient experiences creates value

for the healthcare organization (Lee, 2019). Healthcare leaders ask for patient reviews to

change the organization’s culture, thus meeting patient’s need and keeping a high-level

reputation for satisfaction, quality, and care.

The value-based program rewards healthcare providers with incentives for

providing quality care to patients with Medicare to support improved care for individuals.

Through the value-based program, clinicians receive incentives to provide better care for

patients and communities and decreased costs to patients (CMS, n.d.). The value-based

program allows for payments to providers based on the quality-of-care patients received

instead of the number of patients the provider has seen (CMS, n.d.). Transitioning the

focal point of a healthcare visit to the actual patient instead of the number of patients the

physician sees may improve the patients’ overall outlook of healthcare.

The CMS website shares the results of the CAHPS, allowing consumers and

patients to review hospital ratings. The results of the CAHPS affect a percentage of the

PPACA’s hospital value-based purchasing program. A percentage of the program

reimbursements results from the CAHPS scores, and these scores predict the

compensation disbursed to healthcare organizations (CMS, n.d.). In addition to the

valuebased purchasing program, CMS currently withholds a percentage of Medicare

payments to healthcare organizations (CMS, n.d.). As CMS enhances the value-based

purchasing program payments, healthcare leaders seek strategies to improve patient

satisfaction to enhance the competitive advantage in healthcare (Lee, 2019). With the

now continuous review of payments, the withholding of reimbursements will increase

year after year. CAHPS results could affect the overall finances for healthcare

organizations, including physicians’ reimbursement through CMS. Physicians who

provide average performance will not experience a change in pay, while physicians who

perform below standards; or worse than average; will receive a decrease in payment.

CMS shifted its reimbursement from the quantity of care to quality of care to lower costs

for healthcare organizations and maintained sustainability (CMS, n.d.). The most

significant bonus payment allowed to clinicians is equivalent to a percentage of Medicare

fees (CMS, n.d.). The incentive is a method to improve patient care and quality, with

better results for the healthcare organization.

CMS provides reimbursement for the number of services given to patients, and

the quality of the service provided based on the patients’ perception of care. Determining

the quality of services given includes a review of the clinician, the administrative team,

and the use of patient experience to determine reimbursement (CMS, n.d.). It uses the

value-based payment system to reward healthcare providers for excellent care, with

payments adjusted based on the patients’ perceived quality of care (CMS, n.d.).

Reimbursement for services provided aligns with the value-based payment system,

indicating that patient visits must meet or exceed the patients’ expectations if

organizations receive maximum payments.

Through CMS reporting, healthcare leaders measure and evaluate how often a

provider gives the best treatment and results. Healthcare leaders can assess the

department’s performance and implement changes to improve patient satisfaction using

the results of the CAHPS. CAHPS findings also allow consumers to compare services

and physicians using the CMS hospital compare website (CMS, n.d.) or Physician

Compare website, and other hospital and academic health centers’ websites made

available for the public audience (Golda et al., 2018). The review of clinicians and

services provides healthcare transparency for individuals to make healthcare decisions

based on patients’ perceptions of care received.

CMS launched the Hospital Compare database in 2005. Consumers use the

database to inform consumers and patients about individual physicians and the healthcare

organizations in which the physicians work through patient reviews and feedback as

reported through the CAHPS (CMS, n.d.). CMS encourages and empower patients to

make patient care decisions using Medicare’s compare tools (CMS, n.d.). The site

provides information to consumers on the quality-of-care patients received from specific

providers and support staff. Consumers can access the information they need to make

informed decisions about healthcare and physicians (CMS, n.d.). The website also allows

individuals to review information about patients’ experiences, quality of care,

complications, readmissions, deaths, and the value of care (CMS, n.d.). Healthcare

leaders can draw upon patient reviews to ensure that individuals receive adequate care at

every visit.

Many patient’s perceptions begin the moment they enter the healthcare facility.

Others develop positive assessments of quality service through ongoing communication

with healthcare workers, who keep patients abreast of all aspects of treatment (P.

Leonard, 2017). Patient’s reported communication expectations show differences in how

healthcare providers keep them informed (Grocott & McSherry, 2018). Research shows

that an overwhelming proportion of patient complaints are related to interpersonal

communication (Stewart, 2018). Patient feedback aids in understanding the needs and

concerns of patients and improves communication between the patient and the clinician

(Thornton et al., 2017). Addressing patient’s concerns and providing adequate feedback in

a prompt and efficient manner may improve the patient’s perception of the healthcare

organization.

Patient satisfaction is an intended result of the care patients receive at every visit.

With the increase in awareness of CAHPS results, healthcare leaders are adopting

transformational and innovative processes to improve patient satisfaction (Delaney,

2018). Healthcare is evolving into patient-centered care, improving patient outcomes

while holding healthcare leaders and clinicians accountable for quality services.

Continuous improvement to patient satisfaction must include all aspects of the healthcare

organization, which could otherwise result in poor reviews for the healthcare

organization.

Compliance

The third strategy healthcare leaders use to improve patient satisfaction is to

ensure compliance with CMS patient satisfaction regulations, thus minimizing financial

risk. To achieve compliance and reduce financial hardship, healthcare leaders look to

build sustainable, resilient, cost-efficient, and value-based organizations. Insurers are

enforcing physicians and other providers to deliver on the growing demand for

valuebased care and provide safe, high quality, and affordable care to every patient

(Padilla, 2017). Value-based healthcare aligns with patient-centered care, patient

satisfaction, and positive perception of care.

Value-based care has created a shift in healthcare delivery to patients, creating an

environment of quality, safety, and transparency. Healthcare leaders acknowledge the

need to shift delivery to a value-based system (Kanters & Ellimoottil, 2018). Value-based

care allows for optimal use of resources that enabling physicians to improve healthcare

outcomes at the patient, population, and care levels (Jani et al., 2018). Healthcare leaders

who identify the interventions needed to increase value base care reflect a reduction in

cost and an improvement in the quality of care (Xu et al., 2020). Value-based care ensures

the patient is involved in healthcare decisions creating an environment of transparency.

Healthcare reform has created challenges for healthcare leaders. Under the

PPACA, the healthcare culture has adapted to declining reimbursement rates, reduced

research funding, and expectations of lower cost, higher quality from payers and insurers

(Itri et al., 2017). The rising cost of healthcare creates ambiguity in the relationship

between the quality of care and healthcare spending, resulting in an urgent need to

strategize efficient payment methods that align with quality care and value (Resnick,

2018). The U.S. government is the largest healthcare insurance payer, providing coverage

to over 71 million individuals in the Medicare and Medicaid programs (Resnick, 2018).

