saurabh verma final report
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A Research Project Report
ON
“A study of Service Quality & Customer Satisfaction in Health Care System”
SUBMITTED FOR
APPROVAL FOR COUNDUCT OF RESEARCH PROJECT REPORT
FOR
PARTIAL FULFILLMENT OF THE DEGREE OF MASTER OF BUSINESS ADMINISTRATION FROM
U.P. TECHNICAL UNIVERSITY, LUCKNOW
Batch (2008-10)
UNDER THE GUIDENCE OF: SUBMITTED BY:
Dr. Neeraj Saxena Saurabh Verma ( Director ) M.B.A. IV Sem. Roll no- 0801670063
SUBMITTED TO:
DEPARTEMENT OF BUSINESS ADMINISTRATION
RAKSHPAL BAHADUR MANAGEMENT INSTITUTE
BAREILLY (U.P.)
ACKNOWLEDGMENT
This report incorporates the contribution of many people and without their support
this work would not have come in completion.
So I would like to extend my immense ineptness to all of them who have guided
and motivated me throughout my winter training project. I sincerely thank to all of
them for their valuable contribution without which this project report would have
not reached its goals.
I sincerely wish to acknowledge a deep sense of gratitude to Mr. Abhijeet Das
(Assistant Director RBMI) for giving me this opportunity & to be my supervisor &
guiding my dissertational project to fruitful result.
I am indeed grateful to respected Dr. Neeraj Saxena (Director) for their valuable
support & guidance throughout the research project.
DATE:
(Saurabh Verma)
PREFACE
As markets are Dynamic in nature, so does marketing. Marketing is no longer a
company department consists of a limited number of tasks, managing advertising,
sending out direct mail, finding sales leads, providing customer services, building
relationship with distributors and retailers. Marketing must be a company-wide
undertaking. It must drive the company’s vision, mission and strategic planning.
Marketing is about generating utilities in the customer’s mind and develop a
compatibility between market potential with its product and services and making
strategies for making a Brand image by continuous improvements in Quality of
services provided and taking care of the customers as well as seeking new
opportunities in the untouched areas by developing partnership with other
company’s.
Marketing deals with the whole process of entering markets, establishing profitable
positions, and building loyal customer relationship. This can happen only when all
the departments work together.
DECLARATION
I do hereby declare that the summer research report titled “A study of Service
Quality & Customer Satisfaction in Health Care System” submitted in partial
fulfillment of requirement of the M.B.A. programme 2008-2010 batch offer by
Rakshpal Bahadur Management Institute, Bareilly is based on genuine works
undertaken during the course of the research report.
This report has not been submitted to any other institution or university
to the fulfillment of any other course of the study or any other purpose.
(Saurabh Verma)
CONTENTS
Introduction
Research Objectives
Research methodology
Data Analysis
Conclusion
Limitation
Bibliography
Questionnaire
Introduction
HOSPITAL
A hospital is an institution for health care providing patient treatment by
specialized staff and equipment, and often, but not always providing for longer-
term patient stays.
Today, hospitals usually are funded by the public sector, by health organizations,
(for profit or nonprofit), health insurance companies or charities, including by
direct charitable donations. In history, however, hospitals often were founded and
funded by religious orders or charitable individuals and leaders. Similarly, modern-
day hospitals are largely staffed by professional physicians, surgeons, and nurses,
whereas in history, this work usually was performed by the founding religious
orders or by volunteers.
Service Quality and Customer Satisfaction in Health Care System
Patient perception of the quality of the services offered in hospitals follows latent
patterns, which can not be adequately reduced to a set of variables, but can be
approximated by multidimensional scaling. Thus, hospitals which are similarly
appreciated by their patients cluster close together. By examining what these
hospitals have in common, what are their best practices and quality recipes, one
can indirectly find out what is that which patients look for, in terms of service
quality in healthcare. Our analysis revealed that the profile of the hospital (general
vs. specialized) is related to the way the hospital is perceived, in terms
of quality, and that there are differences, inside the clusters, in the quality
perception, the sample of specialized hospitals being more homogenous than the
sample of general hospitals.
Patient satisfaction is measured with respect to technical and non- technical
characteristics of health care service encounters, categorised into four basic
components: attitude towards doctors, attitude towards medical assistants, quality
of administration and quality of atmospherics. All four factors are closely related to
consumer satisfaction. The study measures the degree of consumer satisfaction
experienced by patients through the tested self-developed five-point Likert scale
and has highlighted the problem faced by them. The impact of age, education level
and gender of the decision maker on satisfaction, dissatisfaction is analysed using
relevant statistical tools. The responses have been integrated into important factors
on the basis of factor analysis after verifying the validity and reliability of the
schedule.
SERVICE QUALITY
The good health of nations is a key to human development and economic growth
and it is important to analyze health systems’ performance and to share what we
knew with governments and the international community .
Large segments of the population in developing countries are deprived of a
fundamental right: access to basic health care. Without an appropriate and
adequate health support and delivery system in place, its adverse effects will be felt
in all other sectors of the economy. In simple terms, an ailing nation equates to an
ailing economy as manifested in lower income earning capacity of households and
significant productivity losses in those sectors that sustain the economy.
According to a World Bank (1987) estimate, ‘only 30% of the population has
access to primary health services and overall health care performance remains
unacceptably low by all conventional measurements.’ A subsequent study (Sen and
Acharya 1997) notes some improvements but indicates that ‘the poor qualities of
health services . . . are persistent concerns.’ The poor performance of the health
care sector was attributed to the following: critical staff are absent, essential
supplies are generally unavailable, facilities are inadequate, and the quality of
staffing is poor. The problems of supervision and accountability exacerbate the
problems; and if corrupt practices are added to the list, it is not difficult to imagine
the predicament of the patients. In fact, these conditions and a general perception
of poor and unreliable services may explain why those who can afford it have been
seeking health care services in other countries. In a country where the population
growth rate will place additional demands on the health sector, its preparedness to
serve its constituencies effectively is particularly troubling as the future begins to
catch up. To address the impending problems, consideration has been given to the
privatization alternative. Thus, the Medical Practice and Private Clinics and
Laboratories Ordinance was promulgated in 1982 to encourage the growth of
private health-care service delivery. By June 1996, a total of 346 private hospitals
and clinics with more than 5500 beds were registered with the Directorate of
Hospitals and Clinics. Of this total, 142 were established in Dhaka alone with a
capacity of 2428 beds (Khan 1996). Additional considerations are seen in the
proportion of GDP allocated to the health care sector: it was more than doubled
between 1985/86 and 1994/95, from 0.6 to 1.3% (Kawnine et al. 1995). A
significant proportion of this allocation was earmarked for primary health care.
While these allocations are encouraging, the perceptions that people have about the
relative quality of health care services in the country may not be so favourable and
remains to be assessed. This assessment is important because even if the problems
of access were to be substantially alleviated, quality factors are likely to strongly
influence patients’ choice of hospitals. In Nepal, for example, the Government
made substantial investments in basic health care; yet utilization remained low
because of clients’ negative perceptions of public health care (Lafond 1995). In
Vietnam, poor service in the public sector led to increased use of private providers
(Guldners and Rifkin 1993). Apparently, quality is important and demands
continuous attention. With the growth of private health care facilities, especially in
Dhaka city, it is important to assess the quality of services delivered by these
establishments. In particular, it is important to determine how the quality of
services provided by private clinics and hospitals compares to that of public
hospitals. If quality issues are being compromised by these establishments, it calls
for the re-evaluation of policy measures to redefine their role, growth and
coverage, and to seek appropriate interventions to ensure that these institutions are
more quality-focused and better able to meet the needs of their patients. A search
of the literature suggests that such a comparative study has not been undertaken.
While anecdotal evidence suggests the existence of serious service-related
problems in both sectors, this study was designed to determine and compare the
quality of services provided by both private and public hospitals. The study also
attempts to determine whether the service quality ratings are reasonable predictors
of the type of hospital chosen by patients. Demographic variables of income and
education were included with service quality ratings to test the model’s predictive
capability. The theoretical basis of this paper is that the quality of services
provided by the hospitals is contingent on market incentives: because private
hospitals are not subsidized and depend on income from clients, they will be more
inclined than public hospitals to provide quality services and to meet patients’
needs better. By doing so, they will not only be able to build satisfied and loyal
clients who will revisit the same facility for future needs; the clients will also serve
as a source of referrals to recommend the private establishments to friends and
family, thereby sustaining the long-term viability of private hospitals. In public
hospitals, on the other hand, there is little or no market incentive to motivate the
staff to take extra initiative or effort to improve the condition of patients and
ameliorate their suffering. This suggests that their service quality will be rated
lower than private hospitals. Quality assessment, however, requires careful
consideration. Two major concerns are: who will assess quality and on what
criteria. While quality care may be defined as the degree of excellence in overall
care, the judgment of quality may depend on whose perspective is sought.
