HUMRES-00523; No of Pages 13

Human Resource Management Review xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Human Resource Management Review

journal homepage: www.elsevier.com/locate/humres

When the customer is the patient: Lessons from healthcare

research on patient satisfaction and service quality ratings☆
Timothy J. Vogus a,⁎, Laura E. McClelland b
a
Owen Graduate School of Management, Vanderbilt University, 401 21st Avenue South, Nashville, TN 37203, United States
b
Department of Health Administration, Virginia Commonwealth University, 1008 E. Clay St., PO Box 980203, Richmond, VA 23298, United States

a r t i c l e i n f o a b s t r a c t

Available online xxxx As customer satisfaction and service quality have become increasingly important, management
scholars have developed an impressive body of research regarding their antecedents. However,
Keywords: important gaps remain regarding satisfaction in diverse populations, better specifying practices
Patient satisfaction and mechanisms, and the forms and effects of co-production practices. Oft-overlooked health
Healthcare services research on patient satisfaction and experience provides evidence of how the sector man-
Measurement ages the extreme complexity, co-production, and intangibility of health care delivery where the
Service quality financial and human consequences of low quality are high. Consequently, health care organiza-
tions, out of necessity, have developed specific practices to manage complexity and diversity
(cultural competence and relational work systems), intangibility (compassion practices), and
co-production (patient-centered care) to customize care and improve patient satisfaction and ser-
vice quality. We also discuss the interpersonal processes (e.g., empathic communication) by
which they do so. Then, we briefly explore unique temporal dynamics of care delivery and its mea-
surement over time, and conclude with implications for future research on customer satisfaction
and service quality (e.g., novel practices in health care as natural experiments) and patient satis-
faction and service quality (e.g., building on management research to examine the effects of lead-
ership, service climate, and emotional labor).
© 2015 Elsevier Inc. All rights reserved.

Customer experience is an increasingly important topic due to macro-changes in industry composition in the developed world
(i.e., more service work, less manufacturing work) and technological advances that allow consumers to make their assessments im-
mediately and widely known (e.g., social media like Yelp!, Facebook, and Twitter). More generally, services possess three interrelated
characteristics that make them especially worthy of inquiry by organizational scholars including — 1) the complexity arising from and
the diversity and unpredictability of customer needs and timing of those needs (Argote, 1982), 2) the difficulty of evaluating service
quality due to its inherent intangibility, and 3) the need to co-produce services with customers (Bowen & Schneider, 1988).
Fortunately, research on customer experience provides insights into how to manage the unique challenges of service delivery
(Bowen & Schneider, 2014). In addition to the broad and multi-faceted work on services in marketing research, there are two active
and vibrant literatures in the management literature on customer service and its effects on customer experience — a micro-literature
on emotional labor or how individuals manage emotional regulation, including expressions (surface acting) and perceptions and feel-
ings (deep acting) (Grandey, 2000; Hülsheger & Schewe, 2011). There is also a macro-literature on service climate — the shared sense
of service quality and the practices which foster it (Hong, Liao, Hu, & Jiang, 2013). The literature on service climate typically examines

☆ We would like to thank Special Issue Editor Doug Pugh and the two anonymous reviewers for a set of constructive, specific, and thoughtful comments that sig-
nificantly improved the contribution and quality of our manuscript.
⁎ Corresponding author.
E-mail addresses: timothy.vogus@owen.vanderbilt.edu (T.J. Vogus), lemcclelland@vcu.edu (L.E. McClelland).

http://dx.doi.org/10.1016/j.hrmr.2015.09.005
1053-4822/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
2 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx

leader characteristics (e.g., service-focused leadership, Schneider, Ehrhart, Mayer, Saltz, & Niles-Jolly, 2005), leader behaviors
(e.g., empowering others, Martin, Liao, & Campbell-Bush, 2013), and bundles of high-performance work practices (e.g., empower-
ment, extensive training, rigorous selection) occasionally with a service-specific focus (Chuang & Liao, 2010; Subramony & Pugh,
2015). These antecedents influence customer perceptions through service climate (Hong et al., 2013 for a review and meta-
analysis), with the “strength” of the service climate (Schneider, Salvaggio, & Subirats, 2002) enhancing the effects. Service climate
itself shapes other behaviors that are associated with customer experience outcomes including employee capabilities (i.e., human
capital, Haber & Reichel, 2007; Van Iddekinge et al., 2009), responsiveness (Grandey, Goldberg, & Pugh, 2011), and customer-
focused discretionary effort (Martin et al., 2013). Despite this substantial progress, important gaps remain in the literature. First,
emerging evidence suggests that community demographics affect the employee–customer relationship (Brief, Butz, & Deitch,
2005), but there has been limited empirical examination of how organizations manage a diverse customer base and the resulting cus-
tomer experience (Subramony & Pugh, 2015). Recent research also finds that customer satisfaction measures may be systematically
biased (Hekman et al., 2010). Second, research on customer experience consistently finds that “concern for customers” and high per-
formance work practices are associated with higher ratings of customer experience, but the practices and underlying mechanisms by
which they do so are imprecise. Third, although there is an active literature on co-production in marketing and services research, there
is comparatively little management research. Specifically, there are interesting anecdotes and examples of how organizations use spe-
cific management practices to engage in co-production with their customers (Bowen & Pugh, 2009), however, there is a relative pau-
city of management research regarding the use of specific practices and their consequences.
We turn to a parallel literature on patient satisfaction and service quality experience from health services research to help fill some
of the identified gaps in the organizational behavior and human resource management literatures. Health services research may be
especially useful because healthcare organizations experience acute challenges of complexity, co-production, and service intangibility.
The heightened conditions in healthcare organizations can be useful for theoretical development as well as providing a potential lead-
ing indicator of how to cope with challenging conditions (Eisenhardt & Graebner, 2007; Farjoun & Starbuck, 2007).
Healthcare delivery is irreducibly complex because human disease is inherently complex and may manifest itself differently across
patients. Even when the diagnosis is apparent, the best course of treatment may not be (Nembhard, Alexander, Hoff, & Ramanujam,
2009). The demographic heterogeneity of patients amplifies the complexity (Sofaer & Firminger, 2005). Healthcare professionals can
provide the same service, but the patient may experience it differently as a function of their current condition. Thus, high quality care
is highly customized care; it is based in an intimate and particular understanding of the patient (Benner, Tanner, & Chesla, 1996).
There is also extreme knowledge asymmetry between provider and patient due to the highly educated, professionalized, and special-
ized healthcare workforce. The knowledge gap is often exacerbated by the emotionality and vulnerability felt by patients and their
families as they cope with health problems and managing complex disease processes (Dempsey, McConville, Wojciechowski, &
Drain, 2014). Yet providers are also highly reliant on information from the individual patient. These conditions necessitate making
care delivery more tangible, often by engaging patients and their families in the co-production of the care. Co-producing care is par-
ticularly difficult though due to the history of medicine that has privileged the interests of the provider (Abbott, 1991, 1993;
Nembhard et al., 2009) over the interests and preferences of the patient.
Healthcare presents two additional and unique challenges to achieving high customer satisfaction and service quality. First,
the potential consequences for the patient (i.e., customer) and, recently, the organization (i.e. hospitals and other healthcare delivery
settings,) are qualitatively different in healthcare. Care delivery carries with it a high risk for harm from services performed relative to
other industries. The cost of failure is much greater in terms of patient injury and in some cases death, especially for vulnerable pop-
ulations (i.e., young, old, chronically ill, minorities, and lower socio-economic status patients, Sofaer & Firminger, 2005). Healthcare is
also delivered under high regulatory scrutiny that, recently, began linking payment to delivering what patients perceive to be a high-
quality experience (Federal Register, 2011). Second, care delivery may unfold over a longer time horizon than other service encoun-
ters, and satisfaction with the care experience influences patients' willingness to participate in their care and comply with the treat-
ment plans (e.g., go to follow-up appointments, take medication). Both participation and compliance influence subsequent health
outcomes (Golin, DiMatteo, & Gelberg, 1996; Sofaer & Firminger, 2005).
The difficult conditions in healthcare delivery have led these organizations to adopt and implement specific practices to ensure a
high quality patient experience by carefully customizing and tailoring care to patients' unique needs. To address the heightened com-
plexity and diversity of patients and their conditions, healthcare organizations implemented practices like relational work systems to
ensure cross-boundary coordination (Gittell, Seidner, & Wimbush, 2010), and cultural competency (Weech-Maldonado et al., 2012)
to provide customized care to diverse populations. Relatedly, there has been an industry-wide effort to develop a better, more action-
able, and unbiased set of measures of patient experience known as the Consumer Assessment of Healthcare Providers and Systems
(CAHPS, (Elliott, Edwards, Angeles, Hambarsoomians, & Hays, 2005; Elliott, Kanouse, Edwards, & Hilborne, 2009a, Elliott et al.,
2009b; Giordano, Elliott, Goldstein, Lehrman et al., 2010; Goldstein, Farquhar, Crofton, Darby, & Garfinkel, 2005). Given the multiple
forms of suffering that characterize care delivery for patients and those who treat them (Dempsey et al., 2014), healthcare organiza-
tions have also moved beyond “concern for customer” (Burke, Borucki, & Hurley, 1992) to implement specific compassion practices to
make the care process more tangible and increase the amount, clarity, empathy, and quality of communication with patients (Lown,
Rosen, & Marttila, 2011). Lastly, some healthcare organizations have implemented macro-practices that radically restructure care
through co-production known as patient-centered care (Rathert, Wyrwich, & Boren, 2013), as well as micro-practices like bedside re-
ports (i.e., care transitions between providers occur with the patient as participants, Gregory, Tan, Tilrico, Edwardson, & Gamm, 2014).
The purpose of this paper is to highlight how findings from research in the challenging healthcare context may help fill important
gaps in research on customer satisfaction and service quality ratings in other industries. To do so, we explore sets of practices and
processes implemented in healthcare to address the service challenges of complexity (cultural competence, relational work systems,

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx 3

and CAHPS), intangibility (compassion practices and communication processes), and co-production (patient-centered care and relat-
ed innovations), respectively. Next, we briefly explore the unique temporal dynamics of care delivery and its measurement over time.
We conclude with a discussion of how current innovations in health care (new organizational forms, leadership roles, and incentives)
provide natural experiments for developing new insights, and how health services research can benefit from more fully incorporating
mechanisms (leadership, service climate, and emotional labor) from management research on customer satisfaction and service
quality.

1. Managing complexity and diversity

When organizations serve diverse populations, it matters who provides the service. Prior research established the importance
of community demography to organizational climate and intraorganizational conflict (Pugh, Dietz, & Wiley, 2008). Consequently, re-
searchers have posited that diverse employees may be particularly effective in serving similarly diverse populations (Richard, 2000)
for three reasons — 1) matching the community diversity in its own workforce provides a “service clue” (Berry, Wall, & Carbone, 2006)
that grants access to and legitimacy with those markets and constituent groups (Ely & Thomas, 2001, p. 243), 2) lacking demographic
representativeness signals reluctance by the organization to be inclusive (Pugh et al., 2008), and 3) they bring a unique cultural sen-
sitivity that better serves customers (Cox & Blake, 1991). However, there has been limited testing of these ideas with respect to cus-
tomer demographic characteristics (Bowen & Schneider, 2014; Subramony & Pugh, 2015). A small set of recent studies though does
test the representativeness argument and finds that when the demography of an organization is representative of the community it
serves, customers report experiencing higher levels of civility (King et al., 2011). The degree to which organizational demography was
representative of community demography was positively related to civility experienced by customers, customer satisfaction, and even
overall productivity (Avery, McKay, Tonidandel, & Volpone, 2012; King et al., 2011). Although the emerging evidence suggests repre-
sentativeness enhances customer satisfaction, others argue it is not a sustainable strategy. “[I]t's not a question of having Black people
selling to Black people. You have to have people who understand those markets. Short run efforts may match people up Black to Black.
In the long run, the best person to service a segment may not match ethnically” (quoted in Kelly, 1996, p. 34). In other words, provid-
ing individuals with the tools to work with dissimilar others and structuring the contact (Pettigrew & Tropp, 2006) can perhaps pro-
duce the greater cultural sensitivity Cox and Blake (1991) hypothesize is essential.
In healthcare, representativeness is a problematic strategy because there are well documented and longstanding shortages for
skilled caregivers (e.g., Buerhaus, 2008), and frequently changing team composition (Klein, Ziegert, Knight, & Xiao, 2006). In addition,
demographics are increasingly influential in healthcare because regulators, accreditors, and specific policy initiatives highlight the im-
portance of equal access to high quality care (Institute of Medicine, 2002; U.S. Department of Health and Human Services, 2011).
Persistent discrepancies in the patient experience across demographic lines pose significant service challenges. The abbreviated
review in this paragraph reflects the most consistent findings regarding the patient demographics that influence patient satisfac-
tion and service quality as well as other healthcare disparities. In general, older (Jackson, Chamberlin, & Kroenke, 2001; Nguyen
Thi, Briancon, Empereur, & Guillemin, 2002; Sofaer & Firminger, 2005), Caucasian (e.g., Elliott et al., 2010; Lehrman et al., 2010;
Young, Meterko, & Desai, 2000), healthier (Cleary et al., 1991; Jackson et al., 2001; Nguyen Thi et al., 2002; Weech-Maldonado,
Morales, Spritzer, Elliott, & Hays, 2001; Young et al., 2000), educated (Hekkert, Cihangir, Kleefstra, van den Berg, & Kool, 2009), English
speaking (Weech-Maldonado et al., 2001), and not poor (Cleary et al., 1991) patients in the U.S. tend to be more satisfied with their
care, especially inpatient care (i.e., patients admitted to a hospital versus patients seeing a doctor in a clinic). Patient characteristics
that create barriers to high quality care such as limited access/not having a regular provider, no insurance, and speaking a language
other than English, all negatively impact patient satisfaction and service quality ratings (Seid, Stevens, & Varni, 2003; Weech-
Maldonado et al., 2001). Some researchers suggest that lower ratings of care by minority patients is suggestive not of differences in
patients as a function of race, but in how they are treated (higher incidence of racism) and having less access to care. Researchers
also suggest these patients receive care in hospitals that are lower in technical quality and are geographically concentrated in areas
heavily populated by minorities (Weech-Maldonado et al., 2001), and have potentially different cultural expectations (Sofaer &
Firminger, 2005) that then negatively affect care ratings. Just as patient demographics matter, so too do regional demographics. Pre-
vious research shows that patients in rural hospitals tend to be more satisfied with inpatient care (Jha, Orav, Zheng, & Epstein, 2008;
Young et al., 2000), and patients in the northeast and central regions of the U.S. are less satisfied than patients out west or in the south
(Jha et al., 2008; Young et al., 2000). As a whole, these findings have motivated the development and implementation of innovative
practices and measures to address them.