The goal of the Department of Health and Human Services is to have 90% of Medicare’s

fee-for-service payments linked to quality or value while favoring a transition to

alternative payment models.

Various factors affect healthcare spending increases, and those factors include

multiple factors associated with technology, spending, and quality of care. According to

the Organization for Economic Cooperation and Development (n.d.), the estimated

average annual expenditure on healthcare is $10,000 per U.S. citizen. Healthcare in the

United States is the most significant expense in household consumption (Organization for

Economic Cooperation and Development, n.d.). Reasons for the rising U.S. healthcare

costs include medication cost, physician reimbursement, and a fragmented care delivery

system (Owaid, 2017). The increase in Medicare enrollments contributes to the rise in

healthcare spending sponsored by the federal, state, and local governments, with an

expected increase of 47% by 2027 (CMS, n.d.). As the population grows, the citizens age

and face illness; thus, the increasing cost of care could decrease patient care.

The need for healthcare insurance continues to rise as patients develop health

issues and emergencies. Healthcare per capita cost in the United States is the highest

among industrialized nations, Medicaid state spending in 2017 increase to 29%, up from

20.5% in 2000 (Emanuel, 2018). Access to health insurance is available to individuals

who are employed (private insurance or marketplace), low-income (Medicaid), or over

the age of 65 years (Medicare). Medicaid is a state-funded benefit with an inflation rate

higher than any segment of the state budget (Emanuel, 2018). When an uninsured patient

seeks a physician’s care, the healthcare organization may have to cover the cost of care.

Although a patient with Medicare or Medicaid insurance receives care, healthcare

reimbursement covers only a portion of the cost. Because many patients lack insurance

coverage, healthcare leaders must rely on patients with private insurance to balance

spending and investments for a sustainable fiscal model (Sowers, 2016). However,

depending primarily on private insurance could create additional financial risk for

healthcare organizations.

Improved incentive programs are a method to deliver safe, quality patient care by

providing incentives to physicians. The Hospital Quality Incentive Demonstration, a

voluntary CMS program from 2003 to 2009, became the model for the hospital

valuebased purchasing program established after the PPACA (Bonfrer et al., 2018). The

hospitals that took part in the Hospital Quality Incentive Demonstration received

financial incentives to improve quality, providing those hospitals with a competitive

advantage (Bonfrer et al., 2018). Early evidence suggests that the hospital value-based

program has had minimal impact on patient outcomes, including the hospitals that

volunteered for the Hospital Quality Incentive Demonstration program (Bonfrer et al.,

2018). Value-based care is a way to improve patient perceptions through the quality of

care, healthcare transparency, and healthcare safety.

To transition to a value-based care plan, the Department of Health and Human

Services moved most Medicare fee-for-service payments to other payment models. The

moved models included bundled payments, accountable care organizations, and changing

fee-for-service reimbursement based on patient experience, harm, and quality (Francis &

Clancy, 2016). Half of the payments made are through alternative payment models, such

as accountable care organizations or bundled payment arrangements (Arnold, 2017). The

implementation of the PPACA included many financial changes. The Medicare

Disproportionate Share Hospital funding became available for uncompensated care

payments after reducing in the percentage of uninsured patients in 2014 (CMS, n.d.). As

the number of uninsured patients grows, the need for uncompensated care payments

increases.

The fee for service compensation metric provides payments to physicians for

services rendered for patient care. Using a value-based compensation metric, CMS makes

payments based on the value of care each patient receives. The compensation metric for

physicians replaces the volume of patients with the value of care provided to patients

(Miller & Mosley, 2016). In 2019, Medicare implemented a replacement formula for

physician payments (CMS, n.d.). The new method requires physicians to choose one of

two ways to participate in the Medicare payment system (Miller & Mosley, 2016): the

merit-based incentive payment system (MIPS) or the advanced alternative payment

model (APM). Providers must participate in one of the programs in the performance year

2018 or will be subject to a 5% penalty in the payment year 2020 (Copeland & Woo,

2018). If the provider chooses not to participate in one of the programs in a performance

year, the physician is subject to a payment penalty 2 years later (Woo et al., 2018). The

method holds the physician accountable for participation and payments in providing safe

and quality care to every patient, regardless of the number of patients seen.

The first value-based option includes MIPS which combines the physician quality

reporting system and meaningful use into one program to provide physicians with a

quality score. The higher the quality score, the higher the reimbursement rates. If the

quality score stays at the set average, there will be no adjustment; if the quality score is

below the set average, the Medicare payment will be subject to reduction or elimination

(Miller & Mosley, 2016). Thus, value-based compensation metrics pose a further

financial risk to the healthcare organization if their physicians do not meet the quality

scores.

The MIPS uses a scoring system from 1 to 100. Physicians with scores between

3.76 and 14 will receive a negative payment adjustment of five percent in 2020 for the

performance year 2018 (Woo et al., 2018). A score of 15 does not include a change. In

contrast, a score of 16 to 69 earns a positive five percent adjustment and scores 70 and

above qualify for an outstanding performance adjustment of a shared $500 million bonus

among all exceptional performers (Woo et al., 2018). Four component categories make up

the final score: (1) Quality of service provided equals 50% of the score, (2) advancing

care information is 25% of the score, (3) Improvement activities are 15% of the score,

and (4) Cost management is the remaining 10%. Each category is weighted and

calculated differently and individually to the performance year 2018 and all performance

years after that (Woo et al., 2018). The 2018 performance scores reflected an adjustment

to the Medicare Part B payments in 2020 (Woo et al., 2018). 2019 was the first payment

year for MIPS, bonuses or penalties were paid up to 4% to participating U.S. healthcare

providers, by 2022 the payments will be adjusted up or down by 9% (Johnston et al.,

2020). As healthcare leaders adjust to the outcome of the adjusted annual payments, there

may be a continuous change in the delivery of healthcare due to these requirements.

The second choice, the alternate payment model (APM), includes a medical

group of physicians who take a lump sum of money to care for a specific group of

patients. If the physicians provide care for the patient and meet specific quality metrics,

the physicians can keep any money remaining from the lump-sum payment as set by the

APM. The APM aligns with high-value services (CMS, n.d.). Participants in this model

will receive a 5% bonus each year from 2019 to 2024, equal to the Medicare Part B

payments (Opelka et al., 2018). In 2026, physicians will qualify for a 0.75% increase in

payments every subsequent year (Miller & Mosley, 2016). The payment model can be

beneficial to the healthcare leaders who support higher quality scores and patient

satisfaction through the physicians’ commitment to delivering quality care to every

patient.