Historically, the establishment of quality standards has been delegated to the
medical profession and has been defined by clinicians in terms of technical
delivery of care. More recently, patients’ assessment of quality care has begun to
play an important role, especially in the advanced industrialized countries, and
their satisfaction or dissatisfaction with services has become an important area of
inquiry. Thus, Donabedian suggests that, ‘patient satisfaction should be considered
to be one of the desired outcomes of care . . . information about patient satisfaction
should be as indispensable to assessments of quality as to the design and
management of health care systems.’ Because customers or clients of hospitals and
clinics have the most direct experiences with the services provided by these
institutions, this study focuses on their perspective. On a complex issue like health
care, while some feel that the customer cannot really be considered a good judge of
quality and dismiss their views as too subjective, Petersen (1988) suggests that, ‘It
really does not matter if the patient is right or wrong. What counts is how the
patients felt even though the caregiver’s perception of reality may be quite
different.’ In Bangladesh, the customer’s viewpoint is neither sought, nor given
any importance (as far as we know) in strategy formulation; thus, very little is
known about how the ‘customers’ assess health-care service quality. Since the
recipients of health care can provide valuable, albeit partial, insights, and since
their opinions should drive meaningful changes in the system, their perspective
was central to this paper.It was also important to establish the criteria for assessing
service quality. Some guidelines were available from research on this topic
conducted in other countries.
Conceptual framework
The important components of hospital services as derived from theoretical
consideration sand the data structure are as follows.
Responsiveness
The literature identifies responsiveness as an important component of service
quality and characterizes it as the willingness of the staff to be helpful and to
provide prompt services. Six items were used to delineate and measure the
construct.
Assurance
Assurance is defined as the knowledge and behaviour of employees that convey a
sense of confidence that service outcomes will match expectations. Six items were
used to measure this construct and reflect the competence, efficiency and
correctness of services provided to patients.
Communication
Communication with patients is vital to delivering service satisfaction because
when hospital staff take the time to answer questions of concern to patients, it can
alleviate many feelings of uncertainty. In addition, when the medical tests and the
nature of the treatment are clearly explained, it can alleviate their sense of
vulnerability. This component of
service is valued highly as reflected in the in-depth interviews and influences
patient satisfaction levels significantly. Four items were used to measure this
construct.
Discipline
Lack of discipline pervades many organizations and institutions and is commonly
manifested in absenteeism and non-performance of prescribed duties. Manipulation
of or non-adherence to written rules are also not uncommon. In the hospital
environment, lack of discipline can be tremendously disruptive, attenuating
perceptions of quality services. Thus, maintenance of the facilities or ensuring that
the staff maintain clean and proper appearances are some indicators of the extent of
discipline in the environment. Adherence to visitation hours and keeping noise
down to acceptable levels in the hospital environment are additional indicators of
discipline or the lack thereof. Six items were used to measure discipline.
Baksheesh
The concept of baksheesh, the extra compensation that is expected in many service
settings in Bangladesh for ‘due’ services, is becoming notoriously common,
especially in the public sector. It represents a payment to service providers to
ensure that expected services are delivered. Baksheesh is distinguished here from
bribes in the sense that bribes can represent solicited or unsolicited demands for
money to render ‘undue’ services. For example, a bribe may be required to obtain
hospital admittance out of turn or to obtain priority access to a particular doctor;
baksheesh will ensure that a scheduled appointment is met.
The above constructs represent the initial set of factors along which hospital
services were compared; they were also used to model the type of hospital that
patients would select. The research method is explained next.
The health care industry is undergoing a rapid transformation to meet the ever-
increasing needs and demands of its patient population. Hospitals are shifting
from viewing patients as uneducated and with little health care choice, to
recognizing that the educated consumer has many service demands and health care
choices available (Howard J.E., 2000). Within all systems there are many highly
skilled, dedicated people working at all levels to improve the health of their
communities. To move towards higher quality care, more and better information is
commonly required on existing provision, on the interventions offered and on
major constraints on service implementation. Consumers need to be better
informed about what is good and bad for their health, why not all of their
expectations can be met, and that they have rights which all providers should
respect (WHO, 2000). The challenge is to develop health systems that equitably
improve health outcomes, respond to people’s legitimate demands and are
financially fair. Recent research indicates that the way health systems are designed,
managed and financed seriously affects people’s lives and equitable health
outcomes are essential for global prosperity and the well-being of societies.
There is growing interest in improving the performance of health systems in many
countries. It is a major preoccupation, reflecting common pressures for cost
containment on the one hand and rising consumer expectations on the other. This
has led to a number of recent initiatives both to measure and to improve
performance against quality, efficiency and equity goals. Many countries are
developing initiatives to measure performance to guide and inform he
improvement process. Indeed, measurement and improvement are increasingly
linked, as is indicated by familiar phrases such as ‘evidence-based medicine’ and
‘evidence-based policy’. Equally important, if action is to be taken to improve
performance,it is the need to understand the roles and motivation of different actors
and available instruments in each health system. “Performance” is defined as the
extent to which the health system is meeting a set of key objectives. The key
objectives for the health system are suggested as being: improving health outcomes
and responsiveness to consumers, economic efficiency and equity of health (or
access to care). The success or failure of any initiative to improve health
performance will depend on the political and institutional context in which it is
placed.
Many countries face similar problems in assuring and improving the performance
of their health care system. Some of the main topics that are increasingly being
raised on the health policy agenda in most countries include the following:
Improving health status and outcomes for the entire population; Raising clinical
effectiveness -ensuring that clinical decisions are based on the best current practice
(avoiding over-use and under-use); Improving safety or reducing medical errors -
developing health care organizations that are capable of detecting medical errors or
adverse events to patients, and which are then able to effectively act on them to
avoid future occurrences; Raising responsiveness of the system - providing timely
services (reducing wasteful delays) which are patient-centered and respectful of
individuals' preferences, needs, and values; Improving efficiency/containing costs -
providing the right incentives to providers, funders and consumers to get better
value for money; and, Ensuring the equity - ensuring that the same quality of care
is provided to all, regardless of race, gender, geographic location, or ability to pay,
and reducing the gaps in health outcomes across different regions and socio-
economic or ethnic groups.
In all health systems, regulation plays an important role in determining the
availability, accessibility, and cost and, increasingly, the quality of services
provided. The major values and objectives of each health system are often secured
via regulation. Regulation has been used to serve quite different functions in each
country. It can have an extensive control function by defining and checking on
unacceptable medical practices, or it can encourage good practice by providing
positive principles according to which the medical profession should operate.
Regulation also plays an important role in facilitating the accountability of the
system and protecting patient’s rights.
Health care quality is a global issue. Despite differences in the levels and methods
of health care funding the challenges and solutions in quality are remarkably
similar between countries. There are defined such common national concerns over
quality: unsafe health systems; unequal access to health care services, waiting lists;
dissatisfaction on the part of users and the wider public; unacceptable levels of
variations in performance, practice and outcome; overuse, misuse or under-use of
health care technologies; ineffectual or inefficient delivery; unaffordable waste
from poor quality and unaffordable costs to society (Shaw Ch., 2002).
Technological innovations, particularly in the fields of biotechnology, genetics,
and information and communication technologies, are bringing substantial benefits
in the prevention, diagnosis and treatment of disease, as well as access to care
(Cotis J.P., 2003). Such innovation is costly and is predominantly carried out in the
private sector, although drawing on knowledge created in the public sector science
base. Innovation is also a risky process with many promising leads failing at
successive hurdles before a safe, efficacious and high quality product is brought to
the market. Meanwhile, many countries are seeking to establish health priorities.
Such priorities should take account of, and help guide, the direction of innovation –
so a better match is delivered between innovation and a society’s health needs.
Patient empowerment can cut health care costs and improve quality .There is now
a body of literature showing that better-informed patients have better outcomes,
choose less risky procedures and avoid equivocal treatments. This should increase
confidence that patients can not only make constructive use of performance data
designed for them, but can also be reliable informants for performance assessment.
The role of the health care professionals are of the great importance in order to
assure high quality services which should be provided to the patients with dignity
and respect. The general notion of responsiveness can be decomposed in many
ways. One basic distinction is between elements related to respect for human
beings as persons – which are largely subjective and judged primarily by the
patient – and more objective elements related to how a system meets certain
commonly expressed concerns of patients and their families as clients of health
systems, some of which can be directly observed at health facilities (WHO, 2000).
