The ability to receive critical healthcare for rural areas is crucial because people live in isolated regions (Thompson et al., 2019; Ruiz-Pérez et al., 2019). What can be even more challenging is when much of the population suffers from economic poverty (Palozzi, Schettini, and Chirico, 2020). This reduces an individual’s ability to receive the valued healthcare that they need promptly.
Native American communities found in Montana reservations with the federally funded Indian Health Service (IHS) fall within the category of rural healthcare systems (Estradé et al., 2020). In many cases, low-level satisfaction results from a disconnect in what patients look for in the service compared to what a clinic has determined to be the appropriate service.
Since 2008, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has offered a valid standard comparison tool for satisfaction criteria collection and reporting (Giordano et al., 2010; Dorothea et al., 2011). Figure 1 presents a CMS report comparing patient satisfactionwith their healthcare on the Blackfeet Indian Reservation with the state of Montana and nationally (Medicare, 2020).
The report shows lower levels of satisfaction in the Blackfeet Nation than state and national averages. Communities such as the one on the Blackfeet Reservation can benefit from changes that could improve patient satisfaction and increase their health services’ quality.
Patient satisfaction or dissatisfaction is associated with the Service Quality Gap (SQG), which is the difference between what patients expect from a service and their perception of the service they received (Oliver, 1980; Oliver, 1993). Figure 2 depicts the patient-provider interaction that could lead to SQG. The figure is based on the Service Quality Gap Model (Parasuraman et al., 1985; Seth et al., 2005).
The SQG starts with a patient having a concern or a need. The patient then chooses a healthcare provider according to past experiences, word of mouth, or simply because that is the only provider available (Fitzsimmons and Fitzsimmons, 2011; Hageman et al., 2015, Ungureanu and Mocean; 2015, Roe, 2013). According to the SQG Model (Fig. 2), there are many opportunities in which gaps or divergences could occur. For instance, Gap 1 focuses on a misalignment between patients’ expectations from the service and what the provider thinks the patient expects. Gap 2 identifies what healthcare providers think patients expect versus what they think patients need (which could differ in their expert opinion).
The Design Gap (Gap 3) focuses on how staffing, operations, processes, layout, and patient and information flow are designed to provide the best healthcare service possible. It also includes the physical surroundings, ambient, decorations, and cleanliness of the location. The Service Delivery Gap or Service Encounter Gap (Gap 4) is related to the human resources aspect, such as friendliness, responsiveness, empathy, inclusivity, and employee thoughtfulness.
These four gaps combine to influence patients’ service experiences and their perception of the quality of a service (Parasuraman, Zeithaml, V., and Berry, 1988; Mohebifar et al., 2016; Mehrotra and Bhartiya, 2020). The difference between expected service and the perception of the service received creates the Service Quality Gap. Therefore, minimizing the first four gaps can increase patients’ satisfaction levels at a facility while still allowing the healthcare staff to provide the needed services (Mohebifar et al., 2016). By doing so, there is potential for improvement of the patient’s experience in their local clinics. This, in turn, could improve the satisfaction rating of the facility, which is standardized and reported not only for public use but for accreditation and reimbursement purposes (Shaffer and Tuttas, 2008).
The literature shows evidence of healthcare providers using HCAHPS or other types of surveys to improve their customer service (Otani et al., 2009; Smith et al., 2014; Al-Abri and Al-Balushi, 2014; Thiels et al., 2016; Levin et al., 2017; Wallace et al., 2018; Findlay et al., 2019; Lynch et al., 2020). However, many of the reported cases appear to react to survey results as improvements are made only after services have been provided and measured.
In retrospect, this approach can still leave a SQG that needs to be addressed and service design can take a long time to align with patient expectations. With the ability to bring forward what each party values in their services, the ability to meet needs and expectations satisfactorily becomes more viable prior to the visit and leads to a proactive approach.
On the other hand, relying too heavily on satisfaction surveys could lead to poor healthcare practices since providers would be focusing too much on what patients want to achieve higher scores (Junewicz and Youngner, 2015). This implies that “patient wants” need to be considered but only concerning what the healthcare staff can do to treat patients effectively (patient wants vs. patient needs; Gap 2). This balance between designing for patients’ expectations versus effective care can be difficult to assess through post-service surveys such as HCAHPS. It is important to include patient feedback when designing or re-designing a process. Baker (2001) maintains that patients want to be part of the healthcare process; listening to their voice before they receive service is an important dimension of a Patient-and Family-Centered Care (PFCC) approach to healthcare design and improvement (Stichler, 2012; Berghout, van Exel, Leensvaart, and Cramm, 2015). In fact, it is one of the eight dimensions of PFCC (Berghout, van Exel, Leensvaart, & Cramm, 2015) which is essential to any health provider, but in particular, for those in isolated regions (Thompson et al., 2019) like the one on the Blackfeet Indian Reservation. From the results presented in Fig. 1, it was important to investigate why the Native American community in Browning, Montana has lower HCAHPS overall scores than state and nation averages.
Weidmer-Ocampo et al. (2009) adapted CAHPS and surveyed a Native American population in Oklahoma. Interviews were conducted with a small group of patients to ensure the survey's cognitive understanding was developed. Afterward, the survey was distributed via mail one week after their visit to assess their satisfaction with the healthcare facility. Their results were successful in providing meaningful direction to improve patient satisfaction of the service. While Weidmer-Ocampo et al. (2009) assessed a Native American population, service expectations were not assessed prior to the visit to allow patients to have a voice in the re-design or improvement process. It was assumed that the CAHPS assessed patient expectations.
This research study explored if the services provided at a Blackfeet outpatient clinic are designed to care for the patient and meet the expectations patients anticipate. The research focused on the first two gaps of the SQG model to uncover potential misalignments between patient and healthcare provider service expectations in the Blackfeet Indian Reservation clinic. Staff and patients interviews and surveys allowed service expectations to be assessed according to the clinic’s ability to meet those expectations.