Like MIPS, the APM payments depend on reported quality measures with at least

one outcome measure. The outcome measure includes 50% usage of a certified electronic

medical record within the healthcare organization; if healthcare organizations cannot meet

quality measures, they will assume the financial risk of monetary loss (Kuebler, 2017).

Healthcare organizations with a productive population health model could achieve ample

cost savings resulting in more increases in physician payments (Ali & Dinizio, 2018). The

details of the APM model are still in the planning stages to ensure the APM model is fair

for all clinicians and physicians.

Consumers’ perception of the care received affects financial incentives for

healthcare organizations. The CMS hospital compare website presents the results of

patient experiences allowing consumers and patients to review the hospitals they are

considering for care. The PPACA’s hospital value-based purchasing program bases

reimbursement on CAHPS scores, leading to unfavorable compensation or favorable

reimbursement. In addition to the value-based purchasing program, CMS currently

withholds three percent of the Medicare payments.

As CMS enhances the value-based purchasing program for payments, healthcare

leaders seek strategies to improve patient perceptions of care. To adapt to the continuous

changes of healthcare, healthcare leaders need to continuously pursue innovative

processes to maintain sustainability (Persaud & Murphy, 2020). The value-based program

rewards healthcare providers with incentives for providing quality care to patients with

Medicare supporting improved care, better health for patients and the communities they

live in, and decreased patient costs (CMS, n.d.). The value-based program allows for

payments to providers based on the quality of the care patients received instead of the

number of patients seen (CMS, n.d.). The value-based program provides incentives for

physicians to focus more on preventative care and spending more time with patients.

Dedicated Leadership Skills

The fourth strategy named is the healthcare leader’s role in improving patient

satisfaction through dedicated leadership skills. Strong leadership plays a significant role

in improving and supporting a patient-centered healthcare organization. As healthcare

leaders adjust to healthcare reform, training and educating solid and dedicated leaders is

equally important to improve patient satisfaction and organizational financial health.

Through solid leadership skills, the benefits of employee engagement and patient

satisfaction may be limitless (Rotenstein et al., 2019). Hospitals with the highest

performance levels have used transformational leaders who empower employees, build

staff engagement in decision-making processes, and create an evenly distributed

leadership team (Lee et al., 2019). Through transformational leadership, healthcare

leaders may have the opportunity to foster new and improved processes and procedures

for engaging employees and patients.

The healthcare industry is undergoing significant transformations through

healthcare reform and the PPACA. Leaders need to develop practical skills to ensure a

robust, teamwork-based foundation through those transformations, grounded on the

principle that improving patient care and satisfaction is the organization’s primary

organizational goal. The greatest need is for healthcare leaders who are dedicated quality

clinical care delivery (Kelly, 2021). To maintain validity, healthcare organizations must

adjust to various elements of patient demand, including changes in leadership structure,

culture, and goals (Peng et al., 2021). Transformational leadership has become a prevalent

style across many industries, especially healthcare (Giddens, 2018). A transformational

leader can positively influence change and job satisfaction, thus reducing clinical errors

and creating an optimal workplace (Seljemo et al., 2020). Through the changes set forth

by the PPACA, leaders with a strong focus on patient care and patient outcomes are allies

in improving patient satisfaction, having the ability to lead the healthcare organization to

improved patient satisfaction and financial stability.

Interest in transformational leadership has increased as the need for dedicated and

focused leadership has grown and developed in diverse organizations, especially

healthcare. Transformational leadership in healthcare influences organizational and

individual outcomes to achieve the organization’s goals through inspiration and

excitement (Alqatawenah, 2018). As the healthcare industry faces ongoing reform, the

organization’s success relies on the capacity for change implementation (Spaulding et al.,

2017). Healthcare requires providers to put the patient first while leadership requires

providers to make decisions based on the business of healthcare (Bronson & Ellison,

2021). Creating a healthcare environment with a primary focus on the patient requires

change agents with a record for improving service, care, and teamwork to meet the needs

of all patients, as required by the PPACA.

Through the required healthcare reform changes, creating a strong leadership

culture focused on patient perceptions and care is key to maintaining a solid healthcare

organization. Engaged and robust leadership are invaluable traits in healthcare and crucial

to the changes necessary for quality improvement. Transformational leaders establish

trust with employees and emphasize the organization’s goals creating an atmosphere

empowered through growth and development (Asif et al., 2019a). Communicating and

listening are the core of effective leadership, leaders with these skills can articulate the

vision and goals of the organization to every employee within the organization, regardless

of the position title (Sacks & Margolis, 2021). Healthcare leaders should clearly explain

the goals; for change and the rationale behind those goals, launch a clear, concise vision

of how the change will improve patients’ overall care. The American Institute of

Medicine recommends transformation leadership as a leadership style used to create the

highest-level work environment that focuses on patient safety and employee engagement

(Seljemo et al., 2020). Leaders’ and physicians’ commitment to strengthening and

improving patient care is critical to the healthcare organizations’ initiatives (Bokhour et

al., 2018). Leaders play a pivotal role in serving as a model for organizational goals and

initiatives. Engaged healthcare leaders help to strengthen employees, which results in

improved patient outcomes. Shared experience through open dialogue between leaders

and employees further engages the employees and sets an example of transformational

leadership.

In healthcare, the primary leadership styles are transformational and ethical

leadership. Transformational leaders play a significant role in effecting the changes

needed to improve patient satisfaction in healthcare organizations, exhibiting engagement

and relationships with employees while encouraging to improve processes. Ethical

leaders also contribute significantly to improving patient satisfaction by using employee’s

creativity to engage and employ teamwork methods. Leaders serve as role models of

expected behaviors and encouragement within the healthcare organization (Walumbwa et

al., 2017). The healthcare organization’s success depends on the leader’s ability to engage

employees to meet or exceed the organization’s goals. Leaders enable followers to work

toward a results-driven goal, despite the challenges (Gilson & Agyepong, 2018). Through

those challenges and uncertain conditions, and exemplary leadership, leaders gain a better

insight into the healthcare organizations’ areas of improvement. Engaged healthcare

leaders contribute to improved patient satisfaction (Bruno et al., 2017).

Employees reach a sense of empowerment in learning, leading to a better outcome for the

healthcare organization.

Leaders who exhibit transformational leadership skills fall into one of four

dimensions, befitting the title of a transformational leader. The four dimensions of

transformational leaders are leaders with influence, individualized or supportive leaders,

inspirational leaders, and leaders who provide intellectual stimulation (Jambawo, 2018).

Transformational leaders positively influence the work environment and reduce adverse

clinical events (Seljemo et al., 2020). Leading by example, motivation, and empowerment

to work toward organizational goals is a hallmark of this leadership style.