Respect for persons includes: 1) respect for the dignity of the person; 2)
confidentiality or the right to determine who has access to one’s personal health
information; 3) autonomy to participate in choices about one’s own health. This
includes helping choose what treatment to receive or not to receive.
All people are consumers of health services. What are their expectations with the
health services? Users of health services want safe, appropriate interventions,
treatment and care. They want to be treated with dignity and respect. They want
information that is accurate, timely and relevant. Consumers believe that if this is
to happen then consumers of the health services must be involved and consulted,
not only in relation to their own healthcare, but also about service planning and
delivery, health evaluation and research (Graham J.D., 2001). Many errors could
be avoided because of intervention or questioning by a consumer or career. Errors
increase when the consumers are not heard. The closest most health services come
to measuring consumers’ experiences is the occasional satisfaction survey. But
only targeting a reduction in complaints is not a sign of improvement. What is
needed is an effective evaluation of the accessibility of complaints procedures and
the introduction of incentives, such as feedback and proof of real action, to
encourage and support complaints. To participate as equal partners, health
servicesconsumers need to be able to consult, to develop policy and strategies and
to train for their advocacy role.
Considerable attention has been given to the literature on the value of measuring
patient satisfaction with medical care. Measuring and improving levels of
satisfaction is important for a number of reasons. For one, patient satisfaction can
be viewed as a positive outcome of the medical care provided; patients, as
consumers, deserve to be satisfied with the product. Also, patient satisfaction
measures provide health care managers with useful information about the structure,
process, and outcomes of care. They alert administrators to the positive and
negative aspects of their institutions. Patients increasingly expect choice as well as
quality in healthcare. But in order to make informed choices, they need to know
how well different hospitals or doctors are performing compared with their
colleagues elsewhere. Patient satisfactions assessments help maximize an
organization's quality and the value of the care it provides.
The following dimensions of care that patients’ value was established (Edgman-
Levitan S,Cleary P., 1996): respecting a patient's values, preferences and expressed
needs ;information and education; access to care; emotional support; involvement
of family and friends; continuity and transition; physical comfort; coordination of
care.
Researchers have reported that patients' judgments of quality care rely on the
Responsiveness of healthcare providers to patients' unique needs (Atkins P.M. et
al., 1996). To patients, the "appearance of environment and employees, reliability,
dependability of service delivery, responsiveness, and competence, understanding
the patient, access, courtesy, communication, credibility, and security" indicate
quality care. Patient satisfaction also hinges on whether the "service experience
meets consumer expectations". Consequently, assessing patient satisfaction and
quality care depends on the way in which quality care is defined. Data from patient
satisfaction surveys are used to identify particular
patient needs and develop interventions addressing those needs and priorities, thus
enabling hospital administrators and clinicians to evaluate the services they
provide. Although the literature pertaining to patient satisfaction in the inpatient
setting is extensive, there is a paucity of data on patient satisfaction pertaining to
outpatient clinical services.
The study addresses the issue of quality in health care sector. Patients’ satisfaction
was chosen as the indicator of service quality provided by ambulatory care units.
The study is focused on searching for main sources of satisfaction versus
dissatisfaction with health care services and their relation to socio-demographic
characteristics of ambulatory care units’ patients.
CORE CONCEPTS OF HEALTH CARE QUALITY
QUALITY VALUES IN HEALTH CARE
Openness, confidence, motivation and commitment are the foundations of a quality
culture. But often, traditional practices and attitudes towards authority, mutual
support and individual responsibility actively resist improvement. These create a
culture of low expectations (from public and professions), vertical command
structures, restricted information and a negative view of accountability and
responsibility. This is still a major problem in central and Eastern Europe.
Quality design involves service providers, clients, and managers in a structured
process to explicitly identify client needs and design service processes with key
features to meet those needs. In the context of quality design, features are concrete,
practical expressions of clients’ needs, desires, and expectations. While quality
design is often applied to develop an entirely new process or service where a
comparable one does not exist, it may also be used to substantially redesign an
existing process or service.
DEFINITIONS OF HEALTH CARE QUALITY
The most comprehensive and perhaps the simplest definition of quality is that used
by advocates of total quality management (W. Edwards Deming, 1982): "Doing
the right thing right, right away.”
Almost as universal is the view by Ovretveit J. (1992), who, almost a decade later,
recognized the three "stakeholder" components of quality, namely client,
professional and management quality. Client quality addresses what the clients and
carers want from the service. Professional quality indicates whether the service
meets the needs as defined by professional providers and referrers and whether it
correctly carries out techniques and procedures which are believed to be necessary
to meet the client needs. The management quality aspect is concerned with the
most efficient and productive use of the resources with in limits and directives set
by higher authorities and purchasers.
The integrated definition of health care quality combines these three elements: “A
quality health service/system gives patients what they want and need at the lowest
cost” (Ovretveit J., 1992).
The client-focused definitions of quality come from Donabedian A. (1980) and
Morgan and Murgatroyd (1994): "Client satisfaction is of fundamental importance
as a measure of quality of care because it gives information on the providers'
success at meeting those client values and expectations on which the client has
authority”.
Defining quality means developing expectations or standards of quality (Brown L.
et al.). Standards can be developed for inputs, processes, or outcomes; they can be
clinical or administrative. Standards can be applied at the level of an individual,
facility, or a healthcare system. A good standard is explicit, reliable, realistic,
valid, and clear. Standards of quality can be developed according to the dimensions
of quality and should be based on the best scientific evidence available.
Stakeholders (including client and community) expectations of quality should also
be incorporated in the definition of quality standards. Defined standards or
definitions of quality are prerequisites for measuring quality. If standards don’t
exist, they must be designed. Although standards are context-specific, universally
accepted standards are often a good starting point for developing local standards.
Sometimes, even when they exist, standards must be refined to make them usable
by health professionals.
QUALITY DIMENSIONS IN MEDICAL CARE
Diversity arises when examining what is meant by quality in medical care. Medical
quality consists of a mixture of hard technical elements such as correct diagnosis,
appropriate interventions and effective treatments as well as soft elements such as
good communications, patient satisfaction and consideration for patient
preferences (Gill M., 1993). It is not sufficient to consider only the technical
competence of those providing care. Rather, a high quality service is one that
provides effective care and is delivered humanely and efficiently. Good medical
quality consists of technical competence as well - the correct decisions and
appropriateness of interventions, audit and evidence based medicine. Ovretveit J.
(1990) stated that: "Professional quality has two parts: (1) Whether the service
meets the professionally assessed needs of its clients; and (2) Whether the service
correctly selects and carries out the techniques and procedures which professionals
believe meet the needs of clients”.
Brown L. et al. describe nine quality dimensions of health service delivery:
effectiveness, efficiency, technical competence, interpersonal relations, and access
to service, safety, continuity and physical aspects of health care
THE MEANING OF QUALITY
The definitions and dimensions outlined above constitute a broad conceptual
framework that includes almost every aspect of the health system performance. All
these dimensions come into play as clients, health providers, and health care
managers try to define quality of care from their unique perspectives. What does
quality of health care mean for the communities and clients that depend on it, the
clinicians who provide it and the managers and administrators who oversee it?
The Client. For the clients and communities served by health care facilities, quality
care meets their perceived needs, and is delivered courteously and on time (Brown
L. et al.) In sum, the client wants services that effectively relieve symptoms and
prevent illness. Because of satisfied clients often are more likely to comply with
treatment and to continue to use health services, the dimensions of quality that
relate to client satisfaction affect the health and well-being of the community.
Patients and communities often focus on effectiveness, accessibility, interpersonal
relations, continuity, and amenities as the most important dimensions of quality.
However, it is important to note that communities do not always fully understand
their health service needs - especially for preventive services - and cannot
adequately assess technical competence. Health providers must learn about their
community’s health status and health service needs, educate the community about
basic health services, and involve it in defining how care is to be most effectively
delivered. Which decisions should be made by health professionals and which
should be made by the community? Where does the technical domain begin and
end? This is a subjective and value-laden area that requires an ongoing dialogue
between health professionals and the community. Answering these questions
requires a relationship and two way communication between the parties.
The Health Service Provider. From the providers’ perspective, quality care implies
that he or she has the skills, resources, and conditions necessary to improve the
health status of the patient and the community, according to current technical
standards and available resources. The providers’ commitment and motivation
depend on the ability to carry out his or her duties in an ideal or optimal way.
Providers tend to focus on technical competence, effectiveness, and safety. Key
questions for providers may be: How many patients are providers expected to see
per hour? What laboratory services are available to them, and how accurate,
efficient, and reliable are they? What referral systems are in place when specialty
services or higher technologies are needed? Are the physical working conditions
adequate and sanitary, ensuring the privacy of patients and a professional
environment? Does the pharmacy have a reliable supply of all the needed
medicines?