1.1. Cultural competency

To respond to the challenges of an increasingly heterogeneous patient population, hospitals and other healthcare organizations
have moved beyond demographic matching and invested in practices tailoring service for diverse populations. These practices are
commonly known as the organization's “cultural competency.” Cultural competency reflects the institutionalization of policies and
practices that ensure a nuanced understanding of the needs of the population served so care can be better customized, training
staff to be culturally competent (i.e., knowledgeable of specific cultural practices and norms), and readily providing interpreters
and translation services (Weech-Maldonado et al., 2012). Cultural competency provides the infrastructure for cross-cultural interac-
tions across a range of sociocultural factors. Recent research has found that cultural competency affects a number of dimensions of the
patient care experience for all patients including more positive ratings of communication with doctors, overall hospital rating, and
willingness to recommend the hospital to others (Weech-Maldonado et al., 2012). Cultural competency also enhanced the care

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
4 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx

experience overall for nonwhite patients. These patients reported better staff responsiveness, quietness of patient rooms, and pain
control (Weech-Maldonado et al., 2012). In particular, cultural competency benefits nonwhite patients by improving nurse commu-
nication. This is especially noteworthy because nurse communication is the strongest indicator of patients' overall assessments of
their care (Elliott et al., 2009a; Elliott et al., 2009b; Kutney-Lee et al., 2009). Furthermore, the quality of communication between care-
giver and patient is critical to the patient's health. Improved communication means nurses have better information to tailor the care
based on an intimate and particular understanding of the patient (Benner et al., 1996). In addition, cultural competency helps ensure
that patients better understand the treatment plan and their role in executing it (i.e., medication dosing instructions, symptom man-
agement, and self-care practices).

1.2. From satisfaction to experience measures

Management research on measures of customer satisfaction suggests that they may systematically suffer from rater biases
(Hekman et al., 2010). Specifically, Hekman et al. (2010) find that customer satisfaction judgments of minority and female service em-
ployees are discriminatory. They post that it is partly a function of anonymous judgments by untrained raters that typically solicit
summary opinions and attitudes (Schneider et al., 2005). This has led to calls for using objective measures of customer behavior
(Subramony & Pugh, 2015).
The same complex confluence of factors that contribute to patient expectations, also make global assessments of patient satisfac-
tion prone to bias and difficult to interpret. These factors, coupled with looming payment reform, inspired health services research,
practitioners, and regulators to move away from traditional measures of satisfaction (Sofaer & Firminger, 2005) to a more comprehen-
sive, objective, and fine-grained set of measures of patient experience (Sofaer & Firminger, 2005). The move to more refined measures
of patient experience is important because it conveys more nuance regarding the precise nature of the patient's experience and the
specific aspects of the care they receive from their provider. In doing so, experience measures provide a clearer basis for actionable
improvements that simultaneously guide managers to more focused interventions, and researchers to better identify the mechanisms
by which organizational practices and processes influence aspects of the patient experience (Jenkinson, Coulter, & Bruster, 2002). In
parallel, there have been efforts to tailor measures to specific treatments, medical devices, or health care delivery contexts such as the
emergency department (Burstin et al., 1999), oncology (Brédart et al., 1999), and outpatient clinical practices (Choong, 1999).
The Agency for Healthcare Research and Quality (AHRQ), in partnership with the Centers for Medicare and Medicaid (CMS) and
the CAHPS research collaborative, developed a series of standardized instruments that were extensively developed, piloted, and tested
(Elliott et al., 2005; Elliott et al., 2009a; Elliott et al., 2009b; Giordano, Elliott, Goldstein, Lehrman, & Spencer, 2010; Goldstein et al.,
2005). This series of instruments reflects a set of core questions, as well as questions that differ by instrument as a function of the
care delivery setting (i.e., Nursing Home CAHPS, HCAHPS for hospitals, CG-CAHPS for clinic/outpatient settings). The CAHPS instru-
ments examine the following core domains of care—nurse and physician communication (e.g., regarding medicine) and interactions
(e.g., respect shown for patient), staff responsiveness/timeliness of care, and overall quality ratings including provider ratings and the
likelihood of recommending the facility.
In addition to standardizing patient experience ratings with CAHPS, this initiative also provided greater insight into factors that
predict how patients experience their care. It has enabled scholars to readily account for confounding factors such as patient demo-
graphic characteristics (e.g., patient age, education) over which hospitals have little control. As a result, all hospital CAHPS data
(HCAHPS) are patient-mix adjusted so that hospitals and the public have a more accurate and comparable picture of patient percep-
tions of the care experience and care quality. In addition to patient-mix adjustments, the CAHPS surveys also adjust for mode of ad-
ministration (i.e., telephone versus mail), to account for previously identified systematic differences in ratings (Elliott et al., 2009a;
Elliott et al., 2009b).
In 2007, CMS required that most hospitals administer the HCAHPS survey to its discharged patients or be subject to a congressio-
nally mandated payment reduction (Centers for Medicare and Medicaid, 2014). The HCAHPS data were then made publicly available
through CMS' Hospital Compare website (Giordano et al., 2010). This enables patients to access care quality ratings and choose their
care provider based on these publicly reported care ratings. Public reporting of ratings may influence a hospital's market share in mar-
kets where patients have a choice in care providers. Easier comparisons, combined with CMS' 2013 introduction of the Value-Based
Purchasing (VBP) initiative, substantially intensified the direct financial impact of patient service quality ratings. VBP provides finan-
cial incentives/penalties to hospitals based on their performance scores of how patients rate their care experience on the HCAHPS
instrument (Federal Register, 2011). How well patients experience care now directly affects CMS' reimbursement of hospital charges.
The CAHPS approach is an especially useful step forward with utility for management scholars because it outlines an approach for
developing, standardizing, and validating a set of metrics for industry level assessments of customer experience. The mandated col-
lection of CAHPS and the public dissemination of its data through Hospital Compare allows for meaningful comparisons across orga-
nizations and, over time, a more cumulative body of research. Overall, the healthcare industry's development and implementation of
HCAHPS suggests a model for industry-based measures of customer experience, and the importance of oft-overlooked exogenous fac-
tors in shaping them (Bowen & Schneider, 2014).