Transformational leaders show the skills needed in healthcare to implement and change

processes, cultures, and patient care to improve patient satisfaction and the financial

wellbeing of the healthcare organization.

Transformational leadership promotes employee engagement as a tool to meet

organizational goals. Transformational leadership is an instrumental skill in healthcare.

Crucial for boosting employee satisfaction, recognizing near-miss patient errors, and

successful conflict resolution (Lee et al., 2019). Transformational leaders can encourage,

convince, and motivate followers to challenge the current processes or usual ways of

enriching innovative behaviors (Ng, 2017). Change is constant in healthcare; as such,

leaders play a vital role in assuring employee engagement and quality patient care.

Another essential leadership skill often used by healthcare leaders is ethical

leadership, promoting moral and equitable behaviors, employee creativity, and innovation

(Duan et al., 2018). The characteristics of ethical leadership include fostering principled

and respectful practices for human dignity (Barkhordari-Sharifabad et al., 2017). Ideally,

a leader who exhibits both transformational and ethical leadership skills ensure adherence

to the people aspect of the organization. The practice of ethical leadership improves

overall confidence in leaders and employees, thus increasing patient satisfaction and

employee engagement. Healthcare warrants ethical leadership to empower employees to

reduce conflict and misconduct with one another and patients (Walumbwa et al., 2017).

Ethical leaders ensure the highest moral behaviors while implementing accountability

tools to improve patient satisfaction and employee engagement.

Understanding the importance of transformational and ethical leaders and what

these leaders can provide a healthcare organization is crucial for building a strong

organization with positive results. Support for transformational and ethical leaders is vital

for healthcare organizations to ensure that every patient and employee receives, has

access to, and provides quality healthcare (Jambawo, 2018). Under the PPACA

recommendations, leaders must develop and expand teamwork and support a robust,

healthy work environment to continuously improve patient care and optimize

performance (Geraghty & Paterson-Brown, 2018). With transformational and ethical

leaders, employees engage in patient care and have a sense of responsibility to the

healthcare organization to meet the needs of patients. Employees should be familiar with

the leader’s leadership styles and feel trusted and valued while supporting the needs of

the organization and the leader (Purwanto et al., 2020). Establishing a culture of

transparency builds trust among the teams, and a commitment to the leaders and the

overall goal of the organization. Transformational leadership styles positively affect the

organization’s performance (Purwanto et al., 2020). Top leaders (e.g., Chief Executive

Officers) influence employee job satisfaction and improved job performance to

implement change initiatives (Asif et al., 2019a). Transformational leaders lead with

change through influence and engagement; ethical leaders lead through sincere beliefs

and behaviors that promote creativity and risk-taking (Duan et al., 2018). Both styles of

leaders focus on engaging employees, either through influence or creativity, supplying

support and guidance for employees to be part of the organization’s overall goal, either

through creative ideas or engagement through personal development.

The American Nurses Credentialing Center of the American Nurses Association

Magnet designation recognizes transformational leadership as a key leadership principle

in guiding and improving healthcare leadership. The recognition of transformational

leadership as a principal part of nursing and healthcare leadership encourages leadership

in the reform of healthcare (Lee et al., 2019). Healthcare leaders who invest in the clinical

team and quality service receive Magnet designation recognition, showing the highest

level of nursing care quality (Tubbs-Cooley et al., 2017). Leaders who create and

promote a supportive, professional, innovative Magnet designation environment foster

quality improvements and healthcare excellence (Pabico & Graystone, 2018). The

prestigious Magnet designation further supplies advanced quality measures that reflect

the healthcare organization’s status for leadership and quality throughout the United

States.

Quality improvement plays a significant role in the changes in healthcare,

allowing patients to feel confident in the treatment received. Effective leadership must

continuously learn through adaption and innovation in the changing environment

(Persaud & Murphy, 2020). Patient safety, clinical effectiveness, and patient satisfaction

are critical components of quality healthcare (Kumar & Khiljee, 2016). Leaders who

focus on quality seek to improve upon and learn the most effective methods for quality

improvements tailoring the changes to the needs and resources of the organization

(Sandberg, 2018). Patient satisfaction has started a charge in healthcare leadership as a

partnership with patients and building and encouraging employees a call to action in

healthcare organizations (Wolf, 2017). Through strong quality measures and

accountability practices, leaders can keep patient care as a primary focus for all

employees.

Through dedicated leadership, healthcare leaders can create better health

outcomes for patients by engaging physicians and patients jointly to improve the quality

of care of every individual. Understanding the needs of patients means including patients

in the decisions related to their care. Embracing patient satisfaction in healthcare is a

critical indicator of the need to set up strategic plans and goals to provide a better quality

of care by understanding the needs of patients (Batbaatar et al., 2017). Implementing

patient satisfaction interventions may improve patient perceptions through compassionate

care and dedicated healthcare leaders who seek quality improvements and financial

stability for the organization.

The purpose of this qualitative single case study was to explore the strategies

healthcare leaders use to improve patient satisfaction. Researchers have presented

consistent information relative to the CAHPS and quality care, with many scholars

addressing patient satisfaction worldwide (Batbaatar et al., 2017). There is a need for

more rigorous research to identify effective interventions to improve patient satisfaction

in healthcare.

Transition

In Section 1, the goal of this study was to explore strategies healthcare leaders

used to improve patient satisfaction. Section 1 of this study included (a) the Foundation

of The Study, (b) the Research Questions, (c) the Assumptions, Limitations, and

Delimitations, and (d) the Significance of The Study. In the literature review, I explored

the theory of caring, sustaining a culture of patient-centered care, understanding patients’

needs, ensuring compliance, and supporting dedicated leadership skills. The foundation of

the literature review included a discussion about the changes implemented by the creation

of the PPACA and the role that patient satisfaction plays in healthcare organizations’

financial viability. The problem statement and purpose statement included introducing the

business problem and the case for further research. The literature review includes

evidence that patient satisfaction in healthcare affects physicians and healthcare

organizations. Further research will aid in the exploration of strategies to care for the

whole patient, reduce healthcare costs, and improve patient satisfaction in healthcare.

In Section 2, I describe my role as the researcher. I focus on the methodology and

design of the study, the participants, population and sampling, and ethical research. I will

conduct a single case study by interviewing healthcare leaders who have successfully

implemented strategies to improve patient satisfaction. My data collection and analysis

plan include using interview data and reviewing one healthcare organization’s archived

documents. The archived documents include patient satisfaction survey scores, leaders’

notes, reports, standard operation procedures, reporting methods, training plans, and other

documents related to improving patient satisfaction. I used software to support my

findings and documentation.