Are there opportunities for continuing medical education? Just as the health care
system must respond to the patients’ perspectives and demands, it must also
respond to the needs and requirements of the health care provider. In this sense,
health care providers can be thought of as the health care systems internal clients.
They need and expect effective and efficient technical, administrative, and support
services in providing high-quality care. The Health Care Manager. Quality care
requires that managers are rarely involved in delivering patient care, although the
quality of patient care is central to everything they do. The varied demands of
supervision and financial and logistic management present many unexpected
challenges and crises. This can leave a manager without a clear sense of priorities
or purpose. Focusing on the various dimensions of quality can help to set
administrative priorities. Health care managers must provide for the needs and
demands of both providers and patients, to be responsible stewards of the resources
entrusted to them by the government, private entities, and the community. Health
care managers must consider the needs of multiple clients in addressing questions
about resource allocation, fee schedules, staffing patterns, and management
practices. The multidimensional concept of health care quality is helpful to
managers who tend to feel that access, effectiveness, technical competence, and
efficiency are the most important dimensions of quality.
Integrated quality development increases the capability of a service to achieve high
quality in quality dimensions (patients, professionals, managers) at the same time.
If quality activities are performed in the right way, then there is no trade-off
between increasing patient satisfaction, improving professional outcomes, and
reducing costs (Ovretveit J., 2001). A definition of quality needs to guide towards
what should be measured. It should be one which resonates with professionals'
values, but also conveys a patient focus, and brings in the idea of reducing waste
and increasing efficiency. According to Donabedian A. (2003), concept of quality
can be rather precisely defined, and that it is amenable to measurements accurate
enough to be used as a basis for the effort to monitor and assure it.
QUALITY EVALUATION METHODS
Common principles of quality evaluation methodology include the following
(Shaw C., 2002): Statutory mechanisms ensure that the safety of public, patients
and staff is established and evaluated. Their regulations, standards, assessment
processes and results are accessible to the public.
Voluntary external quality assessment and improvement programmes are
recognized by and consistent with statutory investigation and inspection. Their
standards, assessment processes and operations comply with international criteria.
There are formal mechanisms to define and protect the rights of patients and their
families in relation to the receipt of health services.
Local quality programmes are systematically planned and coordinated to meet
national priorities and the needs of local stakeholders. They use standards,
measures and improvement techniques which are explicit and known to be
effective.
The capacity to collect meaningful and consistent information on outcomes - in
relation to the means employed and the goals that have been set - is vital for
improving the performance of any system (Shaw C., 2002). The availability or
unavailability of information on specific areas may tell a lot about the strengths
and weaknesses of a system. For example, without information on patients’
experience of the system via satisfaction surveys or on their reoperation, re-
admission rates it may not be possible to evaluate the quality of health care
provided. While there has been an international mobilization for establishing
appropriate performance indicators for health systems, and procedures for
collecting data, system-wide information on the quality of care still remains rare.
What is being measured, and how, is important in a health system, equally relevant
is who is doing the measurement and who has access to the information. The
public dissemination of performance information on individual providers is not an
easy decision in any country. Physicians and hospitals are often skeptical,
underlying difficulties of interpreting data and importance of confidentiality for
medical work. To be able to design new approaches to quality monitoring and
improvement, health policy makers will need to understand the likely origins of
those findings, their magnitude relative to other sectors of the economy and
potential models of improvement (Mattke S., 2002). There is much potential in
sharing the experiences in different countries to understand which factors are
conducive to the design of successful models.
In general, three policy options exist to reform existing arrangements for
performance measurement and improvement:
• Strengthening and/or modifying the institutions for professional self-regulation
• Using improved information to strengthen 'external' regulation
• Providing consumers with sufficient information about performance and with
choice of providers so that market forces can lead to better quality
These choices raise technical, economic and political issues. In particular, they
have different implications for whether the benchmarking of performance is open
or closed to public view. There are different types of measurement of health care
institutions performance (WHO, 2002):
Regulatory inspection. Most countries have statutory inspectorates to monitor
compliance of health care insitution with published licensing regulations.
Inspections standards have legal authority and are transparent, but by the same
token are not easily updated. Standards address the minimal legal requirements for
a health care organization to operate and care for patients; they do not usually
address clinical process or hospital performance. Inspection of health care
insitutions induces conformity, and measures performance in terms of minimal
requirements for safety. It does not foster innovation or information for consumers
or providers.
Surveys of consumers’ experiences. Standardized surveys of patients and
relatives can reliably measure health care insitution performance against explicit
standards at a national level. Performance is becoming more focused on health
education, patient empowerment, comfort, complaint mechanisms and continuity
of care.
Third-party assessments. A research project funded by the European Union
(Shaw C., 2000) identified systematic approaches linking national or international
standards to local practices of private or public health care insitutions. These
approaches have been compared in a number of studies of standards and methods
used by industry-based (ISO, Baldrige) and health-care-based (peer review,
accreditation) programmes (Klazinga N., 2000, Australian Quality Council, 1999,
Donahue K.T., van Ostenberg P., 2000, Bohigas L., Heaton C., 2000). The
programmes, which are voluntary and independent to varying degrees, use explicit
standards to combine internal self-assessment with external review by visits,
surveys, assessments or audits (Shaw C., 2001).
ISO Standards. International Organization for Standardization certification
measures health care institution performance in terms of compliance with
international standards for quality systems, rather than in terms of institution
functions and objectives. ISO developed a series of standards (ISO 9000)
originally for the manufacturing industry (medicines, medical devices) that have
been used to assess quality systems in specific aspects of health services and
hospitals and clinics. Health care institutions (or, more commonly, parts of them)
are assessed by independent auditors who are themselves regulated by a national
“accreditation” agency. The theoretical advantage is that ISO certification is
internationally recognized in many other service, but ISO 9000 standards relate
more to administrative procedures rather than to health care performance.
Furthermore, the terminology of the standards is difficult to relate to health care,
and interpretations vary among national agencies (Sweenwy J., Heaton C., 2000).
The audit process tests compliance with standards and is not intended for
organizational development.
Peer review. Peer review is a closed system for professional self-assessment and
development. Peer review schemes could provide a source of standards and
assessments to harmonize professional and human resource management within
and between countries with reciprocal recognition of training.
Accreditation. Accreditation programmes measure health care institution
performance in terms of compliance with published standards of organizational –
and, increasingly, clinical – processes and results. They are mostly independent
and aimed at organizational development more than regulation but could contribute
reliable data to national performance measurement systems.
Statistical indicators. Statistical indicators can suggest issues for performance
management, quality improvement and further scrutiny. They provide relative
rather than absolute messages and need to be interpreted with caution inversely
proportional to the quality of the underlying data and of the definitions used.
The OECD project on Health Care Quality Indicators (HCQI) is developing
measures to help decision-makers formulate evidence-based policies to improve
the performance of health working group (WHO, 2003) began to define
performance measures for hospitals’ voluntary selfassessment and for external
benchmarking in six domains: clinical effectiveness, patient centeredness,
production efficiency, safety, staff development and responsive governance. The
group has considered background information on international, national and
regional or provincial systems that use standardized data to evaluate several
dimensions of health care institution performance for purposes of public reporting,
accountability, accreditation or internal use (Guisset, A.L, Sicotte C, Champagne
F., 2003). Factors such as underlying values, financing and organizational
arrangements plays role in the selection of possible performance measurement
methods (Leatherman Sh., 2001). The choice of method also depends on whose
behaviour is tried to change: providers, professional bodies, citizens or managers.
Identifying a best method may not be realistic, but being aware of the possible
approaches, their strengths and limitations, and the experience of countries that
have tried them, can help in making a choice.
Performance indicators are employed for four basic functions: facilitating
accountability; monitoring healthcare systems and services as a regulatory
responsibility; modifying the behaviour of professionals and organizations at both
a macro (population) and micro (patient) level; and forming policy initiatives.
Professional accountability, dominant in most health systems historically, views
the physician as the key to controlling quality and uses certification, accreditation,
licensing and litigation as instruments for enforcement. But the professional model
of accountability is increasingly regarded as insufficient unless accompanied by
one of the other two. The economic model is based on the idea that the competitive
market can be used to enforce accountability. Health plans can influence
physicians’ choice of treatment by declining to fund some practices or encouraging
others. And accountability through public reporting is believed to have resulted in
improved performance in certain areas. The political model meanwhile views the
citizen as receiving a public good, so the governments role is to act as an agent of
change on behalf of the public. Objective measures of performance are
increasingly used at several levels. Importantly, performance indicators can help to
make policy priorities explicit, for example by defining national priorities and then
identifying specific performance targets within those priorities. Assisting
healthcare professionals in practicing evidence-based medicine is a key objective
for improving quality. Performance indicators, embedded in clinical guidelines and
peer reviews, are among the most common approaches aimed at bridging the
knowledge gap, but have limited effectiveness when used alone to change
physician behaviour.
