Addressing Service Recovery Practice With Radiation Oncology Frontline Managers: A Project Brief.

The relationship between patient satisfaction, care compliance, and treatment outcomes suggests patients who report dissatisfaction perceive receipt of suboptimal care. Patient satisfaction plays a role in defining quality of care, affecting institutional reimbursement and reputation capital. Using an explanatory sequential mixed methodology approach, this study explored frontline management's role in effective service recovery, actively addressing instances of patient dissatisfaction to improve the overall patient experience. A survey of frontline managers, document and artifact reviews, and probing interviews identify the importance of consistent performance measurement, feedback, and frequent leadership training on the relevance and importance of service recovery.

Introduction

Patient satisfaction is an important measure of health care quality (1). The link between patient satisfaction, cancer care compliance, and treatment outcomes suggests patients reporting dissatisfaction are more likely to perceive receipt of suboptimal disease management (2 –4). Patient satisfaction also plays a role in determining a hospital’s competitive position, with satisfied patients more likely to return and offer positive word-of-mouth endorsements (5,6).

Management’s investment in service recovery positively impacts patient satisfaction (7). Service recovery strategically addresses patient dissatisfaction through active intervention, salvaging the experience (7,8). While other studies have examined the impact of employee rewards, customer service training, and customer service orientation on service recovery in various public and private sector health care arenas (7 –9), this has been unexamined in radiation oncology. This project is the first to look specifically at the frontline managers’ knowledge, motivation, and organizational influence factors in radiation oncology, offering added patient-focused value within the discipline.

In 2019, the Radiation Oncology department at a large northeast comprehensive cancer center committed to implementing a service recovery strategy that addressed any patient dissatisfaction experiences. Service recovery best practice ensures that patient needs and expectations meet regulatory and practice standards, such as meeting their emotional needs, reducing wait-times, and providing coordinated care (2). The department leadership established this goal after reviewing low-percentile patient satisfaction scores spanning several years, despite maintaining outstanding patient care outcomes, decreasing morbidity, and expanding services.

This study’s stakeholders are the frontline management team that ensures compliance with actions that impact patient experience and satisfaction. Compliance with critical activities like efficient patient scheduling, effective communication before and during care, invoking remedial action for poor service, and displaying a caring demeanor is critical to the patient’s feelings of quality engagement. Failure to consistently meet these expectations negatively impacts patient satisfaction, leading to adverse reporting on patient satisfaction surveys, solidifying the project aims to evaluate the effectiveness of service recovery within the stakeholder group.

Methods

Using an explanatory sequential mixed methods design, a pilot sample of participants was asked to complete qualitative and quantitative measures to assess current service recovery knowledge and practice.

This pilot population consisted of full-time managers who supervise the practitioners that provide radiation oncology treatment delivery across practice disciplines. A survey consisting of Likert scale items to assess service recovery attitudes and practices was completed and analyzed descriptively in Qualtrics. Trends identified in the quantitative data were used to inform the domains of the qualitative interview guide. Participants were resampled to complete a 30-minute semi-structured interview with the study’s qualitative methods specialist. Interviews occurred via phone or in-person and explored service recovery best practice knowledge, motivations, and organizational practice influences. Interviews were audio-recorded and transcribed verbatim for analysis. Two independent coders participated in line-by-line coding using NVivo v. 12.0 to identify major thematic content. Key documents and artifacts related to service recovery training, preparation, and implementation were also collected and analyzed to uncover thematic trends. Analysis of the survey, interview data, and documents and artifacts were guided by the 3 domains described by Clark and Estes’s KMO framework that assesses the knowledge, motivation, and organizational influences in problem assessment (10). A review of the separate data sources before triangulation offered a perspective that deepened the understanding of this study’s service recovery experience.

Results

Twelve of 15 eligible managers participated in the survey (80% response rate), and 11 completed the qualitative interview (73.3% completion rate). Survey results and an overview of qualitative themes are described in Tables 1 and 2. Of the 11 interview participants, 5 were (45.5%) female, and 6 were (54.5%) male. Interviewed managers worked in disciplines ranging from radiation therapy (45.5%), to administrative (27.3%), to others such as nursing (27.3%). Thirty-three documents and artifacts were reviewed, including meetings and personal notes, departmental service recovery policies and procedures, and staff education materials. Detailed in the following sections, analysis of staff knowledge, motivation, and organizational influence across each data set uncovered new perspectives on service recovery trends and practice.