1.3. Relational work systems

An impressive of body of research on high-performance work practices, including multiple meta-analyses (Combs, Liu, Hall, &
Ketchen, 2006; Jiang, Lepak, Hu, & Baer, 2012; Subramony, 2009), consistently finds that these practices are positively associated
with organizational performance, especially for operational performance outcomes like customer satisfaction and service quality

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx 5

(Crook, Todd, Combs, Woehr, & Ketchen, 2011). The relationship between high-performance work practices and performance be-
comes reciprocal over time. High-performance work practices are associated with better performance, which in turn allows for
strengthening of the practices (Shin & Konrad, in press). The effects of high-performance work practices on customer service are
strongest for the employees who have the greatest degree of customer contact and responsibilities for their needs (i.e., frontline em-
ployees, Dietz, Pugh, & Wiley, 2004; Liao & Chuang, 2004).
High-performance work practices are thought to operate by signaling what the organization values, supports, and rewards, there-
by influencing how employees then relate to customers (Pugh, Dietz, Wiley, & Brooks, 2002). For example, using rigorous practices to
select for higher levels of human capital (Van Iddekinge et al., 2009), extensive training to build employee human capital (Crook et al.,
2011), or making employees feel more engaged in serving customers (Salanova, Agut, & Peiró, 2005) are all associated with customer
satisfaction and service quality. A small set of studies has focused on a more fine-grained set of high-performance work practices such
as the extent to which specific aspects of service delivery were emphasized in training (e.g., providing quick service, introducing cus-
tomers to menu items and ingredients, being sensitive to customers' individual needs and wants). These practices were associated
with perceptions of service climate and customer satisfaction and service quality (Chuang & Liao, 2010; Liao & Chuang, 2004).
Prior health services research has linked organizational characteristics including size (Jha et al., 2008; Young et al., 2000), for-profit
status (Jha et al., 2008), condition of patient room (i.e., cleanliness), and efficacy and efficiency of hospital routines (e.g., informed con-
sent, admission, discharge, and post-discharge training and follow-up processes) with patient satisfaction and service quality ratings
(Bendall-Lyon & Powers, 2004; Jackson et al., 2001; Kennedy, Craig, Wetsel, Reimels, & Wright, 2013; Mira, Tomás, Virtudes-Pérez,
Nebot, & Rodríguez-Marín, 2009). More recent research in healthcare organizations linked high-performance work practices with pa-
tient satisfaction and service quality ratings (e.g., Weinberg, Avgar, Sugrue, & Cooney-Miner, 2013).
A key form of complexity in healthcare is the recurring need for cross-boundary coordination during a care episode. Consequently,
healthcare organizations require practices to manage smooth coordination across subunit and professional divides (e.g., among
doctors, nurses, physical therapists, and social workers) because patients experience a system of care, not just a specific caregiver
or even a caregiving unit (Nembhard et al., 2009). The nature of care delivery has given rise to a novel form of a high performance
work system — the relational work system (Gittell et al., 2010). Relational work systems consist of an integrated bundle of cross-
functional practices related to conflict resolution, performance measurement, boundary spanner roles, selection, and flexible job de-
sign (Gittell et al., 2010). Taken together, these practices prioritize care and interprofessional coordination such that the care delivery
system is able to be more responsive to the individualized needs of patients and their families. The relational work system yields
higher levels of patient satisfaction through relational coordination. Relational coordination is the combination of frequent, timely, ac-
curate, and problem-solving communication between healthcare professionals (and across professions) with relationships character-
ized by shared knowledge, shared goals, and mutual respect (Gittell, 2002). Specifically, in a study of hip and knee arthroplasty
patients (knee and hip replacement), higher levels of relational coordination were not only associated with important patient out-
comes such as lower post-operative pain, improved functioning and shortened hospitals stays, but also higher levels of overall satis-
faction with care (Gittell et al., 2000). Gittell (2002) found that the effect of relational coordination on patient satisfaction was
strengthened when task interdependence, operational uncertainty, and time-constraints were all high. Relational coordination re-
search also provides a useful example of how health services research can be incorporated into management research. Mayer,
Ehrhart, and Schneider (2009) fruitfully use relational coordination to theorize why interdependence should moderate the relation-
ship between service climate and customer satisfaction. More research of this type is warranted.

2. Making service tangible through compassion practices and empathic communication

As we noted above when discussing high-performance work practices, customer satisfaction and service quality are thought to be
a function of an organization's “concern for employees” and “concern for customers” (Burke et al., 1992). Subsequent research has
broadly validated the idea that the importance management places on service is associated with service climate, patient satisfaction,
and service quality (Borucki & Burke, 1999; Johnson, 1996; Schmit & Allscheid, 1995). However, these high level appraisals lack the
necessary specificity to implement in practice.
Healthcare research has focused concern for employees and concern for patients more directly on alleviating suffering, and in
doing so made the corresponding practices and processes more explicit, and the experience more tangible. Multiple forms of suffering
are endemic to care delivery. They include physical pain and discomfort from the diagnosed condition (i.e., nausea, pain, fatigue, and
other physical symptoms), the discomfort caused by the provision of medical care itself to improve the condition (i.e., medication side
effects, pain caused by procedure such as surgical site pain), adverse effects, disruptions to one's life, and the effects of the hospital
environment that exposes patients to incessant loud noises, a lack of privacy, awakenings in the middle of the night, and frequent ex-
aminations by strangers (Dempsey et al., 2014). Care providers also experience workplace suffering due to their extended exposure to
patient suffering and their vulnerability to compassion fatigue and burnout, which can hinder the intimate and particular understand-
ing of a patient needed to provide high-quality care (Benner et al., 1996).
To that end, healthcare organizations have developed and implemented compassion practices that allow caregivers to detect and
respond to the unique suffering patients and their families experience (i.e., concern for patients), and encourage providers to treat
them accordingly (Lown et al., 2011; Von Dietze & Orb, 2000). Prior work finds that organizational practices can foster compassion
by enhancing the degree to which an organization and its employees notice, feel, and respond to workplace suffering (Dutton,
Worline, Frost, & Lilius, 2006; Lilius, Worline, Dutton, Kanov, & Maitlis, 2011). Specifically, compassion practices - recognizing and re-
warding compassionate acts by caregivers and compassionately supporting caregivers in coping with the stresses and traumas expe-
rienced at work (McClelland & Vogus, 2014), create conditions where caregivers can more effectively detect and respond to suffering.