PATIENTS SATISFACTION AS QUALITY INDICATOR
Consumers of health care services play a variety of roles in health care quality
assessment and monitoring. By expressing their preferences, they supply the
valuations needed to choose among alternative strategies of care (Donabedian A.,
1987). They help define the meaning of quality in the technical sense. Moreover,
their preferences are the paramount consideration in defining the quality of the
interpersonal process and of the amenities of care. Consumers are also valuable
sources of information in judging the quality of care. Some data, mainly, about
non-technical aspects of care are most easily obtained from consumers. Most
importantly, consumers can and do, through expressing satisfaction or
dissatisfaction, pass a judgment about many aspects of the process of care and its
outcomes. Consumers, if properly informed, could help to regulate the quality of
care by means of their choices. Health care is now entering an age of "accountable
consumerism" in which patients demand service excellence. Patients’ expectations
for care have been defined differently in the literature. Some studies view patients'
expectations as probabilities, judgments about the likelihood that a set of events
will occur (Mc Kinley, 2002; Conway T., Willcocks S., 1997). Others view
expectations as values-patients' desires about care are expressed as perceived
needs, wants, importance, standards, or entitlements (Kravitz R. L., 1996). These
expectations may pertain to health care in general or to a specific health care
encounter such as a clinic visit or hospitalization. Whether patient expectations are
considered as probabilities or values, an understanding of patient expectations is
important because meeting these expectations may lead to greater satisfaction with
care.
The measure of patient satisfaction is viewed as important in outcomes research
and quality improvement efforts (Maxwell D., 2001, Kenagy et al., 1999, Pichert et
al., 1998). In addition to increased patient compliance and health outcomes, patient
satisfaction has been linked to greater service utilization and risk management. As
a result, managed care organizations are placing greater emphasis on patient-
perceived outcomes measures, such as satisfaction and functional status. Patient
satisfaction even has been found to moderate individuals' decisions to sue in the
face of adverse outcomes. As the patient is becoming widely recognized as a
reliable and important source of information about quality of medical practice
(Lawthers A.G., Rozanski B. S., Nizankovski R., Rys A., 1999), important steps
towards making performance transparent comes with the publication of concrete
figures on the quality of outcomes relevant to patients. Patient surveys are an
important part of this. Advantages of the patients’ surveying are that it identifies
what is valued by patients and the general public, and standardized surveys can be
tailored to measure specific domains of experience and satisfaction. However, to
reach the valid and reliable results still remain a challenge for the health care
organisations (Sitzia J., 1999). If questionnaires and the process itself are validated
by rigorous scientific scrutiny, then a useful comparison of the data is guaranteed.
Health care institutions using performance indicators to differentiate themselves
and demonstrate customer focus reap considerable advantages, especially if they
have a quality management system to underpin the development of performance.
That is thebenefit of bothpatients and staff (Kolking H., 2003, Dolan T.C., 1998).
The Commission for health improvement has embraced patient centeredness as a
core organizational value (CHI, 2004). It states: “Patients, careers and service users
matter to CHI. Our inspections help improve the quality of care people receive on
the NHS. We work with patients and patient organizations to do this”. One of these
principles is that CHI will be patient centered. Placing the patient at the center of
the provision of care is yet another new and important approach to improving the
quality of medical care (Grol R., 2001, Elaine Y. et al., 2002). From an ethical
perspective, patient autonomy is seen as a basic value and underlying premise for
the provision of health care in itself. From a psychological perspective, greater
patient involvement and greater patient control are assumed to lead to better
adherence to treatment recommendations and thus to better health. From an
epidemiologic perspective, patients are seen as rational beings who, after being
informed of the relevant benefits and risks of treatment alternatives, can share in
decision making. Satisfaction of health care consumers can refer to two things: first
to “revealed preferences”, that is to real consumption, assumed to be the
expression of what consumers want, and second to what consumers say they want
(“stated preferences”) (Dussault G., 1999). In health, there are so many economic,
social, cultural, organizational potential obstacles to the expression of consumers’
real preferences that revealed preferences say little about what consumers really
want. Also, consumers have only imperfect information about their needs and
about the options of services available, and most of their utilization of services is
on the recommendation of providers. Indeed, the utilization of services probably
reflects more the preferences of providers, than of users. There are now many
validated indicators which measure the stated satisfaction of consumers, and it is
possible to rely on these to assess satisfaction. According to Jenkinson C. et al.
(2002), patients’ experiences of health and medical care are at the very core of the
purpose of clinical medicine. If medical treatment succeed only in a limited
technical sence, but without any benefit to those receiving them, then interventions
have failed. Health care providers must consider whether and how patient
expectations of their services can be managed (McKinley et al., 2002).
Dissatisfaction with the health care services provided could be reduced if
consumers know what they can expect
and then receive it.
LEGISLATION ON QUALITY IN HEALTH CARE
Quality in health care is strongly linked with quality assurance (QA) and patients’
rights. Quality assurance - is a planned and systematic approach to monitoring,
assessing and improving the quality of health services on a continuous basis within
the existing resources. QA should encompass three perspectives on quality:
• Clinical standards
• Performance management
• Client satisfaction
In March 1996 the UEMS (European Union of Medical Specialist) launched the
Charter for quality assurance in European Union. The charter contents 6 articles
about QA for individual specialist group practice, for hospital, professional
scientific organizations, EU Member State or region and financing of QA (Charter
on quality assurance in medical specialist practice in the European Union, 1996).
QA is a professional concept initiated and controlled by professional itself.
Professional and scientific organizations are required to develop quality criteria in
their specialty. QA is moral and ethical obligation for individual specialist, but
basically it should be a voluntary responsibility. The policy of UEMS is the
encouragement of the implementation of the process of QA projects at all practice
whether for individual specialist, group practice, department hospital, professional
scientific organizations, EU Member State or region.
CUSTOMER SATISFACTION
The modern age can be called as the “Age of Consumers”. In today’s cut-throat
competition the consumer is considered as the king. Many policies of various
organizations are aimed at keeping the consumer happy and satisfied. It is very
important for each and every organization to keep its consumers satisfied in order
to maintain its competitiveness in the market. Not only does this help the
organization to maintain the size of its share in the market, it might even help it to
increase the size of its share. It might also be instrumental in increasing the overall
market size. This helps in increasing the overall profitability of the organization. It
also helps the long-term survival prospects of the organization. Consumers when
viewed on the macro level exhibit similar traits. However when we take a closer
look and come down to the micro level, we find that the consumers vary as
compared to one another on one aspect or the other based on a variety of attributes
(Kotler, 2003). In the present business scenario of cutthroat competition, customer
satisfaction has become the prime concern of each and every kind of industry.
Companies are increasingly becoming customer focused. Companies can win 2
customers and surge ahead of competitors by meeting and satisfying the needs of
the customers. World over businesses have realized that marketing is not the only
factor in attracting and retaining customers. Other major factors responsible for the
same are satisfaction through service quality and value. Even the best marketing
companies in the world fail to sell products and services that fail to satisfy the
customers’ needs. So customer satisfaction is the keyword in today’s fiercely
competitive business environment.
Whether the buyer is satisfied after purchase depends on the product’s performance
in relation to the buyer’s expectations. In general, satisfaction is a person’s feelings
of pleasure or disappointment resulting from comparing a product’s perceived
performance in relation to his or her expectations. If the performance falls short of
expectations, the customer is dissatisfied. If the performance matches the
expectations, the customer is satisfied. If the performance exceeds expectations,
the customer is highly satisfied or delighted. The link between customer
satisfaction and customer loyalty is not proportional. Suppose customer
satisfaction is rated on a scale from one to five. At a very low level of customer
satisfaction (level one), customers are likely to abandon the company and even bad
mouth it. At levels two to four customers are fairly satisfied but still find it easy to
switch when a better offer comes along. At level five, the customer is very likely to
repurchase and even spread good word 3 out of mouth about the company. High
satisfaction creates an emotional bond with the brand or company, not just a
rational preference.
CUSTOMER EXPECTATIONS
How do buyers form their expectations? From past buying experiences, friends’
and associates’ advice, and marketers’ and competitors’ information and promises.
If marketers raise expectations too high, the buyer is likely to be disappointed.