Table 1.

Selected Frontline Manager Survey Questions and Findings (n = 12).

Demographics	N (%)
I am employed as a _____
Therapy Managers/Supervisor	6 (50)
Administrative Manager/Supervisor	4 (33.3)
Other Manager/Supervisor	2 (16.7)
I have worked for ____ years in my current position.
0-1.99	4 (33.3)
2-3.99	2 (16.7)
4-5.99	3 (25)
6+	3 (25)
Service Recovery Questions	n (%)
Service recovery training has prepared me to address patients when they are not satisfied with their care.
Strongly agree	3 (25)
Agree	3 (25)
Somewhat agree	5 (41.7)
Neither	0
Somewhat disagree	0
Disagree	1 (8.3)
Strongly disagree	0
I can fully identify the steps required in the service recovery protocols.
Strongly agree	2 (16.7)
Agree	4 (33.3)
Somewhat agree	5 (41.7)
Neither	0
Somewhat disagree	0
Disagree	1 (8.3)
Strongly disagree	0
Department of Radiation Oncology promotes an action-oriented commitment to gain expected results by taking on difficult challenges with urgency when invoking service recovery.
Strongly agree	6 (50)
Agree	4 (33.3)
Somewhat agree	2 (16.7)
Neither	0
Somewhat disagree	0
Disagree	0
Strongly disagree	0
Department of Radiation Oncology promotes an action-oriented commitment to gain expected results by taking on difficult challenges with enthusiasm when invoking service recovery.
Strongly agree	5 (41.7)
Agree	5 (41.7)
Somewhat agree	2 (16.6)
Neither	0
Somewhat disagree	0
Disagree	0
Strongly disagree	0
Department of Radiation Oncology provides adequate resources to ensure staff development to facilitate consistent service recovery delivery.
Extremely adequate	2 (16.7)
Moderately adequate	4 (33.3)
Slightly adequate	2 (16.7)
Neither	1 (8.3)
Slightly inadequate	2 (16.7)
Moderately inadequate	1 (8.3)
Extremely inadequate	0
Department of Radiation Oncology provides adequate resources to ensure information transfer to facilitate consistent service
Extremely adequate	0
Moderately adequate	9 (75)
Slightly adequate	0
Neither	2 (16.7)
Slightly inadequate	1 (8.3)
Moderately inadequate	0
Extremely inadequate	0
Department of Radiation Oncology provides adequate resources to ensure timely feedback to facilitate consistent service recovery delivery.
Extremely adequate	2 (16.7)
Moderately adequate	6 (50)
Slightly adequate	2 (16.7)
Neither	0
Slightly inadequate	1 (8.3)
Moderately inadequate	1 (8.3)
Extremely inadequate	0

Table 2.

Frontline Manager Qualitative Interview Overall Results and Findings.

Category	Codes	Themes
Knowledge Influence	Criteria for Success Definition of service recovery Connection to patient Satisfaction Policy and Procedures	Participants had similar definitions of service recovery, centered on the patient experience. Most participants correctly understood the department’s policies and procedures for service recovery, with a few exceptions. While immediate outcomes for service recovery were well understood, long-term goals of service recovery were unclear.
Motivation Influence	Personal motivations Extrinsic motivations Staff interest Staff receptivity to feedback	The desire to facilitate a positive experience for patients was a high internal motivating factor. Department emphasis on service recovery and job expectations served as a form of external motivation. Staff were generally receptive to service recovery, but successful onboarding and tactful follow-up are key.
Organizational Influence	Expectations and Importance Feasibility of 24-hour period 3-star threshold Need for support Staffing challenges	Participants perceive that the department has high expectations for service recovery. Participants understand the rationale for the 24-hour follow-up but have difficulty meeting this expectation. Participants pushed back against the expectation that they carry out service recovery after a 3-star review. High expectations increase call volume: Staffing support is needed to meet department expectations.

