Stimulating high performance in frontline staff.

During a recent epidemic, I contracted a particularly bad case of erythema infectiosum, or fifth disease.[1] It's caused by the parvovirus B19 pathogen and is the fifth disease in the group of six childhood exanthems. Like most physicians, I am in the habit of minimizing or discounting my own illness. About one week into my attack, I developed severe vertigo and began vomiting without remission. I was so dizzy that I was barely able to walk a straight line. I told my husband, the medical civilian, "I think we'd better go to the emergency department. I feel like I am going to die!" I was quickly bundled into the car for the five-minute ride to the hospital.

What followed was most illuminating, especially since I had just studied service quality in business school. As a patient, my interpretation of events differed so much from my husband's view that I decided to write about my observations.

Creating a positive patient encounter in a medical setting is very complex. When the care is emergent, or high risk, the service encounter is considered even more complex. The reason for the complexity is that customized processes are necessary for problem resolution.

Forty minutes after entering the emergency department as a patient, I was once again fairly comfortable and in control. I had been admitted, gowned, and given an emesis basin. Vital signs had been taken several times. The triage nurse, admitting clerk, and emergency department physician had a chance to finish their tasks. Intravenous hydration and Compazine were quickly ordered. An electrocardiogram and portable chest x-ray were completed and ready for final reading. Blood work was

I thought the service was exemplary. By the time my husband found me, I was feeling well enough to joke. The entire event lasted only 40 minutes. Part of my satisfaction was due to the family-like atmosphere. Doctor friends stopped at my gurney to see me. My feelings made sense. In research on satisfaction, investigators have demonstrated that nontechnical interventions influence assessment of service quality for health care providers as much or more than the technical aspects of the service.[2] My perceptions were conditioned by specific aspects of my own expectations of the emergency department and familiarity with staff.

My husband had a different set of expectations, which resulted in a different experience. Upon arrival, he became unhappy with the staff because I was given no emesis basin while I waited for the triage nurse. I used the wastebasket. Once I was transferred to the treatment area, he was left waiting without staff communication for more than 40 minutes. He made several inquiries about my condition, pressuring the guards for information. Their indifference was apparent. The admitting office, visible from the waiting area, was understaffed. Other equally sick patients waited a long time for the triage nurse. He thought the facilities appeared dirty. A patient, sitting untended in the waiting area, was bleeding from a facial injury. This scenario spells failure at the frontline. There are many potential reasons for frontline failure: improper staffing, inadequate preparation of front-line personnel, and low involvement cultural norms.

In 1988 and 1990, Zeithaml, Parasuraman, and Berry[3,4] described five significant dimensions of service contributing to patient or customer satisfaction. These five dimensions of service are: reliability, tangibles, responsiveness, assurance, and empathy. They developed a marketing model, called SERVQUAL, which measures customer satisfaction by taking a discordance score of categorized expectations and perceptions. A full description of the scored categories can be found in the Sloan Management Review.[5] The model measures a series of responses from the five service dimensions. The cumulative score gives insight into how well a service organization is meeting the expectations of its customers. Reidenbach and Sandifer-Smallwood 1990)[6] and Babakus and Mangold(1992)[7] modified the model for the hospital setting.

Service Industry Safisfaction Measures

Universal to all service industries is the importance of reliability in the service encounter. Issues of staff responsiveness, knowledgeability, and empathy are almost as important. Appearance of facilities and personal grooming patterns, although important, contribute least to the satisfaction score.

In a competitive environment, organizations need to find service "tie-breakers" for success. Understanding components of satisfaction helps in the creation of tie-breakers. In my example, creation of a more family-friendly emergency environment may have served as a tie-breaker, because urban facilities are impersonal places to obtain care.

SERVQUAL is a useful model for measuring how the organization is doing, but the model stops short of telling us how to change our operations to improve service satisfaction. Finding out how we can improve service quality and satisfaction requires understanding of the components of optimal resource allocation. Our primary resources are personnel, time, and capital. An interdisciplinary research team from the University of Southern California plans to study the correlation of patient satisfaction and operational components of patient care delivery systems. In the language of operations management, the operational components of the service encounter are: task, treatment, and tangibles.[8] From a practical standpoint, it is easier to quantify task and tangibles, but more difficult to assess treatment. The reason for difficulty in measuring treatment rests in intangible aspects of treatment process. Ideally, new data will aid managers in design of optimal health care models.

Characteristics of Low involvement

Organizations

Service delivery process cannot be maximized without eliminating problems of low involvement. In the emergency department case, frontline staff demonstrated low involvement by responding indifferently to customer needs. The characteristics of low involvement are summarized in the apathetic attitude that goes with the phrase "not in my job description." Organizational performance is further paralyzed by fear about the consequences of decisions, anxiety over possible job loss, and the normal urge to keep a low profile.

Creating High involvement

Organizations

One of the most important characteristics of high involvement organizations is participation. Decisionmaking takes place throughout the organization, even at the frontline. Individuals must not fear censure when contributing to organizational goals and development. Usually, effective participation requires elimination of hierarchical layers.

In many service organizations, encounter-level staff members feel powerless to change service operations. Lower level concerns are generally ignored. In some organizations, there is no forum for idea interchange with encounter-level staff. Fear of job loss may be warranted. Caring evaporates in this type of environment. At the frontline, the culture of fear or indifference is apparent to customers. Staff members must feel that they have control in order to appear competent at assigned tasks.

Staff involvement requires creativity and extra effort. One institution used fixed-dollar allocations for staff to use on the spot to solve problems, thereby facilitating solutions without frustrating management authorization delays. Employees can be trusted to make more decisions now than in the past. In 1993, Vogl[9] wrote that a positive work environment comes with permitting staff greater decision autonomy and more diverse job experience.