However, if the company sets expectations too low, it won’t attract enough
customers. Some of today’s most successful companies are raising expectations
and delivering performances to match. These companies are aiming for TCS- total
customer satisfaction. A customers’ decision to be loyal or to defect is the sum of
many small encounters with the company. The key to generating high customer
loyalty is to deliver high customer value. So a company must design a
competitively superior value proposition aimed at a specific market segment,
backed by a superior valuedelivery system.
The value proposition consists of the whole cluster of benefits the company
promises to deliver; it is more than the core positioning of the offering. Whether
the promise is kept depends on the company’s ability to manage its value delivery
system. The value delivery system includes all the experiences the customer will
have on the way to obtaining and using the offering. Customer satisfaction is a
feeling of pleasure or disappointment on the offers perceived performance in
relation to buyers’ expectations. Expectation is defined as what the customer
wants/requires from the product/service and 4 perceived performance is the
perception of the customer about the product/service i.e. evaluation of the
product/service after using it. So perception is what the customer actually
receives/gets from the product/service. The evaluation is done by comparing the
expectations with the perceived performance of the product/service. Therefore
customer satisfaction is a function of perceived performance and customer
expectations. Customers who are just satisfied find it easy to switch over when a
better offer comes than those who are highly satisfied. For customer focused
companies satisfaction is both a goal as well as a marketing tool. What a consumer
thinks about the product or services offered by a firm can have a marked effect on
the purchase of its products or services. So one of the tasks before the management
is to know what the consumer expect and what they are getting in return.
Satisfaction is a judgment that a product or service feature, or the product or
service itself, provided (or is providing) a pleasurable level of consumption related
fulfillment, including levels of under- or over fulfillment. The expectations-
disconfirmation paradigm provides the most popular explanation of consumer
satisfaction. However, and as is occasionally noted, if a customer experiences
disconfirmation after consuming a product, future expectations regarding the
product should be revised toward the performance perceived by the customer. If
expectations do not change in the face of disconfirmation, the implication would be
that the customer did not learn from their consumption experience (Oliver, 1997).
MEASURING SATISFACTION
Although the customer oriented companies seek to create high customer
satisfaction that is not is main goal. If the company increases customer satisfaction
by lowering its price or increasing its services, the result may be lower profits. The
company might be able to increase its profitability by means other than increased
satisfaction. Also, company has many stakeholders, including employees, dealers,
suppliers, and stockholders. Spending more to increase customer satisfaction might
diverts funds from increasing the satisfaction of other partners. Ultimately, the
company must operate on the philosophy that it is trying to deliver a high level of
customer satisfaction subject to delivering acceptable levels of satisfaction to the
other stakeholders, given its total resources.
Complaint and suggestion system
A customer-centered organization makes it easy for customers to register
suggestion and complaints.
Customer Satisfaction Surveys
Responsive companies measure customer satisfaction directly by conducting
periodic surveys. While collecting customer satisfaction data, it is also useful to
ask additional questions to measures repurchase intention and to measure the
likelihood or willingness to recommend the brand to others. Ghost Shopping
Companies can hire people to pose as potential buyers to report on strong and
weak points experienced in buying company’s and competitors’ products. Lost
Customer Analysis Companies should contact customers who have stopped
buying or who have switched to another supplier to learn why this happened.
The measurement of customer satisfaction has become very important for the
health care sector also. The concept of customer satisfaction has encouraged
the adoption of a marketing culture in the health care sector in both developed and
developing countries. As large numbers of hospitals are opening up and the people
are becoming more aware and conscious of health, great competition has emerged
in this industry. So to retain their patients hospitals have to provide better
facilities/services to its customers. Various factors that can affect the patients’
satisfaction include behaviour of doctors, availability of specialised doctors,
behaviour of medical assistants, quality of administration, quality of atmosphere,
availability of modern facilities etc. As grew the competition, so grew the trend of
providing better facilities to the customers by the hospitals. In last few years, a
plethora of hospitals have mushroomed in and around the city. These hospitals are
advertising heavily about the specialized treatments provided by tthese hospitals.
There are various hospitals that provide specialized treatments for various diseases.
Because of neck to neck competition between hospitals customers run to these
hospitals for specialized treatments. Interestiongly all hospitals claim to have a
high success rate. They claim to provide the best treatment and other essential
facilities at reasonable cost and in easy way to their customers. But how much of
this is true and how many of their claims are myths are not known to vast majority
of customers. As competition is increasing, the hospitals are making their best
efforts to provide quality health care services to its customers. They have begun
practicing a patient satisfaction strategy comprising consumer-oriented plans,
policies and practices to genuinely meet the needs of customers. Also, with
increased awareness and high expectations of the customers’ hospitals have to
provide them better facilities. Patients have begun to demand high quality of
services i.e. a consumer oriented approach. These days patients have become more
aware about their rights so they want they should be better facilities like
responding to their queries promptly, friendly environment, understanding their
problems, availability of specialized doctors, maintaining cleanliness, regular
repots etc. i.e. providing them every type of essential facilities. So, if the hospitals
want that their customers must be satisfied, they have to provide not only better
treatment but other facilities also.
The current study is focused on examining the various factors related to patient
Satisfaction with the following specific objectives:
1. To study the customer expectations from hospital services.
2. To study the customer perception of hospital services.
3. To study the degree of satisfaction of customers from hospital services.
REVIEW OF LITERATURE
Many studies have been conducted on the customer satisfaction. An attempt
has been made to present in brief, a review of literature on customer satisfaction in
general as well as on the customer satisfaction from hospital services. Priscilla et al
(1983) proposed a cognitive model to assess the dynamic aspect of consumer
satisfaction/ dissatisfaction in consecutive purchase behavior. They found that
satisfaction have a significant role in mediating intentions and actual behavior for
five product classes that were analyzed in the context of a three- stage longitudinal
field study. They found that repurchases of a given brand is affected by lagged
intention whereas switching behavior is more sensitive to dissatisfaction with
brand consumption. David and Wilton(1988) have extended consumer satisfaction
literature by theoretically and empirically examining the effect of perceived
performance using a model first proposed by Churchill and Surprenant,
investigating how attractive conceptualizations of comparison standards and
disconfirmation capture the satisfaction formation process and exploring possible
multiple comparison processes in satisfaction formation. They suggest that
perceived performance exerts direct significant influence on satisfaction in addition
to those influences from expected performance and subjective disconfirmation.
Saha (1988) made an attempt to investigate the interrelationships between job-
satisfaction, life satisfaction, life satisfaction-over-time and health. The
relationship among these four variables and biographical variables were also
examined. The study was conducted over the nurses in Nigeria. The data was
collected from the full time employees only because statements about job
satisfaction and other variables are different when supplied by retirees, part-time
nurses. Bolton and Drew (1991) proposed a model of how customers with prior
experiences and expectations assessed service levels, overall service quality and
service value. They applied the model to residential customers of local telephone
services. Their study explored how customers integrate their perceptions of a
service to form an overall evaluation of that service. They developed a multistage
model of determinants of perceived service quality and service value. The model
described how customers expectations, perceptions of current performance and
disconfirmation experiences affected their satisfaction or dissatisfaction with a
service, which in turn affected their assessment of service quality and value.
Boulding et al (1993) stated that the service quality relates to the retention of
customers at aggregate level. The author has offered a conceptual model of the
impact of service quality on particular behavior that signal whether customers
remain with of defect from a company. The results of the study show stron
evidence of their being influenced by service quality. The findings also reveal
difference in the nature of the service quality. Aurora and Malhotra (1997) had
done a comparative analysis of the satisfaction level of customer of public and
private sector banks, in order to help the bank management to formulate marketing
strategies to lure customers towards them and hence increase customer base.
Grewal et al had expanded and integrated prior price perceived value models
within the context of price comparison advertising. More specifically, the
conceptual model explicates the effects of advertised selling and reference prices
on buyers’ internet reference prices, perceptions of quality, acquisition value,
transaction value, and purchase and search intentions. Two experimental studies
test the conceptual model. The results across these two studies, both individually
and combined, support the hypothesis that buyers’ internal reference prices are
influenced by both advertised selling and reference price as well as buyers’
perception of product quality. The authors also find that effect of advertised selling
price on buyers’ acquisition value was mediated by their perceptions of transaction
value. In addition, effects of perceived transaction value on buyers, behavioral
intentions were mediated by their acquisition value perceptions. Voss (1998) had
examined the rule of price, performance and expectations to determine satisfaction
in service exchange. When price and performance are consistent, expectations have
an assimilation effect on performance and satisfaction judgments; when price and
performance are inconsistent, expectations have no effect on performance and
satisfaction judgments. To examine these issues authors develop a contingency
model that they estimate using data from a multimedia experimental design. The
results generally support contingency framework and provide empirical support for
normative guidelines that call for creating realistic performance expectations and
offering money-back service guarantees.