In Section 3, I include a detailed description of the presentation of the findings,

application to professional practice, and social change. The implication for social change

includes investigating healthcare leaders’ practices to improve patient satisfaction in

healthcare. Healthcare leaders can use the findings from this study to improve patient

satisfaction and the financial performance of healthcare organizations. The results of this

single case study may create an awareness of the need to establish effective strategies to

improve patient satisfaction in all healthcare organizations. I close Section 3 with

recommendations for action for further research and reflections of the study.

Section 2: The Project

In Section 2, I describe the data collection process for the project. I discuss the

purpose of this single case qualitative study, the role of the researcher and participants,

and the research method and design. I reviewed data collection, data organization, and

data analysis processes. Section 2 concludes with the importance of ethical research and

steps I took to ensure reliability and validity of the study.

Purpose Statement

The purpose of the proposed qualitative single case study was to explore strategies

healthcare leaders used to improve patient satisfaction. The target population included

leaders of a healthcare organization located in metropolitan Detroit, Michigan who have

successfully implemented strategies that improved patient satisfaction. The study could

influence the way healthcare leaders address patient satisfaction and patients’ perceptions

of service quality, resulting in improved outcomes for patients and their families.

Role of the Researcher

In my role as the researcher, I selected participants and established relationships

with them, worked to eliminate internal personal bias, and conducted interviews,

reviewed archival documents, and reviewed databases for data collection. My role was to

act as the primary data collector, ensuring validity, reliability, and prevention of any bias

that hindered honest and fair data collection (van den Berg & Struwig, 2017). As the

researcher and primary data collector, it was my responsibility to collect data to ensure

reliability and validity. I had a limited professional networking relationship with each

participant as well as work experience within a healthcare organization. Because of

healthcare networking events, limited preexisting relationships with each potential

participant existed. I expected each participant to provide information about

implementing successful strategies to improve patient satisfaction.

As the researcher, I am knowledgeable about patient satisfaction because I am a

leader within a healthcare organization that has implemented strategies to improve patient

satisfaction. As a leader, it is my responsibility to ensure that every patient receives

quality care and service at every visit. I am also familiar with the topic because of my

previous work experience within a healthcare organization that implemented strategies to

improve patient satisfaction. Improved patient satisfaction is a daily commitment because

decreased patient satisfaction based on the CGCAHPS and HCAHPS results can harm the

profitability of healthcare organizations not meeting established targets. Inspired by my

background in this study, I sought to understand healthcare organizations’ social and

financial obligations and the role that patient satisfaction has. My work involving patient

satisfaction has led to the development of the research question.

Applying ethical standards in research is the researcher’s responsibility, as is

upholding honesty and transparency in the study (Cumyn et al., 2018). As the researcher,

I did my best to eliminate bias and ethically collect and report data that aligns with The

Belmont Report. The Belmont Report provides guidance for researchers to follow and

ensure the ethical treatment of human participants (National Commission for the

Protection of Human Subjects of Biomedical and Behavioral Research, 1979). To ensure

that I acted according to the tenets of The Belmont Report, I ensured respect for each

participant by providing informed consent forms, assessing risks and benefits of the

project, and ensuring that each participant received fair treatment during research. To

protect participants, I followed guidelines in the National Institutes of Health training

course Protecting Human Research Participants.

To ensure the validity of the study, I developed processes to mitigate potential

bias. Implementing implicit and explicit bias mitigation techniques is essential to mitigate

bias (Babcock et al., 2016). Bias can directly and adversely impact quality of the study, as

results of an investigation can be invalid if the researcher does not account for potential

biases (Dunn et al., 2016). To mitigate bias, I acknowledged and set aside my perceptions

and opinions regarding the topic.

I avoided viewing data using a personal lens via my data collection practices and

member checking. Member checking is a necessary process used by researchers to help

mitigate bias (Birt et al., 2016). Researchers use member checking to ensure that data

reflects participants’ views (Fusch & Ness, 2015). To mitigate bias, I audio-recorded

interviews, transcribed interview responses, and then followed up with participants using

member checking. Throughout interviews, I used an interview protocol to facilitate

discussions and reduce bias.

I used an interview protocol to mitigate personal bias. An interview protocol can

strengthen the reliability and quality of collected data from participant interviews

(Castillo-Montoya, 2016). Interview protocols use core components to ensure that the

collection of data is consistent. The core components of interviews include (a)

establishing rapport with interviewees, (b) establishing ground rules for the interview, and

collect data consistently and avoid bias (see Appendix). I established a neutral disposition

during interviews with participants to ensure mitigation of bias.

Participants

The study included individuals who successfully implemented strategies to

improve patient satisfaction. To gather meaningful data, researchers choose participants

with knowledge of the research topic (Grafton et al., 2016; Newton, 2017). Identifying

effective recruitment processes enables efficient and prompt data collection (Marks et al.,

2017). To gain access to participants, I sent an email to the vice president of human

resources. In this email, I explained my study and the data collection process. I requested

access to healthcare leaders within the organization who implemented patient satisfaction

strategies. Once I received approval for access to healthcare leaders from the vice present

of human resources, I documented permission with letters of cooperation. The letter of

cooperation included steps for participant selection, interviews, data collection, the

member checking process, and voluntary and confidential practices of the study. After

obtaining consent to collect data, I identified leaders who successfully used strategies to

improve patient satisfaction.

Upon receipt of the signed letter of cooperation and participant contact

information, I established working relationships with research participants. I contacted

them using email invitations to participate in my study and continued our relationship

through the interview process.

Research Method and Design

In this subsection, I discuss the qualitative research method and why I selected

this method for my study. I then describe the qualitative research design, and reasons why

the case study design was the most appropriate design for my study.

Research Method

There are three research methods for the study. The three research methods are

qualitative, quantitative, and mixed methods (Yin, 2018). I employed the qualitative

approach to explore strategies healthcare leaders used to improve patient satisfaction by

gathering information from participants and interpreting findings. Researchers use the

qualitative method to present information related to the study through interviews and data

collection (Hewitt & Pham, 2018). The qualitative approach involves understanding

perceptions through interviews and data collection (Cypress, 2017; Vass et al., 2017). The

qualitative method was most appropriate for this study as I conducted interviews and data

collection related to strategies used by healthcare leaders.

The quantitative approach requires close-end questions and involves testing

hypotheses (Barnham, 2015; Saldaña, 2015). Hypothesis testing and analysis of variable

relationships or differences was not a requirement to address the purpose of this study.

The quantitative method involves measurable and quantifiable data (McCusker &

Gunaydin, 2015). For this study, measurable and quantifiable data were not relevant;

therefore, the quantitative approach was not appropriate for this study.