Bowen and Lawler have studied the high involvement organization, publishing their findings in a 1992 paper.[10] They found that less hierarchical organizations have greater opportunities for involvement. In order to alter traditional hierarchical decisionmaking processes, organizations must be prepared for significant changes in structure and culture. The shift from a traditional hierarchy, or top-down decisionmaking, to teams is not easy.

Enrichment of Work Experience

Enrichment of the work experience reduces staff boredom and indifference. Formal education has increased the capabilities of the work force, thus enabling performance of more complex tasks. A more diverse job experience is created by making assignments involving total process participation from beginning to end. Recent techniques, utilizing patient-centered care for hospitalized individuals, demonstrate efforts to create job diversity and involvement. Cross-training and job rotation reduce repetitiveness of certain tasks, potential boredom, burnout, and indifference.

Financial and Other Rewards

As organizations trim staff size and expect more work from fewer people, staff commitment to organizational goals can continue to be stimulated by increased financial recognition tied to performance indicators. Staff members need to feel like partners (owners). Pay-for-performance is just a starting point for an incentive program. Providing other non-financial benefits for employee and family members will contribute to staff loyalty. Adequate pay, personal goalsetting, decisionmaking autonomy, and opportunity for personal development will improve overall job performance.

An organization that motivates staff, delivers on quality expectations of customers, and allows for flexibility in goalsetting will survive the highly competitive health care market. Great technical performance does not replace frontline finesse. My own experience illustrates how much the least skilled worker can influence public perceptions of quality. Receptionists, security guards, and other primary contacts need to learn customer management skills for successful consumer interaction. In health care settings, assignment of skilled nursing personnel for the care of family needs may pay off in better community relations. Whether nonprofessionals or triage nurses fulfill public relations tasks, management may need to lead all frontline staff through role-playing exercises. If staffing is inadequate, cross-trained individuals must be available for periods of peak flow.

Traditionally, health care management has been preoccupied with technical performance and less prepared to invest in job training for nontechnical staff. Clearly stating frontline behavioral expectation reduces problems of role ambiguity for staff.

My perception of service quality was never solicited while I was in the emergency department. Failure to collect survey data represents an opportunity lost. In all probability, the organization described has still not recognized the problem, thereby eliminating opportunity for solution. The impact of emergency department security guard behavior needs to be discussed with them. Guards need opportunities to be trained for frontline duty, so that they may contribute to total patient care. Individuals in all encounter-level positions unable to improve performance, even after training attempts, must be transferred or replaced. Failure to remove poor frontline performers is costly to the organization. Dissatisfied customers speak louder than those who are satisfied with service.

To stimulate high involvement among staff, health care organizations must do the following: * Encourage participation on policy decisions. * Let staff self-evaluate performance. * Base compensation on performance. * Rotate assignments to reduce burnout. * Develop variety within task assignments. * Use technology to improve timeliness of

communication. * Reduce unnecessary hierarchy. * Get staff buy-in for organizational goals. * Identify customers and potential customers

appropriately. * Seek customer evaluation of organizational

performance. * Use customer data to improve performance.

Encounter level individuals need specific training for frontline work. The guard at the gate, the receptionist, or the admitting clerk is a communication link with the customer. Frontline employees must be taught communication skills and encouraged to feel a part of the organization. In any future organizational planning, frontline staff must be given an opportunity to participate in goalsetting.

References

[1.] Erythema infectiosum fifth disease) is characterized by several days of high fever, migratory myalgias and arthralgias, lymphadenopathy, anemia, and the presence of a maculopapular rash that appears as the fever breaks. The rash gradually becomes confluent over several days. Typical of other childhood exanthems, the illness is worse in adults. Weakness and arthralgias may persist for several months following the acute episode. In fact, the post viral syndrome sometimes simulates one of the mixed connective tissue diseases, rheumatoid arthritis, or systemic lupus. Fortunately, symptoms usually abate without sequelae. The disease can also be a cause of infrequent fatal aplastic anemia and for fetal wastage in the pregnant gravida.

[2.] Soliman, A. "Assessing the Quality of Health Care" A consumerist Approach." Healthcare Marketing Quarterly 10(1-2):121-41, Summer-Fall 1992.

[3.] Zeithaml, V., and others. Delivering Quality Service: Balancing Customer Perceptions and Expectations. New York, N.Y.: The Free Press. 1990.

[4] Parasuraman, A., and others. "SERVQUAL: A Multiple Items Scale for Measuring Customer Perceptions of Service Quality." Journal of Retailing 64(1):12-40, Spring 1988.

[5.] Parasuraman, A., and others. "Understanding Customer Expectations of Service." Sloan Management Review 32(3):39-48, Spring 1991.

[6.] Reidenbach, R., and Sandifer-Smallwood, B. "Exploring Perceptions of Hospital Operations by a Modified SERVQUAL Approach." Journal of Health Care Marketing 10(4):47-55, Dec. 1990.

[7.] Babakus, E., and Mangold, W.G., "Adapting the SERVQUAL to Hospital Services: An Empirical Investigation." Health Services Research 26(6):767-86, Feb. 1992.

[8.] Chase, R., and others. "Project Title: Improving Service Quality in Healthcare." Unpublished grant proposal, National Science Foundation Announcement No. 94-30/08/08/94, University of Southern California, School of Business Administration, Los Angeles.

[9.] Vogl, A. "Bureaucracy Busting." Across the Board 30(2):23-27, March 1993.

[10.] Bowen, D., and Lawler, E. "The empowerment of Service Workers: What, Why, How, and When." Sloan Management Review 3(3):31-9, Spring 1992.