Garbarino and Johnson (1999) analyze that the relationships of satisfaction,
trust and commitment to component satisfaction attitudes and future intentions for
the customers of a New York off-Broadway repertory theater company. For the
relational customers ( individual ticket buyers and occasional subscribers), overall
satisfaction is the primary mediating construct between the component attitudes
and future intentions and for the high relational customers (consistent subscribers),
trust and commitment, rather than satisfaction, are the mediators between
component attitudes and future intentions.
Sharma and Chahal (1999) had done a study of patient satisfaction in outdoor
services of private health care facilities. They had done a survey to understand the
extent of patient satisfaction with diagnostic services. They have constructed a
special instrument for measuring patient satisfaction. The instrument captures the
behaviour of doctors and medical assistants, quality of administration, and
atmospherics. The role of graphic characters like gender, occupation, education,
and income is also considered. Based on their findings, they also suggested
strategic actions for meeting the needs of the patients of private health care sector
more effectively. In their study provided suggestions like becoming more friendly
and understanding to the problems of patients, maintaining cleanliness in the units,
both internally and externally, providing regular report regarding the patients’
progress without waiting for them to demand, conducting surveys to know about
the attitude of the patients with regard to the employees and adopting patient-
oriented policies and procedures. Simester et al (2000) have studied that
multinational firm uses sophisticated, state-of-the-art methods to design and
implement customer satisfaction improvement programs in the United States and
Spain. Their experiments reveals a complex and surprising picture that highlights
implementation issues, a construct of residual satisfaction not captured by
customer needs and the managerial need for combining nonequivalent controls and
nonequivalent dependent variables. Ofir and Simonson (2001) in their study found
that customer evaluations of quality and satisfaction are critical inputs in
development of marketing strategies. Given the increasingly common practice of
asking such evaluations, buyers of products and services often know in advance
that they subsequently will be asked to provide their evaluations. In a series of field
and laboratory studies, the authors demonstrate that expecting to evaluate leads to
less favorable quality and satisfaction evaluations and reduces customer’s
willingness to purchase and recommend the evaluated services. The negative bias
of expected evaluations is observed when actual quality is either low or high, and it
persist even when buyers are told explicitly to consider both the positive and
negative aspects. Dholakia and Morwitz (2002) have examined the scope and
persistence of the effect of measuring satisfaction on consumer behavior over time.
In an experiment conducted in a financial services setting, they found that
measuring satisfaction changes one-time purchase behavior, changes relational
customer behaviors and results in effects that increase for months afterward and
persist even a year later. Their results raised questions concerning the design,
interpretation and ethics in the conduct of applied marketing research studies.
Sharma and Chahal (2003) stated that due to increased awareness among the
people patient satisfaction had become very important for the hospitals. The
authors examined the factors related to patient satisfaction in government
outpatient services in India. They said that there are four basic components which
had impact on the patient satisfaction namely, behaviour of doctors, behaviour of
medical assistants, quality of atmosphere, and quality of administration. They also
provided strategic actions necessary for meeting the needs of the patients of the
government health care sector in developing countries. Folkes and Patrick (2003)
in their study showed converging evidence of a postivity effect in customers’
perceptions about service providers. When the customer has little experience with
the service, positive information about a single employee leads to perception that
the firm’s other service providers are positive to a greater extent than negative
information leads to perception that the firm’s other service providers are similarly
negative. Four studies were conducted that varied in the amount of information
about the service provider, the firm, and the service. The positivity effect was
supported despite differences across studies in methods as well as measures.
Vernoer (2003) had investigated the different effects of customer relationship
perceptions and relationship marketing instruments on customer retention and
customer share development over time. Customer relationship perceptions are
considered evaluations of relationship strength and a supplier’s offerings, and
customer share development is the change in customer share between two periods.
The results show that affective commitment and loyalty programs that provide
economic incentives positively affect both customer retention and customer share
development, whereas direct mailings influence customer share development.
However, the effect of these variables is rather small. The results also indicate that
firms can use the same strategies to affect customer satisfaction that can have
impact on both customer retention and customer share development.
Research Objective
Proposed study aims at accomplishing the following objectives:
To study the impact of monitoring mechanism on customer
satisfaction in a hospital.
To study the impact of attitude of medical & paramedical staff on
customer satisfaction.
To study about the customer awareness for new equipments in
hospital.
To study the impact of “Information sharing on customer
satisfaction”.
RESEARCH METHODOLOGY
IMPORTANCE OF RESEARCH METHODOLOGY
Without using research methodology to find new facts and knowledge is not
possible.
What is research?
“Research is a scientific and systematic search for pertinent information on a
specific topic. In fact research is an art of scientific investigation”.
Defining research problem:
There are two types of research problem, viz., those that relate to states of nature
and those that relate to relationship between variables. At the very outset the
researcher must single out the problem he want to study, i.e. he must decide the
general area of interest or aspect of a subject matter that he would like to inquire
into, initially the problem may be stated in a broad general way and then the
ambiguities, if any, relating to the problem be resolved. Then, the feasibility of a
particular solution has to be considered before a working formulation of the
problem can be set up.
The best way of understanding the problem is to discuss it with one’s
own colleagues or with those having some expertise in the manner. In an academic
institution the researcher can seek the help from a guide who is usually an
experienced man and has several research problems in mind.
Preparation of Research Design:
A research design is the overall plan or program of research. It includes an outline
of what the investigator will do from writing the hypothesis and there operational
implication to the final analysis of data.
Various uses of having a research design are as follows:
It provides answer to various questions.
It acts as a standard guidepost.
It helps in carrying out research validity, objectively, accurately and
economically.
The research problem having been formulated in clear cut terms, the research will
be required to prepare a research design, i.e. he will have to state the conceptual
structure with in which the should be conducted. The preparation of such a design
facilitates research to be as efficient as possible yielding maximal information.
Specifying data requirement:
The first job is to ask certain questions and find suitable answer for them. They
asked ourselves: what specific data will be necessary to test the hypothesis or
establish relationship in which they are interested? What variables are to be
measured?
Determining type of question:
After specifying the required data, they have decided the type of question required
to be asked from the respondent to the illicit data. They have understood various
existing types of questions and decided which of these suited the most to our
project situation.
I have to visit different type of listener having variations in the mindsets towards
the same type question being asked i.e. why I have to admit various categories of
question, which are as follows.
Open Ended Question:
Also termed as free-answer questions. These questions have no fixed alternative
(choice) to which the answer must conform. The respondent answers in his/her
own words and at any length he/she chooses. As such, this form of question
provides the opportunity for greater ambiguity in interpreting answer.
Closed Ended Questions:
Also termed as fixed alternatives questions. They refers to those questions in
which, the respondent is given a limited number of alternative responses from
which he/she selects the one that most closely matches his/her opinion or attitude.
1. The means of obtaining the information.
2. The time available for research, and
3. The cost factor relating to research, i.e. the finance available for the
purpose.
Types of Research
Research purposes may be grouped in four categories, viz
1) Exploratory:
Exploratory research studies are used to formulate a problem for more precise
investigation or of developing the working hypothesis from an operational
point of view. The main emphasis in such study is on the discovery of ideas
and insights.
2) Descriptive and Diagnostic research:
Descriptive research studies are those studies which concerned with
describing the characteristics of a particular individual, or of a group, whereas
diagnostic research studies determine the frequency with which something
occurs or its association with something else.
3) Experimental research:
Experimental research design refers to the framework or structures of an
experiment and as such there are several experimental designs. They can
classify experimental design into two broad categories, informal experimental
design and formal experimental design. Informal experimental designs are
those designs that normally use a less sophisticated form of analysis based on
differences in magnitudes.
“As my objective is to go for a survey hence it can be regarded as a
Exploratory research.”
Determining sample design:
I. Type of universe:
The first step in developing any sample design is to clearly define the set of
objects, technically called the universe, to be studied. The universe can be
finite or infinite. In finite universe the number of items is certain, but in case
of an infinite universe the number of items is infinite, i.e. one cannot have
any idea about the total number of items.
II. Sampling unit:
A decision has to be taken concerning a sampling unit before selecting
sample. Sampling units may be a geographical one such as state, district,
village, etc., or a construction unit such as house, flat, etc., or it may be a
social unit such as family, club, school, etc., or it may be an individual.
III. Source list:
It is also knows as ‘sampling frame’ from which sample is to be drawn. It
contains the name of all items of universe (in case of finite universe only). If
source list is not available, researcher has to prepare it.