Mixed methods research includes both qualitative and quantitative data (Tillman

et al., 2011). Researchers use the quantitative method to measure data and describe

aspects of a phenomenon (Morse, 2016). The mixed methods design was not appropriate

for this study because I did not collect and analyze quantitative data.

Research Design

Researchers use one of four research designs to develop their research. The four

research designs considered for this qualitative study were: (a) ethnography, (b)

phenomenology, and (c) case study. After considering the four qualitative study designs,

I selected a single case study research design.

Researchers use the ethnography design to focus on a cultural group and its

values, behaviors, beliefs, and language through participant observation and

documentation in natural settings (Anderson et al., 2014; Walliman, 2017). Researchers

use the ethnography design to study participants and understand their culture (Garson,

2017). I selected a single case study research design after considering the three qualitative

study designs. The ethnography design was not appropriate for this study as this study

does not involve exploring a cultural group in a natural environment.

Researchers use the phenomenological design to highlight an event or

phenomenon in terms of bringing together experiences, assumptions, and perceptions

based on spoken or written accounts of personal experiences related through participant

observations, interviews, and discussions (Anderson et al., 2014). Researchers who use

the phenomenological design research experiences of participants in real life settings Lien

et al., 2014). The phenomenological design was not appropriate for this study because

this study is not about an individual participant’s personal experiences with the

phenomenon.

Case study researchers seek to conduct empirical explorations of phenomena

within a real-world context bounded by time (Yin, 2018). Researchers who use the case

study design seek to explore intricate research issues through a broad scope (Harrison et

al., 2017). The case study design was most appropriate for this study because I explored a

phenomenon within a real-life context. The case study design allowed me to gain insight

into best practices to improve patient satisfaction in healthcare organizations.

Using extensive data collection techniques, I analyzed data from interviews,

archival documentation, and CMS data from the hospital compare website. To achieve

data saturation, the researcher must exhaust all available data (Fusch & Ness, 2015). I

continued to interview healthcare leaders until no further information appeared, and I

identified all themes and achieved data saturation. I conducted a rigorous study by

gathering enough data through semi-structured interviews via member-checking, archival

document reviews, and qualitative data obtained from the CMS hospital compare website

to ensure data saturation.

Population and Sampling

The target population for this study was healthcare leaders (vice presidents and

directors). The population is the information source from which the sample emerges (van

Rijnsoever, 2017). For this study, each participant held a director or vice president

position within a healthcare organization that used successful strategies to improve

patient satisfaction.

The sample aligns with the purpose of the study and reflects the specific

phenomenon that occurs with the target population. In qualitative research, sample sizes

tend to be smaller and include data-rich results based on interview questions (Vasileiou et

al., 2018). The proposed sample size of this study was five healthcare leaders.

Using purposeful sampling, I selected participants who met criteria for

participating in the study. Researchers use purposeful sampling to research quality data

that relates to the phenomenon (Palinkas et al., 2015). Purposeful sampling helps in terms

of identifying participants for information rich cases (Etikan et al., 2016). As purposeful

sampling subjects, participants provided rich and unique data. Purposeful sampling was

appropriate for this study because with the information rich data that purposeful sampling

identifies, an in-depth understanding of the research.

Participants successfully implemented strategies to improve patient satisfaction as

members of the senior leadership team. Participants had awareness of patient satisfaction

scores, as reported in the CGCAHPS and HCAHPS. Focusing on participants that met

criteria aided with relevant research. I collected data using interviews, archival

documentation, and the CMS hospital compare website. In conducting interviews and

reviewing archival documents from the healthcare organization, I ensured there was no

new data, and no new themes emerged from collected data after reaching data saturation.

I conducted interviews and member checking through virtual conference meetings.

Meetings offered ample time for me to conduct thorough interviews. I requested archival

documentation for review from participants during interviews. I reviewed the CMS

hospital compare website to obtain the healthcare organizations CMS star ratings, which

is comprised of 64 hospital quality measures categorized into 7 specific groupings:

patient experience, mortality, safety of care, readmission, timeliness of care, effective

care, and use of medical imaging (CMS, n.d.). I reviewed the hospital compare website to

get insight of the healthcare organization’s overall patient satisfaction results.

Ethical Research

As the researcher, I am responsible for obtaining and presenting accurate

information. To ensure credible research, participants received and signed informed

consent forms that included the purpose and nature of the study, participant privacy and

confidentiality, voluntary participation, and right to withdraw. Each participant reviewed

and acknowledged consent (see Appendix) before participating in interviews. The

informed consent form included the nature and purpose of the study, participant criteria,

voluntary participation, confidentiality guidelines, and the role of participants.

For this study, if participants wished to withdraw from the study, they could do so

by contacting me by email or telephone expressing the desire to withdraw from the study

without explanation. In research, participants have the right to withdraw from the study at

any time by requesting removal of data (Kaye et al., 2015). There were no consequences

if participants chose to withdraw from the study at any time. There were no incentives for

participating in the study.

I kept all collected data on a password-protected external flash drive used for the

exclusive purpose of conducting this study and stored in a safe for a minimum of 5 years

to protect confidentiality of participants and healthcare organization. After 5 years, I will

discard data on the flash drive by deleting it to protect confidentiality. Walden

University’s Institutional Review Board (IRB) approval number for this study is 04-0221-

0551963. To ensure ethical protection, each participant received a unique numeric

identifier from P1 to P5, and the healthcare organization remained confidential.

Data Collection Instruments

As the primary data collection instrument of this qualitative single case study, I

conducted semistructured interviews and reviewed archived organizational documents to

discover underlying themes. As the data collection instrument, the researcher must collect

rich data and draw meaningful insight (Moon, 2015; Xu & Storr, 2012). The quality of

the data collected relies on the data collection instrument, the researcher’s ability to

objectify and measure phenomena (Sutton & Austin, 2015; Xu & Storr, 2012). As the

primary data collection instrument, I collected quality data objectively.

I collected data through semistructured one-on-one virtual conference interviews

that included open-ended questions using an interview protocol (see Appendix) to guide

the discussion. I followed the interview protocol to ensure interviews remained on track.

In addition to conducting semistructured interviews, I asked participants to share

organizational documents relevant to improving patient satisfaction. Archival

documentation review is a process of collecting data from preexisting records (Pacho,

2015). The archival documentation review included reports, survey results, workflow, and

process improvements that may highlight specific strategies used by healthcare leaders.