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
6 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx

Recognizing and rewarding compassionate acts makes caregivers more likely to establish a connection with their patients (Kahn,
1998) that enables them to sense when patients are “off” or “not themselves” (Lilius et al., 2011), and customize their treatment ac-
cordingly. Such personalized care elicits satisfaction with the caregiving experience (Innis, Bikaunieks, Petryshen, Zellermeyer, &
Ciccarelli, 2004; Wolosin, Ayala, & Fulton, 2012).
In addition, compassion practices reflect a concern for employees by supporting caregivers through stress and trauma, and in so
doing, ameliorate the compassion fatigue resulting from absorbing others' suffering (Figley, 1995). For example, compassion practices
like the Cleveland Clinic's “Code Lavender” team's respond to employees in need of emotional and spiritual support at work (Gregoire,
2013), and provide a forum for processing their emotions (Kahn, 2005). These practices increase psychological engagement (Kahn,
1990) and connection to the organization (Lilius et al., 2008), making caregivers more likely to extend compassionate behavior to pa-
tients and their families (Abendroth & Flannery, 2006; Fowler & Christakis, 2010). McClelland and Vogus (2014) find that compassion
practices are associated with more positive service quality ratings with patients rating the care quality higher and being more likely to
recommend the hospital. Although compassion practices help to create contexts that facilitate more customized treatment, they do
not guarantee it. Thus, specific interpersonal processes are needed to ensure patient satisfaction and service quality.
The unique combination of a highly emotional and consequential context with a sizable gap between patient and provider under-
standing of a patient's medical care means patient satisfaction and service quality ratings are often determined by the more tangible
experience of the amount, content, and form of communication provided to them (Fogarty, Curbow, Wingard, McDonnell, &
Somerfield, 1999). First, patients are both more satisfied with their care and rate it more highly when they receive clearer and
more detailed communication about their treatment process (i.e., the amount of communication). Research consistently shows
that when patients receive adequate communication from nurses (Bendall-Lyon & Powers, 2004; Elliott et al., 2009a; Elliott et al.,
2009b; Kutney-Lee et al., 2009), physicians, interns, surgical teams, even admissions staff (Bendall-Lyon & Powers, 2004), they are
more satisfied with their care or rate it more favorably. Clearly communicating details regarding what to expect during and after
an episode of care predicts high satisfaction, whether it be wait times (Bendall-Lyon & Powers, 2004; Sun et al., 2000) or more patient
specific information including test results, their diagnosis, or post-care instructions like follow-up visits, conditions under which a pa-
tient should go to the ED, and when to resume normal activities (Jackson et al., 2001; Shaw, Zaia, Pransky, Winters, & Patterson, 2005;
Sun et al., 2000). These behaviors can include activities such as sitting down with the patient to show interest, positioning oneself to
make eye contact with the patient, and presenting information slowly, repeated often, and conveyed using a “teach-back” method to
ensure understanding (Dempsey et al., 2014).
Second, research finds that patients are both more satisfied and rate their care more highly when they perceive care providers and
support staff treat them with courtesy, take their problems seriously (Shaw et al., 2005; Thiedke, 2007), respect their patient prefer-
ences, values, and needs (Jenkinson, Coulter, Bruster, Richards, & Chandola, 2002; Rathert, Williams, McCaughey, & Ishqaidef, 2012),
and care for each of them as a whole person rather than as just a patient (Boudreaux, Ary, Mandry, & McCabe, 2000), or just a disease
state (e.g., the liver transplant in room 100, Wen, 2014). Caring for the whole person includes care provider behaviors that attend to
the physical symptoms as well as provide emotional support. Consequently, when healthcare professionals display compassion and
empathy, patients are less anxious (Fogarty et al., 1999), have better health outcomes (Hojat et al., 2011), and they rate their patient
satisfaction and service quality more highly (Anderson, Barbara, & Feldman, 2007; DiMatteo, Taranta, Friedman, & Prince, 1980). Spe-
cifically, the displays of empathy include perspective taking, and attempts to understand how recommended treatment plans fit with
patients' lifestyles in order to customize them accordingly. Customizing care might also include doctors taking the time to get to know
a patient as an individual by asking questions about the nature of patients' work when discussing their treatment plan for their acute
back pain (Shaw et al., 2005). This customized care approach is associated with higher patient satisfaction ratings (Shaw et al., 2005).
Such personalized care also affects patient satisfaction ratings in the ED, where patients were more satisfied with their care when they
rated the quality of their interactions with the ED provider highly (Boudreaux & O'Hea, 2004). In contrast, when patients perceive low
quality communication (feeling rushed, never receiving explanations for tests, and being ignored) from a doctor, it was associated
with higher levels of malpractice claims (Hickson et al., 1994).

3. Co-producing service delivery

One of the especially challenging conditions for providing service is that it heavily relies on co-production. To date, however, co-
production has received scant attention in the management literature (Ryan & Ployhart, 2003; Subramony & Pugh, 2015). There is
anecdotal evidence though that many organizations are experimenting with novel approaches to co-production. For example, General
Electric is known for inviting customers to their training facility for employees at Crotonville (Ulrich & Brockbank, 2005) while
PeopleSoft tied individual compensation to customer satisfaction (Bowen & Pugh, 2009). In both cases, the idea is to involve cus-
tomers as partners in designing, co-producing, staying involved with the services they consume, and creating value (Bowen &
Pugh, 2009). Thus, organizations seek to select, train, and reward customers as “partial employees” (Bowen & Schneider, 1988).
The complexity and intangibility of healthcare delivery means that healthcare organizations must engage in co-production to en-
sure that they have the contextualized information to deliver high-quality care. However, as we noted in the introduction, there are
historical barriers to co-production including the fact that care delivery has historically been provider-centered rather than patient-
centered. Inspired by a report by the Institute of Medicine calling for patient-centered care (Institute of Medicine, 2001), there
have been substantial innovations in patient-centered care (Rathert et al., 2013) like bedside reporting (i.e., including patients during
transitions between care providers, Gregory et al., 2014), provider training (Stang & Wong, 2014), and safety vigilance (Schwappach,
2010).

