Creating an Excellent Patient Experience Through Service Education: Content and Methods for Engaging and Motivating Front-Line Staff.

Service quality and patient satisfaction affect an organization's value-based payments. This new value paradigm calls for a new approach to service education and training for front-line staff. Thoughtfully conceived, department-specific content, infused with patient feedback, value creation, and science of service quality principles, was developed to give front-line staff a deeper understanding of the impact of their performance on patient experience, value creation, and value-based revenue. Feedback from nearly 1500 trainees in 60 educational sessions delivered over 7 years indicates good understanding of the content and appreciation of the targeted approach. On a 5-point scale ranging from 1 (least effective) to 5 (most effective), trainees' ratings of their understanding of service quality concepts and impact on value ranged from 4.7 to 4.9. Verbatim comments showed a positive impact on staff. Employee feedback suggests that value-based service education may be useful in motivating front-line staff, improving service quality, and creating value.

Passage of the Affordable Care Act has sparked an ongoing debate about value-based payment initiatives (1), especially the use of patient perception data in determining value-based payments for clinical care (2,3). A few issues likely fueling this discussion include the difficulty in defining (4) and measuring (5) the multidimensional patient experience, the nonclinical factors that may randomly influence patient perception of quality of care, and the patients’ inability to judge the technical quality (6,7) of their medical care. Industry focus on patient-centered care and the voice of the customer suggests an understanding of the importance of patient feedback; however, the best use of that feedback to determine value seems to be evolving.

Background

Satisfaction with US health care is at its lowest point in 10 years (8). Patient feedback about an organization’s service quality—for example, wait time, nurse responsiveness, staff courtesy, and provider communication—offers a glimpse into an organization’s service gaps and how those gaps influence patient satisfaction with the service experience. Gronroos claimed that customers evaluate service quality by assessing the gap between their preservice expectations and their actual service experience (9). In addition to this theoretical approach, Parasuraman et al asserted that customers rate service quality on 5 basic dimensions—reliability; responsiveness; empathy; assurance; and tangible evidence, such as physical facilities, equipment, and appearance of staff (10,11). These service dimensions were applied to health care in subsequent empirical studies (12 –16).

Typical “customer service” education tends to focus on staff service behaviors; that is, greeting, smiling, making eye contact, communicating, and performing simple acts of kindness (17 –20). One study incorporated the science of service quality in the development and delivery of a nursing curriculum; however, that study did not examine the benefits of providing basic service quality education to nursing students (21). This article proposes service education content and training methods for front-line staff, developed and implemented as part of a comprehensive service improvement model (22 –24) at Mayo Clinic Arizona (MCA). The manner in which the service education content was tailored, incorporating departments’ service-related data and teaching the science of service quality, contributes to the literature a unique approach to service education for health-care staff in a value-based paradigm. Trainee feedback about the service education experience is included to demonstrate new insights gained and the positive impact on service attitudes. The following service content, approach to service education, and literature-based rationale may be useful to other health-care organizations trying to engage and motivate front-line service staff.

Service Quality Education in a Value-Based Paradigm

Health-care value is increased by improving clinical outcomes, patient safety, and service quality relative to costs (25,26). Most front-line staff understand that treating patients with empathy and respect is the right thing to do and that their service performance affects patient satisfaction. In the new value paradigm, they also need to understand how their service performance affects the organization’s revenue under value-based payment. Front-line staff are likely to be more engaged if they have a deeper understanding of basic service quality principles and personal accountability for service performance (27).

The core topics covered in service quality education are noted below in the order in which they are presented to trainees. Patient experience leaders may use this outline as a starting point to develop their own site-specific service education.

Expectations and Perceptions

Service education begins with an introduction to patient perceptions and expectations. Trainees are presented with many factors that influence patient expectations to help them better manage the service experience. These factors include the organization’s brand (28), recommendations from others, social media, experiences with other service providers, price (29), and advertising (30). Trainees are asked to recall MCA’s current radio and billboard advertising and imagine how those messages could inadvertently heighten patient expectations.

Value Creation

Reframing value as the benefits obtained from a service relative to the financial and nonfinancial burdens endured to obtain it (31) helps staff connect their service attitudes and behaviors to value creation and vicariously experience the patient’s burdens. When asked for examples, trainees acknowledge lost wages, travel, lodging, waiting, fear, and anxiety as likely burdens incurred when seeking health care at a destination medical center.