To improve the reliability and validity of the study, I used the interview protocol,

which included the interview questions and member checking processes to ensure

accurate data collection that validates each participant's interview. Member checking

allows the participant to review, comment, and approve the interpretations of the

discussions, increasing the accountability and credibility of the research (Birt et al., 2016;

Naidu & Prose, 2018). I summarized my interpretation of each interview response into a

Microsoft Word document. I shared the synthesis of the interviews and member checking

with each participant to ensure an accurate understanding of the interview responses.

Data Collection Technique

The data collection techniques that I used in this study included the data collected

during the virtual semistructured interviews lead with open-ended questions, archived

documents from the healthcare organization, and data collected from the CMS hospital

database. Methodological triangulation in my study included three data collection

techniques: virtual semistructured interviews, archival document review, and data from

the CMS hospital compare website.

Semistructured Interviews

I collected data for the study by conducting semistructured video conferencing

interviews using WebEx, one participant at a time, that included open-ended questions

using an interview protocol (see Appendix) to guide the conversation. I emailed and

introduced myself to the participants with an invitation to take part in my research study

(see Appendix). Each interview that I conducted was audio recorded with the participant’s

consent as disclosed in the informed consent form (see Appendix). Using an interview

protocol aids with the transparency and accuracy of the research to reduce bias (Galdas,

2017; Heydon & Powell, 2018; Wright et al., 2018). I created the interview questions to

ensure the alignment of the purpose statement, the problem statement, and the research

question. I created the interview protocol to ensure that the conversations in the

interviews remain on track and consistent with the research question. During the

interviews, I kept a notepad to document nonverbal behavior, expressions, and other

nuances not captured by the audio receiver. I audio recorded the participant interviews

using WebEx video conferencing and one device for backup for technical difficulties.

The backup device that I used was an iPhone 6s.

Upon reviewing the details of the study with the healthcare organization’s

leadership and receiving the signed Letter of Cooperation in agreement to allow the

participation of five healthcare leaders, I sought to obtain archival documentation from

the healthcare leaders. The archival documentation included patient satisfaction survey

scores, leaders’ notes, reports, standard operation procedures, reporting methods, training

plans, and other documents related to improving patient satisfaction. The semistructured

interviews include beginning each interview with the informed consent form outlining the

participants’ confidentiality, rights, and my contact information to reduce bias and

address any questions or concerns from the participants.

Upon completing of the interview questions (see Appendix), I scheduled the

60minute virtual conference member checking interview and confirmed the contact

information for the participants. I ended the interview process and thanked the

participants for their time. I again provided my contact information for follow-up

questions and any concerns that the participants may have. I thanked each participant for

their time. I turned off the audio recorder and concluded the interview. During the

scheduled virtual conference member checking interviews (see Appendix), the following

steps took place: I turned on the audio recording device and noted the date and time of the

interview. I began the 60-minute member checking virtual conference interview and

ensured that the participants did not have any questions or concerns before starting the

interview. I explained to the participants that the focus of the member checking interview

was to confirm my interpretation of the interview responses and address any

modifications to my variations of the interview.

The data collection technique, semistructured interviews, has disadvantages and

advantages. A disadvantage of semistructured interviews includes the participants may

feel discomfort with the interviewer and provide vague answers, maximizing the

interviewer's influence in the research. Another disadvantage of semistructured interviews

is timing; the participant's schedule is not conducive for the interviewer, potentially

affecting the number of qualified participants for the study (McIntosh &

Morse, 2015). The researcher’s responsibility is to conduct unbiased research, which

includes fair ethical treatment and may also include flexibility with participants to meet

the needs of the research study.

An advantage of semistructured interviews includes the use of video conferences

for the interviews. Video conference interviews offer flexibility and established control of

the interview (Heath et al., 2018). Through video conference interviews, the interviewer

can capture both verbal and nonverbal cues from the participants during the interview to

help the interviewer identify any moments of discomfort or excitement during the

interview.

Archival Documentation Review

I analyzed and reviewed archived documents from the healthcare organization’s

planning and implementation of best practices to improve patient satisfaction for data

collection. Archival documentation review entails considering historical, present, and

future data (Moore et al., 2016). The process of archived documentation review includes

perusing the leaders’ notes, patient satisfaction scores, and other material related to the

improvement of patient satisfaction within the healthcare organization. An advantage of

using archival documents includes understanding the healthcare organizations’ business

practices as related to patient satisfaction. Data analysis of the archival documents could

produce the analysis of the data with one or more documents (Moore et al., 2016). A

disadvantage of data collection of archival material is that some documents may be

confidential. Another disadvantage of using archived documents includes lost, destroyed,

or damaged documents (Patil & Karandikar, 2016). The request for archived documents

may prove to be a challenge for the researcher if the healthcare leaders do not keep the

records, resulting in further research to enhance the reliability of the data collection

instrument.

CMS Hospital Compare Website

The review of the CMS hospital compare website served as a data collection

technique that provided a global insight into CMS ratings of the healthcare organization

and the patient perspective of the healthcare organization and the clinical care teams.

CMS created the hospital compare website as a tool to provide consumers with insight

into how well healthcare clinicians provide care to patients and the overall performance

of healthcare organizations by comparing each to other healthcare organizations and

clinicians. The hospital compare website is a consumer-based website that provides

prospective patients with data collected from 6 publicly reported quality domains (1)

HCAHPS and CAHPS patient experience surveys, (2) readmission rates and deaths, (3)

timely and efficient care, (4) complications, (5) use of medical imaging, and (6) payment

and value of care for individual healthcare organizations through a quality rating system

(CMS, n.d.). The rating system provides consumers with quality-of-care measures and

data to help consumers make an informed decision about physicians, health plan

coverage, and the overall healthcare organizations.

The advantages of reviewing the hospital compare website include an overall

view of the healthcare organizations rating with CMS and the use of the star system to

rate the organization and the patient’s perception of the healthcare organization. The

disadvantage of reviewing the hospital compare website includes the in-depth data related

to medical imaging and death. The inclusion of multiple quality domains into the overall

star rating does not benefit the patient (Hu et al., 2017). Another disadvantage includes

the inability to confirm if a patient decided to see a physician based on the hospital

compare website. Consumers may choose a healthcare organization or physician based on

recommendations from other physicians, family, or friends, making it impossible to

determine if consumers use the hospital compare site (Blake & Clarke, 2019). The data

used to score and rate healthcare organizations and clinicians may not entirely reflect the

patient’s perception of care and improved patient satisfaction.