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx 7

Patient-centered care represents a transformation in philosophy and work organization as a means to improve care quality. It
differs from a more general concern for customers because it fundamentally rethinks power dynamics and priorities in care delivery,
and translates that new focus into new work practices. Philosophically, patient-centered care puts the patient as the source of control
in the healthcare delivery system (Institute of Medicine, 2001). That substantial ideological shift accompanies a simultaneous change
in work organization that means moving beyond standardized protocols to actually tailoring care to more specific needs (Sofaer &
Firminger, 2005). Patient-centered care requires greater involvement of patients in decisions, increased patient and provider commu-
nication, formally including family members as part of the care team, and respecting specific patient preferences, values, and needs
(Rathert et al., 2013). Overall, patient-centered care increases patient voice on a wide array of issues, ranging from mealtimes to treat-
ment regimens, that were previously the exclusive purview of care providers (Avgar, Givan, & Liu, 2011). The extensive input from the
patient allows doctors, nurses, and staff to have a personalized knowledge of the patient including their health beliefs. It also allows
caregivers to anticipate and attend to the patient's emotional and physical needs (Rathert et al., 2013). In doing so, it works to manage
complexity of care delivery and to tangibilize the service for patients and their families. Patient-centered care also means that doctors,
nurses, and staff need to be able to exercise discretion to act upon the personalized knowledge they receive, and this discretion is often
paired with high-performance work practices or relational work systems (Avgar et al., 2011). Consequently, patient-centered care has
been positively associated with overall patient satisfaction (Rathert et al., 2012) as well as patient service quality (Avgar et al., 2011).
Patient-centeredness is most effective when patients are informed decision makers in their care (Rathert et al., 2013). Granting
patients and their family members' agency and choice during the care process makes the care more patient-centered and satisfying
to patients and families (Rathert et al., 2012). When doctors display less dominant communication styles, (Buller & Buller, 1987),
and give their patients and family members meaningful voice by encouraging them to express their concerns and ideas, patients
rate their care more favorably (Cecil & Killeen, 1997). Similarly, when patients feel that staff respond to their unique needs (Sun
et al., 2000), whether they be related to physical comfort (Jenkinson et al., 2002a, Jenkinson et al., 2002b; Rathert et al., 2012), use
of bathroom facilities (Elliott, Elliott et al., 2009a; Elliott et al., 2009b), or pain management (Jha et al., 2008), they evaluate their
care experience more favorably (Jenkinson et al., 2002a, Jenkinson et al., 2002b; Jha et al., 2008).
Patient-centered healthcare organizations also incorporate patients and their families in three additional specific ways to improve
satisfaction and service quality. First, bedside reporting (i.e., during a shift change, a nurse transitions a patient's care to an incoming
nurse at the patient's bedside rather than outside the patient's room) fosters greater and more engaged communication by allowing
patients and their families greater opportunity to ask questions, share information about medical history, and participate in the
decision-making process during care team member transitions (Gregory et al., 2014). Twenty-five studies report improved patient-
centeredness as a result of implementing bedside reporting (Gregory et al., 2014). Second, patients are increasingly incorporated
into medical training by having actual patients tell their stories and interact directly with learners and other care providers through
formal patient family advisory programs (Halm, Sabo, & Rudiger, 2006). Such interventions both have an emotional impact and help
tangibilize the experience of caregiving (Stang & Wong, 2014). Lastly, there has been significant growth in initiatives to involve pa-
tients and their families to ensure the safe co-production of care (Schwappach, 2010). Such efforts intend to capitalize on the fact
that patients are the only individuals physically present during every consultation and treatment (Schwappach, 2010). They have
valuable insights and contextualized information and are highly motivated to decrease the risk of harm and ensure good outcomes
(Lyons, 2007). When these patient family advisory efforts focus on incidents that are preventable and conform to more traditional
roles (e.g., ensuring accurate transmission of information, asking health care workers to sanitize hands after being briefed on its im-
portance), they are more likely to be effective (Schwappach, 2010). As such, these more specific initiatives observed in health care
organizations may be helpful in more precisely specifying forms of employee and organizational adaptation to customer needs
(Day & Montgomery, 1999; Gwinner, Bitner, Brown, & Kumar, 2005).

4. The role of time and temporal conditions in the patient experience

Recent reviews of the customer satisfaction and service quality literature have called for more longitudinal work to explore the
evolution of customer service over time and the role of timing in customer satisfaction and service quality (e.g., Subramony &
Pugh, 2015). The lingering effects of patient satisfaction and service quality loom large in healthcare because courses of illness unfold
over time and often require patients to adhere to a course of treatment and engage in other follow-up activities. Creating a positive
experience can make adherence more likely (Sofaer & Firminger, 2005). Given the potentially urgent and life-threatening nature of
care delivery and the inseparability of service and customer, timeliness of care delivery plays a critical role in the patient experience
(Berry, Seiders, & Grewal, 2002; Berry & Seltman, 2008). There have been multiple novel practices put in place to manage patient ex-
pectations of timing as well as proactive interventions to ensure patients' needs are met.
Patient expectations regarding timing of care intervention shape their satisfaction and ratings of service quality. For instance, in
outpatient settings, patient satisfaction is more strongly influenced by the subjective (Berry et al., 2002) or perceived waiting times
rather than actual wait time (Boudreaux & O'Hea, 2004; Jensen, Ammentorp, & Kofoed, 2010; Lin et al., 2001; Thiedke, 2007). More-
over, perceived wait time is often inflated relative to actual wait time and anchored to what a patient perceives as a “reasonable” wait.
As a result, healthcare organizations are increasingly trying to manage patient's expectations regarding expected wait times in order
to shape their expectations to be more aligned with the actual wait times. For example, Emergency Departments (EDs) that discuss
and update patients regarding expected waits have less dissatisfied patients than those who do not (Sun et al., 2000). More recently,
EDs have also started displaying current wait times on their websites and on billboards in order to attract patients (Xie & Youash,
2011).