The Science of Service Quality

Measurement and improvement tools

Trainees are given examples of satisfaction survey questions, as well as an overview of rating scales and the benefits of “top box” (32) satisfaction ratings. The influence of staff service performance on patient perception of quality of care, patient choice, and the financial health of the organization (33) is taught. Department service–related data trends (22) are reviewed and linked to service performance, something within each individual’s control. Opportunities are identified, the Plan–Do–Check–Act cycle is presented, and a high-level process map with satisfaction data noted at key touch points in the experience is offered (23).

Service quality gaps framework

The “gaps model,” a conceptual framework of service quality (10), is introduced to help front-line staff identify the most likely causes of poor service. Four gaps, or deficiencies, related to an organization’s service—gap 1, not understanding customer expectations; gap 2, not designing customer-focused processes and performance standards; gap 3, not hiring, educating, and training the right people; and gap 4, not communicating accurately about services—contribute to a service experience that falls short of expectations (gap 5, the “customer gap”). Trainees are asked for their perspectives on management’s understanding of patient expectations; examples of inefficient processes and nonstandardized work-arounds that impact their performance; reasons for inconsistent service delivery; and opinions on the organization’s current advertising messages relative to its ability to consistently deliver on advertised promises. The importance of their role in communicating upward about service deficiencies to managers who have the authority and resources to improve them is emphasized (34). Trainees apply their knowledge in a flip-chart exercise to assess their department’s customer gap. The ideas generated in this exercise are inputs for a future discussion of the department’s service improvement opportunities.

Touch points

The total patient experience is presented to trainees as a collection of touch points (35), any one of which is an opportunity to “wow” the patient right in front of them. In another exercise, trainees identify points in their workflows at which they can humanize the service experience (36) and suggest ways to make positive, emotional connections that will be remembered (37). The following MCA patient comment is used to illustrate staff’s ability to influence the experience at individual touch points (Emphasis is the patient’s.):

EVERYONE from the Check-in Desk to the nurses to the blood lab people to the doctors ALL are so nice and, as bad as you feel, they help you forget about it and make you feel better. Thank you ALL!!!

Customer delight

Responsiveness, empathy, and assurance—the process dimensions of service—afford the best opportunities for employees to surprise and delight patients (10,11). “Above-and-beyond” service that delights is illustrated with real employee stories—the nurse who gave a haircut to a dermatology patient with an embarrassing scalp lesion; the volunteer coordinator who planned a wedding ceremony so the hospitalized mother of the bride could attend; the nurses who planned an anniversary dinner for a heart failure patient and his wife; the front-door attendant who provided minor automotive service for an elderly woman. Trainees then reflect on their roles and offer ways in which they can step outside their job descriptions to delight a patient with unexpected service.

Service recovery

Inexperienced graduate nurses are quick to label patients “difficult” when inevitable service breakdowns occur. The following scenario, written from a collection of patient comments, illustrates for nurses the “pain points” (38) of a hospitalized patient and promotes timely bedside service recovery when issues arise:By drawing a detailed picture of the loss of control associated with the inpatient experience, new nurses are able to see that it is usually the situation, not the patient, that is difficult. Nurses are encouraged to identify touch points at which they can relinquish control (37) to relieve the patient’s anxiety and enhance the experience.

Imagine that you have been dropped into this very complex system for 3 or 4 days. You do not understand the language. You are anxious. Your clothes have been exchanged for a flimsy hospital gown. You are cold, perhaps in pain. You are dependent on others for everything—even for help going to the bathroom. Your nurse seems overworked and is sometimes abrupt. The mattress is hard and the hall outside your door is noisy at night, so you are not sleeping well. You are awakened every morning at 4 am by a phlebotomist who may or may not access a vein on the first attempt.

Service recovery education includes the Apology–Empathy–Solution framework (39). Scenarios are created from the department’s complaints, making service problems relevant to the learning experience (40) and giving trainees a chance to practice responding to difficult service situations most likely encountered.

Excellent service as a differentiator

Trainees are taught that providing excellent service, even with basic commodity offerings such as diagnostic imaging, can help differentiate an organization. Magnetic resonance imaging (MRI) is used as an example. Consumers may select an MRI provider on the basis of price, insurance coverage, or proximity to home. However, an MRI experience created by a caring and compassionate employee who was hired for service attitude, who assures patient comfort during the procedure, and who understands and genuinely tries to alleviate “MRI-induced anxiety” is not easily duplicated.

Just do its’

Front-line employees know where the bottlenecks and work-arounds are, and they usually know the causes of poor service quality. Service education and training concludes by drawing on Japanese business culture (41). Trainees are encouraged to identify 5 minor service improvement opportunities in their work units, write them down, and present them at their next department meeting.