Member Checking

Member checking entails a follow-up interview with participants to ensure the

interpretation of the interview responses is correct. Participants confirm the validity of the

interview during member checking (Caretta & Pérez, 2019). Through member checking,

participants review and identify any gaps or inconsistencies in the data (Yang et al.,

2018). Member checking provides further opportunities to build accountable, trustworthy

relationships with the participants and obtain more insight from leaders that might

enhance the research (Caretta, 2016; Harvey, 2015; Iivari, 2018). Through member

checking, the interview participants play an active role in the study and establishing

trustworthy relationships will help ensure that the interpretations are accurate. I

conducted virtual follow-up interviews with each participant to ensure the prompt

completion of member checking (see Appendix).

Data Organization Technique

I began drafting my interpretations in a Microsoft Word document, which I saved

and imported into NVivo and a flash drive for backup. I discussed my interpretations of

the interview responses with the participants for member checking. Upon the healthcare

leaders’ approval of my elucidations, I progressed to data coding and NVivo. NVivo will

allow me to manage the collected data. NVivo is a qualitative software program used to

facilitate and simplify data analysis (Røddesnes et al., 2019). I saved and scanned all

physical documents as Adobe Acrobat files for importing into NVivo. To ensure the data

accuracy and confidentiality, I created coded folders for each interviewee to protect each

participant’s confidentiality. I scanned the consent form into each participant’s folder. I

interpreted the interview using Microsoft Word, then added the interpretations to each

participant’s coded folder. I kept track of raw data by cataloging and labeling the data by

participants. I documented my understanding of the interviews and saved the audio

recordings to the participant's folder. I used a reflective journal for recording my notes of

the interview to reference any physical observations in the interview with each

participant. The reflective journal will reflect the interview details, handwritten with the

date, time, location of the interview, and the participant’s number identifier to safeguard

each participant’s identity.

I transferred and securely stored all hard copies of the documents collected on a

password-protected flash drive. I secured the flash drive in my personal safe for a

minimum of 5 years from the interview date to protect the identities of the participants

and the healthcare organization. After 5 years, I will destroy all documents and materials

associated with the study as per the Walden University IRB requirements.

Data Analysis

I used methodological triangulation by conducting multiple interviews and

reviewing additional documentation and data to align with the data analysis process. The

use of triangulation in case studies ensures the reliability of the study and increases

understanding of the phenomenon (Farmer et al., 2006). The four types of triangulations

are: (a) methodological triangulation, (b) investigator triangulation, (c) theory

triangulation, and (d) data triangulation (Bruning et al., 2018). Methodological

triangulation includes using multiple types of collected data, including interviews and

review of archived documents (Bruning et al., 2018). I used three data sources to ensure

data saturation, virtual interviews, archival document review, and the CMS hospital

compare website. I followed Yin’s (2018) five-step process for data analysis. The five

steps are: (a) compiling the data related to the research question, (b) disassembling the

data to determine data techniques, (c) reassembling or organizing the data, (d)

interpreting the data, and (e) concluding the data.

Yin’s Five-Step Data Analysis

Compiling

The compiling phase includes reviewing the field notes, recordings, and other data

sources (Yin, 2018). The first step of the five-step process was collecting and compiling

data from the semistructured interviews and documentation review, reflecting the patient

satisfaction data from the most recent 5 years (2017-2021) provided by the healthcare

leaders. I reviewed the documents provided older than 5 years, as the documents provided

additional historical data. I analyzed the interview data obtained from the semistructured

interviews, and I looked for repetitious terms and keywords, universal themes, and

unfamiliar vocabulary. I broke down the data collected into specific details to determine

how the data may answer the original research question. With the collection of detailed

data, I began to organize the data into relevant elements to the study and started

interpreting the collected data into the research. I referred to the literature review to

correlate the emergent themes with the conceptual framework.

Disassembling

The disassembling phase may result in the reduction of data (Yin, 2018). During

this phase, I looked for patterns of common themes while analyzing the audio recordings

of the interviews and the journal notes collected during the interviews. I coded the words

into categories seeking emerging theme identification.

NVivo allowed me to find patterns in the data collected upon completion of

inputting the data into the program to conduct the coding process. The emerging themes

identified during the disassembling phase provided meaning and value to the case study.

After coding, I analyzed the data and included any additional codes and themes to the

current list of articles.

Reassembling

During the reassembling step, I reassembled the data and categorized the data into

a broader theme. I grouped the data to identify any conflicts or similarities in the data to

find emerging themes. When making decisions during this step, comparisons should

continue with other patterns or themes (Yin, 2018). Utilizing NVivo to arrange and sort

data aided with organizing the data into specific themes.

Interpreting

After reassembling the data to find any related patterns and themes, I completed

data interpretation. I interpreted the data using the central research question. Interpreting

data includes complete, accurate, fair, and credible research (Yin, 2018). Interpreting data

should be broad regarding terms of the relationships and global findings in the data

(Castleberry & Nolen, 2018). I interpreted the data while keeping my focus on the themes

of the study.

Concluding

The last step of Yin’s five-step data analysis, concluding, entails presenting the

study results. The interpreted data becomes the findings of the study (Castleberry &

Nolen, 2018). The conclusion of a study provides suggestions for future research (Yin,

2018). I concluded the investigation by confirming my findings while eliminating bias,

achieving data saturation, and accurately reporting the research study. The software

that I used for identifying emerging themes includes crossreferencing the data using

NVivo. I created a matrix for each interview and use + and – to scale the statements by

the respondents into distinct categories to gain an insight into the participant’s role,

views, and expectations of patient satisfaction. I focused on the key themes by

interpreting, reviewing, and coding all the interviews using NVivo to identify the themes

related to the research question.

I used the NVivo software program to aid with data collection. NVivo aided with

identifying key themes from my transcribed data. NVivo is consistent with a complex and

in-depth analysis of data (Castleberry & Nolen, 2018). The NVivo software allows the

researchers to identify themes of codes (Castleberry & Nolen, 2018). I used NVivo to

ensure the accuracy and efficiency of the data collected. I focused on an iterative process

of reflecting on my thoughts about the themes, data, and information in the literature

review.

I compared the themes from the study to the literature and the theory of caring.

Upon comparing the themes, I then classified and coded the themes into categories that

aligned with my research question. The key themes found and correlation to literature

helped me to better understand the successful strategies used to improve patient

satisfaction in healthcare.

Reliability and Validity

Reliability and validity ensure that the researcher conducts verification of all

study perspectives with rigor to reduce any subjectivity to the research. In qualitative

research, the rigor of research is a necessary component to reach the reliability and

validity of the study (Cypress, 2017). Reliability and validity imply trustworthiness in the

study. Four concepts help the researcher to reach reliability and validity to ensure the

rigor and trustworthiness of the research. The concepts include transferability,

dependability, credibility, and confirmability. To accomplish the reliability and validity of

this study, I conducted member checking and methodological triangulation.

Reliability