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
8 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx

Healthcare organizations have implemented hourly rounding – intentionally and proactively checking on patients at regular inter-
vals to address basic needs such as bathroom, positioning, pain control, and proximity of personal items (Mitchell, Trotta, Lavenberg, &
Umscheid, 2014) – to meet expectations for high-quality and timely care. Specifically, hourly rounding is intended to address what is
known as “help uncertainty.” Patients worry that no one will be able to respond to their needs causing them to feel anxious and en-
gage in inappropriate coping mechanisms (pressing the call button for minor issues, getting up to go to the bathroom when they are
especially frail, Mitchell et al., 2014). Halm et al. (2006) finds that hourly rounding reduced call light use and increased patient satis-
faction. In fact, in 9 of 11 studies of hourly rounding, researchers found improvement in patient satisfaction as well as objective mea-
sures of service quality (substantial reductions in call light use and patient falls, Mitchell et al., 2014). These efforts help to mitigate
intense vulnerability patients experience during their care.
In outpatient settings, the length of time a doctor spends with a patient is positively related to patient satisfaction (Bendall-Lyon &
Powers, 2004; Cecil & Killeen, 1997), and even more so when the amount of time spent is greater than was expected (Jensen et al.,
2010; Lin et al., 2001). This suggests that patients use physician time spent as a proxy for the quality of care they receive. Patients con-
sider outpatient visits to be a “time-investment service” (Berry et al., 2002) that has higher perceived value the longer the time spent
in the service transaction with a physician. As a result, doctors often feel rushed (Lin et al., 2001), and doctors with higher volume
practices have less satisfied patients (Zyzanski, Stange, Langa, & Flocke, 1998). Thus efforts to preserve the time allocated to patient
contact by “strategic core” employees like doctors should be especially valuable (Delery & Shaw, 2001).
Lastly, research on patient satisfaction suggests that it is affected by the timing of measurement, confirming the need for additional
longitudinal studies of customer satisfaction and service quality (Subramony & Pugh, 2015). Some research suggests that patient sat-
isfaction declines over time (Savage & Armstrong, 1990) while other studies suggest it increases (Jackson et al., 2001), and patients'
evolving health status may play a role in moderating these results (Crow et al., 2002). In fact, the determinants of patient satisfaction
shift over time, with research showing that immediately following care, the affective experience or interaction between patient and
care provider is the strongest predictor of patient satisfaction (Boudreaux & O'Hea, 2004; Sofaer & Firminger, 2005). Over time though,
health status and symptom resolution become the stronger predictors of patient satisfaction (Jackson et al., 2001).

5. Discussion and conclusion

Management research on customer satisfaction and service quality is impressive and cohering (Bowen & Schneider, 2014). How-
ever, amidst this impressive growth, important gaps remain. We marshaled health services research to help illustrate how organiza-
tions facing high complexity, intangibility, and co-production, coupled with high consequences and extended service episodes, have
coped with these challenges. Health services research provides insight into how to resolve issues associated with customer diversity
(through cultural competence), coordination across professional and organizational boundaries (through relational work systems),
making the care delivery process more tangible (through compassion practices), rethinking care delivery to facilitate co-production
(through patient-centered care), and how these specific practices elicit high levels of satisfaction and service quality. The careful de-
velopment of CAHPS in healthcare also provides a model for creating measures of customer experience that are more behavioral and
less prone to bias (Hekman et al., 2010). Thus, these measures and practices merit further application, examination, and refinement in
non-healthcare settings. As such, we turn to some potential questions next, then discuss how healthcare work might generalize, and
then explore how three recent innovations in healthcare might provide opportunities for advancing our understanding of customer
experience and service quality more broadly. We close with implications from management research for health services research.

5.1. Future research opportunities

Consistent with the majority of the health services research reviewed, we explored the interventions and practices separately.
There are excellent examples though of researchers exploring and finding complementarities among practices. Avgar et al. (2011)
find complementarities between patient-centered care and high-performance work practices that benefit the organization and its
employees. The interactions among the practices merit further exploration. We also echo recent calls for longitudinal studies of cus-
tomer satisfaction (e.g., Subramony & Pugh, 2015) because health services research suggests that timing of service and the timing of
measurement matter to ratings of patient satisfaction and service quality. Furthermore, it seems that the effects observed in
healthcare would be especially useful for understanding service relationships where the provider has special expertise and the rela-
tionship is likely to be longer lasting such as with professional service firms (e.g., auditing firms or consulting firms).

5.2. Generalizability of healthcare research

But do we expect findings from healthcare to generalize? We argue they do because they addresses general problems of service
delivery (complexity, co-production, and intangibility), and prior research suggests cross-industry support for factors like relational
work systems (Gittell, 2003) and high-performance work systems (e.g., Subramony, 2009). However, we would expect the findings
from healthcare to most easily and fully generalize to contexts where expectations of the service experience resemble healthcare —
complex services where there is potentially significant information asymmetry between customer and service provider (e.g., auto re-
pair, consulting, or law). There is also suggestive evidence from rigorous case studies that compassion practices may also be useful for
explaining customer ratings and service quality across sectors ranging from billing departments (Lilius et al., 2011) to business schools
(Dutton et al., 2006). This suggests that practices that reward and support compassionate acts may be a foundation for satisfaction and
service quality, but further quantitative confirmation is needed.

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx 9

5.3. Healthcare as laboratory for examining novel practices

Significant recent changes in healthcare delivery (e.g., the Patient Protection and Affordable Care Act), organization (new roles like
Chief Patient Experience Officers), and payment (VBP), provide a set of natural experiments through which researchers can fill gaps in
understanding customer service more broadly.
The Patient Protection and Affordable Care Act introduced an innovative organizational form – the Accountable Care Organization
(ACO) – as a way of simultaneously reducing cost while improving quality (i.e., patent experience) and population health. ACOs tie
provider reimbursements to quality metrics, and reduce the cost of care for a designated population of patients (e.g., patients with
chronic conditions such as diabetes). To realize these benefits, physician practices, hospitals, and outpatient facilities must collaborate
and coordinate to deliver the care (Barnes, Unruh, Chukmaitov, & van Ginneken, 2014). Thus, ACOs offer a novel context for under-
standing the drivers of customer experience, and whether and how established practices like relational work systems, leader behav-
ior, and service climate operate (or don't) and affect patient experience and service quality when service episodes cross organizational
boundaries. It also raises questions of how leaders simultaneously manage the competing priorities explicitly espoused by ACOs (cost
control, population health, and service quality), and when and how they make tradeoffs. Some research suggests it is possible to si-
multaneously achieve multiple objectives (Glickman et al., 2010; Mitchell et al., 2014), but further work is needed.
With additional external pressures to improve the patient experience and service quality, healthcare organizations began creating
Chief Patient Experience Officer roles, occasionally even bringing in executives from other industries to fill them (e.g., Paul Westbrook
from Ritz-Carlton, Rabin, 2014). Anecdotally, these new positions have led to new practices at the Cleveland Clinic (training all 3000
staff physicians in listening skills, letting the patient set the agenda, and organizing the encounter; showing doctors all their feedback
from patient surveys), and MedStar Washington Hospital Center (reallocating nursing time and how care is delivered to allow for
hourly rounding and sitting with each patient for several minutes during rounding, Rabin, 2014). In health services as well as man-
agement research, there has been relatively little work on the adoption of high-performance work practices (see Baron, Burton, &
Hannan, 1996; Pil & MacDuffie, 1996 for exceptions). A new executive role with a distinct domain of focus might be an exogenous
shock that triggers the adoption of new service-oriented practices shown to affect the patient and employee experience (Bowen &
Pugh, 2009). Do new formal positions actually increase the focus on patient experience relative to other priorities? Do they matter
for performance on CAHPS over time? Lastly, do early adopters look different and experience different effects than late adopters of
the role? Prior research on hospitals suggests early adopters of total quality management more fully implemented the practice,
whereas later adopters implemented the practice more superficially for impression management purposes (Westphal, Gulati, &
Shortell, 1997).
CAHPS and VBP provide a natural experiment to observe and assess the effects of linking service outcomes more directly to finan-
cial outcomes. The policy changes have also intended to increase managerial attention to customer experience and induce adoption
and implementation of new customer experience-oriented technologies and practices. Therefore future research should explore the
consequences of policy changes on attention, practices, technologies, and the effects on customer experience over time. Healthcare is a
useful context in which to study these effects, but there are also implications for service delivery more broadly. For example, the emer-
gence of social media applications, like Yelp!, constitutes another potential link between service experience and financial outcomes
that may affect managerial action, organizational practices, and customer outcomes.