Knowledge

All 12 survey respondents appreciated a link between service recovery and patient engagement. The frontline managers in the study felt prepared by training on the importance of service recovery. Fourteen instances of coded responses in documents and artifacts, such as the policy document and education materials, supported clear expectations framing around service recovery. In the survey, 11 (91.7%) respondents agreed that they could identify the required steps in the service recovery protocol. This finding aligned with the interviews and found that most managers (90.9%) had similar service recovery definitions centered on improving the patient experience. With some exceptions, most of the mangers correctly understood the department’s overall policies and procedures for service recovery. However, frontline managers had less confidence in identifying when it was appropriate to initiate service recovery correctly; 6 respondents agreed or strongly agreed with the statement with 5 somewhat agreed. In interviews, most frontline managers explained that while they could identify general trigger points for service recovery, their confidence in initiating service recovery in complex situations was less definite.

Motivation

One hundred percent of survey respondents understood the level of impact that their patient engagement has on the effectiveness of their service recovery actions. This strongly affirmative response shows confidence in the connection between the perceived caliber of their interventions and service recovery. This was further supported in the interviews when most managers (63.6%) stated that their desire to facilitate a positive experience for patients was a high internal motivating factor. Some (36.4%) managers also noted the department’s emphasis and expectations for service recovery were an external motivational factor to complete service recovery. The survey asked participants the degree to which they ask patients follow-up questions about the source of dissatisfaction, netting a broad array of responses. Three noted that they always followed up with patients, 5 noted that they often engaged patients, and 3 noted that they sometimes performed this patient engagement. Further, one indicated that they never probed patients on their dissatisfaction.

Managers perceived that their staff was generally motivated to perform service recovery. However, they noted that frontline and clinical staff could sometimes become defensive when feedback is passed along after a service recovery call. For instance, some participants indicated that the staff felt frustrated when dealing with a patient in person and did not perceive a need for the issue to be relitigated on a service recovery intervention call.

Organizational Influence

All 12 survey respondents generally agreed that their department promoted an action-oriented commitment to gain expected results when invoking service recovery, by taking on difficult challenges with urgency (Table 1). This is supported by our qualitative findings, which found that managers understood the rationale for the departmental expectation of performing service recovery within 24 hours. Still, over half (54.5%) said they had difficulty meeting this expectation. The interviews also uncovered that additional staff support (81.2%) and training/regular feedback (72.7%) is needed to meet the department expectations. This is further supported by the document and artifacts review, which found that information and training were only provided to the managers at the beginning of the project and did not provide consistent and meaningful feedback.

Discussion

While Boshoff and Allen (11) identified how critical gaps in service recovery knowledge, motivation, and organization impedes service staff’s ability to meet department standards, the literature is silent on similar applications in radiation oncology. Using a mixed methods design, this study identified practices that would have been difficult to uncover from closed-ended surveys or in-depth interviews alone. Conducting interviews after analyzing the survey data facilitated deeper probing into the managers’ practice motivation and organizational influences. This study revealed several areas needing mitigation to achieve service recovery goals. Knowledge baseline challenges require focused training and practice opportunities. Supporting staff motivation and offering continuous communication improvement between frontline managers, staff, and leadership is critical. Uncovered variations in patient follow-up suggest a need to reengage the frontline manager staff to standardize performance. Organizationally, greater consistency in offering feedback and redirection to the staff is needed to promote staff engagement. The organizational culture and variations in practice impede the delivery of the service recovery interventions within 24 hours. An action-oriented commitment to service recovery beyond initial training, such as dedicated time for service recovery calls, consistent feedback, and adequate staffing is required to fulfill this task. Addressing these areas of need will facilitate improved service recovery performance, establishing a sustainable consistency pathway.

Limitations

We have identified the following limitations: The frontline managers in radiation oncology are a finite and tightly knit group of professionals; data validity and reliability reside in their openness and honesty in their communication. Also, the anonymity of the findings limited direct follow-up with addressing any specific challenges to an individual stakeholder.