IV. Size of sample:
This refers to the number of items to be selected from the universe to
constitute a sample. This is a major problem before a researcher. The size of
sample should neither be excessively large, nor too small. It should be
optimum.
“In case of my research project the sample size was 50”
Collecting the data:
After identification of the research program, the next step is to gather the
requisite data. Field survey is necessary for collecting the data.For the purpose
of collecting the data, a questionnaire was prepared. The respondents were
approached & the responses were obtained with the help of questionnaire.
Sources of secondary data
The secondary data are those, which have already been collected by someone
else & have already been passed through the statistical process. Basically
secondary data provides a starting point for research or market survey. The
information about the mindsets of various people especially students can be
retrieved & it will help us in defining our objectives. By the help of this they
can give our approach a right direction.
Primary data
In dealing with any real life problem it is often found that data at hand are
inadequate, and hence, it becomes necessary to collect data that are
appropriate. There are several ways of collecting the appropriate data, which
differ considerably in context of money costs, time and other resources at the
disposal of the researcher.
Primary data can be collected through following techniques:-
1. By observation:
This method implies the collection of information by way of observation,
without interviewing the respondents. The information obtained relates to
what is currently happening and is not complicated by either the past
behavior or future intentions or attitude of respondents.
2. Through personal interview:
A rigid procedure has been followed and answers to a set of preconceived
questions have been sought through personal interview. This method of
collecting data is usually carried out in a structured way where output
depends upon the ability of the interview to a large extent.
3. Through telephonic interviews:
This method of collection information involves contacting the respondents
on telephone itself.
4. By mailing of questionnaires:
The researcher and the respondents do come in contact with each other if
this method of survey is adopted. Questionnaires are mailed to the
respondents with a request to return after completing the same.
Data analysis & interpretation
1-Have you visited any hospital/nursing home in the last 1 year?
a. Yes ( ) b. No ( )
|
Yes98%
No2%
2-Which type of hospital have you visited in the last 1 year?
( a) Govt. hospital
(b) Private hospital
(c) Nursing home
(d) Rural primary health care center
Govt. hospital 38%
(b) Private hospital20%
(c) Nursing home16%
(d) Rural primary health care center
27%
3-How would you rate the behavior of medical staff?
(a) Highly satisfactory
(b) Satisfactory
(c) Dissatisfactory
Highly satisfactory27%
Satisfactory56%
Dissatisfactory17%
4- How would you rate the behavior of para medical staff?
(a) Highly satisfactory
(b) Satisfactory
(c) Dissatisfactory
Highly satisfactory53%
Satisfactory29%
Dissatisfactory18%
5- Do you fell that you were over charged for medicines?
(a) Yes ( ) (b) No ( )
Yes 22%
No 78%
6-Does the hospital use the latest equipments?
(a) Yes ( ) (b) No ( )
Yes 85%
No 15%
7- Do you feel that the charges for room/bad were reasonable?
(a) Yes ( ) (b) No ( )
Yes74%
No 26%
8- Were the room comfortable?
(a) Yes ( ) (b) No ( )
Yes 88%
No 12%
9-Did the room have all the amenities like TV, A/C, HEATER etc.?
(a) Yes ( ) (b) No ( )
Yes35%
No 65%
10- How would rate the quality of food ?
(a) Very good
(b) Good
(c) Average
(d) Bad
(e) Very bad
Very good8%
Good 16%
Average35%
Bad 30%
Very bad11%
Conclusion
A hospital is an institution for health care providing patient treatment by
specialized staff and equipment, and often, but not always providing for longer-
term patient stays.
In a country where the population growth rate will place additional demands on the
health sector, its preparedness to serve its constituencies effectively is particularly
troubling as the future begins to catch up. To address the impending problems,
consideration has been given to the privatization alternative.
Quality assessment, however, requires careful consideration. Two major concerns
are: who will assess quality and on what criteria. Quality assessment, however,
requires careful consideration. Two major concerns are: who will assess quality
and on what criteria.
Customer satisfaction is the keyword in today’s fiercely competitive business
environment. The measurement of customer satisfaction has become very
important for the health care sector also. The concept of customer satisfaction has
encouraged the adoption of a marketing culture in the health care sector in both
developed and developing countries. As large numbers of hospitals are opening up
and the people are becoming more aware and conscious of health, great
competition has emerged in this industry. So to retain their patients hospitals have
to provide better facilities/services to its customers. Various factors that can affect
the patients’ satisfaction include behaviour of doctors, availability of specialized
doctors, behaviour of medical assistants, quality of administration, quality of
atmosphere, availability of modern facilities etc. So, if the hospitals want that their
customers must be satisfied, they have to provide not only better treatment but
other facilities also. The current study is focused on examining the various factors
related to patient satisfaction with the following specific objectives:
1. To study the customer expectations from hospital services.
2. To study the customer perception of hospital services.
3. To study the degree of satisfaction of customers from hospital services.
In order to accomplish the objectives of the study, the primary data was collected.
The population of this study comprised of the BAREILLY patients only. Three
major private hospitals in BAREILLY were selected namely:
1. Shri Siddhi Vinayak Hospital
2. Shri Ram Murti Smarak Hospital,
3. Ganga Charan Hospital,
From these hospitals primary data was collected from the respondents. The
respondents were either the patients themselves or their relatives. For sample
selection, a multistage sampling procedure was followed. At the first stage, sample
units consisted of total number of general wards and private wards in the hospital.
10% of the general wards and 10% private, wards were selected randomly. Then
from each selected general ward 3 to 5 patients were chosen and from each
selected private ward one patient was chosen. The information was collected
through a pre-designed, structured questionnaire. A sample of 50 respondents
selected from these hospitals on the basis of their convenience for the first
objective and the second objective. To suggest solutions to the problems observed
during the survey is done through secondary data.
Limitations of the Study
1. First limitation is with the regard to response tendency, as much time the
respondents were very careless in filling the details contained in the
questionnaire.
2. Many time respondents fill ambiguous response by the lack of their time.
3. The research contains the study on limited causes and reasons of patient
dissatisfaction but their can be many more factors on which the study can be
elaborated.
4. Respondent some time not given the proper data because they want it to
keep confidential.
5. Result taken from the analysis comprises the data from Bareilly only which
doesn’t show the responses from the other cities or areas which could have
been more accurate in the study results.
RECOMMENDATIONS
We would like to make following recommendations for improving quality in health
care:
• To facilitate communication between healthcare providers and patients, specially
at immunology department. The aspects of the patient-doctor interaction , the
extent to which patients perceive that their doctors seek to involve them in decision
making show significant level of satisfaction among patients.
• To decrease waiting time and make waiting time more productive by providing
leafletsand medical journals etc., in the waiting rooms. Improve appointment
system, including telephone communication.
• To provide the access to needed information for the patients as well as
information related to legal issues and their rights.
• To motivate health care personal on devoting more time for patients; increasing
the perception on patients-centered approach.
• To enlarge and developed special accessibility to health care service for
employed patients.
Bibliography
Book Preferred
Marketing Management by Philip Kotler Millenium Edition
Research Methodology C...R.Kothari
Marketing Research – Green & Hill
Service Marketing – C. H. Lovelock
Magazine
International Journal For Quality in Health Care , 2000 vol 3
Websites Preferred
www.healthorg.com
Questionnaire
Person name-
Address-
Phone no-
1-Have you visited any hospital/nursing home in the last 1 year?
a. Yes ( ) b. No ( )
2-If yes then indicate the reason
(a) Treatment of self
(b) Treatment of family member
3-Which type of hospital have you visited in the last 1 year?
( a) Govt. hospital
(b) Private super specialize hospital
(c) Private specialize hospital
(d) poly clinic
(e) Nursing home
(f) Rural primary health care center
4-How would you rate the behavior of medical staff?
(d) Highly satisfactory
(e) Satisfactory
(f) Dissatisfactory
5- How would you rate the behavior of para medical staff?
(d) Highly satisfactory
(e) Satisfactory
(f) Dissatisfactory
6- Do you fell that you were over charged for medicines?
(b) Yes ( ) (b) No ( )
7-Does the hospital use the latest equipments?
(b) Yes ( ) (b) No ( )
8- Do you feel that the charges for room/bad were reasonable?
(b) Yes ( ) (b) No ( )
9-Were the room comfortable?
(b) Yes ( ) (b) No ( )
10-Did the room have all the amenities like TV, A/C, HEATER etc.?
(b) Yes ( ) (b) No ( )
11- How would rate the quality of food?
(f) Very good
(g) Good
(h) Average
(i) Bad
(j) Very bad
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