Education and Training Methodology

Financial and operational challenges may tempt managers to use desktop, web-based methods for service education. However, educating, motivating, and changing behavior are best accomplished with an interactive, face-to-face group format (42), in which trainees are able to role-play, practice new skills, and build confidence. As a high-performing service organization, MCA opted for a targeted, efficient approach to service education that prioritized new employees, departments with low patient satisfaction scores, and entry-level, high-turnover roles, such as medical secretaries and appointment desk staff. In general, staff in these support roles were promoted from within into “higher-level” roles within 1 to 2 years. These employee groups were prioritized for service education to promote consistent service quality as they moved throughout the organization.

Service education was provided by the patient experience administrator, who served as an internal consultant to executive and clinical leaders (43). Department manager and service consultant collaborated prior to the session to set education goals and to discuss department-specific service performance issues. The department manager’s attendance helped communicate to staff the importance of service quality. This participative training style with ample customization added relevance and stimulated interest, as evidenced in this manager’s comment: “Thank you for making the training relevant with department examples. We should do this every year.”

Employee Evaluations of Service Education

Nearly 1500 trainee evaluations from clinical and nonclinical front-line staff attest to good understanding of the content and approach used in the educational sessions. On a 5-point scale ranging from 1 for least effective to 5 for most effective, trainees’ ratings of their understanding of basic service quality concepts ranged from 4.7 to 4.9 (Table 1). Richer verbatim comments give better insight into what resonated and how trainees will use the information in their jobs:These trainee comments indicate enthusiasm for service and a heightened awareness of the importance of front-line service performance. A “train-the-trainer” model was implemented to sustain these positive results and to mitigate the effects of internal staff movement on service quality. One point person in the practice was assigned responsibility for department-level orientation of new medical secretaries and appointment desk staff. The patient experience administrator worked with this individual to ensure appropriate service education content and consistent delivery to these key front-line staff.

Table 1.

Staff Ratings of Service Quality Education and Training.a

Overall Rating of Trainer	I understand how customers judge service quality and the factors influencing perception	I understand the basic behaviors that customers expect in a service provider and can apply them to my job	I understand how excellent service helps to create value, influence customer choice, and sustain the organization	I understand HCAHPSb surveys and how I make a difference	The training was useful and relevant to my work	The overall experience was positive
4.8	4.8	4.8	4.9	4.7	4.7	4.8

aOn a 5-point scale, with 5 being most effective and 1 being least effective, average ratings of Mayo Clinic Arizona’s service quality education and training. N = 1466 trainees.

bHospital Consumer Assessment of Healthcare Providers and Systems.

I will always try to go above service expectations by doing some of the little things that are important to patients.

I will remember that the patient sees everything so pay more attention to details.  I will have more awareness of staff’s impact on patients’ perceptions of quality.  I will remember that I am the face of Mayo Clinic and I influence each patient’s experience.

Lessons Learned

Gap 3, the service-delivery gap, most influences customer perceptions of the experience (44). Service education for front-line staff helps minimize this gap. More than 60 sessions provided over 7 years taught lessons that could help other organizations develop their employees’ knowledge of basic service quality principles, improve front-line customer service skills, and enhance the patient experience.

First, high-performing service organizations need not blanket the workforce with high-level, generic trainings. Efficient and effective service education can be achieved by adopting a targeted approach and by compressing service education into a standing, 1-hour department meeting.

Second, managers and staff appreciated well-conceived, department-specific service education content. Managers were more willing to offer service education if their specific service challenges would be addressed. Designing service education in partnership with the manager allows for customization of content and a positive training experience.

Third, patients today are paying more for their medical care so they have higher service expectations. Service education beyond simple behaviors and catch phrases can give front-line staff the flexibility to perform “above-and-beyond” service, in the moment, to either delight a patient in need or to recover from a service failure.

Conclusion

Front-line employees’ service performance can impact patient satisfaction, likelihood to recommend, and value creation. The use of patient satisfaction data in determining value-based payment has created a need for a different, more in-depth approach to service education and training of front-line staff. Relevant and meaningful service education content delivered in an interactive, face-to-face setting can develop service skills and inspire, motivate, and reinvigorate front-line staff, as evidenced in these trainee comments:Organizations that understand how patients perceive and rate service quality likely will be better able to improve it. Thoughtfully conceived service education content and training methods can give staff the knowledge and tools to satisfy patients, help continuously improve the service experience, keep the organization’s service promises, and help sustain an organization for the future.

Thank you for re-energizing the staff with the tools to care for our patients.

Thank you. We have more excitement to serve.