5.4. Implications for healthcare research

Management research on customer service and service quality also offers three specific factors that can significantly advance
health services research on the antecedents of patient experience ratings — leadership (e.g., servant leadership), service climate,
and emotional labor.

5.4.1. Leadership
Although leadership has been extensively studied in health services research (see Gilmartin & D'Aunno, 2007 for a review), there
has been very little empirical work that considers the effects of leaders' characteristics or behaviors on patient satisfaction and service
quality. One promising direction is examining servant leadership or prioritizing the needs of others above their own and demonstrat-
ing behavioral integrity (Liden, Wayne, Zhao, & Henderson, 2008). Servant leadership cascades through an organization by creating
“behavioral norms and shared expectations of placing a priority on helping others” (Cooke & Rousseau, 1988 p. 255), and the help
can take many forms ranging from emotional support to technical advice. In a recent study of restaurants, servant leadership was as-
sociated with both improved customer service and employee and restaurant performance (Liden, Wayne, Liao, & Meuser, 2014). More
specifically, putting customers' needs ahead of their own was associated with a stronger serving culture (that viewed customers as
members of the organization), greater identification with the organization, and higher levels of customer service behaviors (Liden
et al., 2014).
Servant leadership should be consequential in healthcare because putting others first is at the core of the medical and nursing pro-
fessions. Consequently, servant leader approaches are likely to resonate with care providers by reaffirming the purpose of their work
by reconnecting them with the beneficiaries of their work (Grant et al., 2007). Future research should examine the linkages between
servant leadership and outcomes (patient satisfaction and service quality) as well as the mechanisms by which it works (e.g., prosocial
motivation, Grant et al., 2007).

Please cite this article as: Vogus, T.J., & McClelland, L.E., When the customer is the patient: Lessons from healthcare research on patient
satisfaction and service quality ratings, Human Resource Management Review (2015), http://dx.doi.org/10.1016/j.hrmr.2015.09.005
10 T.J. Vogus, L.E. McClelland / Human Resource Management Review xxx (2015) xxx–xxx

5.4.2. Service climate

Extensive research on the consequences of service climate reveals it influences customer satisfaction and service quality (Hong
et al., 2013). However, service climate has been largely absent from the research on patient satisfaction and service quality in health
services research. This is a significant omission because the relationship between service climate and customer satisfaction and service
quality should be especially strong in healthcare because it is a non-routine, personal (Brown & Lam, 2008), and “pure” (i.e., high in-
tangibility and reliant on extensive interaction, Dietz et al., 2004) service. Thus, service climate should be an important mechanism
underlying the relationship between the practices identified in our review (cultural competence, compassion practices, patient-
centered care, and relational work systems) and patient satisfaction and service quality. Future research should explore service
climate as well as whether its effects are attenuated in more routine, impersonal, and less pure variants of health care delivery
(e.g., “minute clinics” that primarily provide services like flu shots). Studying service climate in healthcare organizations would
also be useful for advancing management research on service climate. Specifically, service climate has typically been studied
among frontline employees, but in healthcare delivery what constitutes the frontline is more varied and interdependent (i.e., doctors,
nurses, and other staff must coordinate care), and organizations like hospitals are loosely coupled (Weick, 1976). When service deliv-
ery requires the effort of individuals from multiple professions, under what conditions (e.g., organizational practices) does service cli-
mate become shared?

5.4.3. Emotional labor

There is an impressive set of empirical studies that investigate emotional labor as a micro-foundation of customer satisfaction and
service quality (see Hülsheger & Schewe, 2011 for a recent meta-analysis). Emotional labor has at its core the emotion regulation or
the process of managing expressions and feelings. Emotional labor follows one of two strategies. Deep acting, which is associated with
positive effects on customer satisfaction and employee outcomes (Hülsheger & Schewe, 2011), entails changing the situation or the
perception of a situation to affect the processing of emotional cues in an attempt to align required and true feelings (Grandey,
2000). Surface acting is emotion regulation in response to an emotion that has already developed by managing emotional expression.
Unfortunately, with the exception of nursing scholarship exploring its effects on burnout, health services research has largely ignored
its importance. It especially seems worth exploring the relationships between the four sets of practices reviewed and the form of emo-
tional labor that follows, and the downstream consequences for patient satisfaction and service quality. Specifically, practices like
compassion practices should produce patient satisfaction and service quality in part because they foster healthy emotion regulation
at work and create more opportunities to experience authentic positive emotions during work (Hülsheger & Schewe, 2011).
In conclusion, the literatures on customer and patient experience have grown largely in parallel. We have argued that manage-
ment research can potentially resolve ongoing problems resulting from the complexity, intangibility, and co-production that often
constitute service work by theoretically incorporating and empirically investigating factors identified in health services research.
Health services findings may also prove useful in environments with high magnitude consequences of service work, and/or in envi-
ronments in which a longer time horizon over which service quality unfolds. These difficult conditions in healthcare delivery have led
these organizations to adopt and implement specific practices (e.g., cultural competency, relational work systems, compassion prac-
tices, and patient-centered care) to ensure a high quality patient experience by carefully customizing and tailoring care to patients'
unique needs. Healthcare continues to produce innovations with novel implications for management research (e.g., ACOs) and man-
agement research can constructively inform health services research by bringing in, for example, service climate. We hope that we
motivate greater collaboration between health services and management researchers so the important work continues in tandem
rather than in parallel.

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