09 Chapter 3

CHAPTER 3
SERVICE QUALITY IN SELECTED HOSPITALS A THEORETICAL FRAMEWORK

MEASURING SERVICE QUALITY GAP
In an attempt to address the issue of how to measure service quality, a scale based upon the utilization of ten elements was developed by Parasuraman, et al (1988)1 based upon a series of focus group interviews, which could be used to measure service quality perceptions. Originally, the ten elements developed for use in measuring service quality were tangibles, reliability, responsiveness, competence, courtesy, credibility, security, access, communications, and understanding the customer. Further studies by Parasuraman, et al (1988)2 brought about a major modification that changed the dimensions that could be used to measure service quality perceptions.
This modification of the ten elements to five elements is clearly depicted in Table 3.2. Three of the original ten elements (as described in Table 3.1); tangibles, reliability, and responsiveness remained unchanged. The other seven original elements were combined into two elements. Those elements known as competence, courtesy, credibility, and security were combined to form one of the new elements known as assurance, and the elements of access, communications, and understanding the customer were combined to form the new element known as empathy as noted in Table 3.2.
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Now, the five elements that made up what the authors called SERVQUAL were the following five dimensions of service quality: tangibles, reliability, responsiveness, assurance, and empathy, which are defined in Table 3.2. Based upon the five elements or dimensions, they postured that service quality could be measured by obtaining the difference between perceptions and expectations of those dimensions. A series of questions were presented to the customer, who was asked to rate their particular choices as to their expectations of service from the service provider.
Table 3.1: Definition of Original Ten SERVQUAL Dimensions
Dimension and Definition Tangibles: Appearance of physical facilities, equipment, personnel, and communication materials.
Questions Raised By Customers Are the hospitals facilities attractive? Is my doctor dressed appropriately? Is my record sheet easy to understand?
Reliability: Ability to perform the When a doctor says she will attend me promised service dependably and accurately. back in 15 minutes, does she do so? Does the nurse or compounder follow the doctors exact instructions? Is my record sheet free of errors? Responsiveness: Willingness to help customers and provide prompt service. When there is a problem with my record sheet, does the hospital resolve the problem quickly? Is my doctor willing to answer my questions? Are charges for medication / hospitalization billed to my account promptly?
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Competence: Possession of the Is the hospital back office able to process required skills and knowledge to perform the service. my transactions without fumbling around? Does my hospital have the research capabilities to accurately track latest developments? When I call front office executive, is the person at the other end able to answer my questions? Courtesy: Politeness, respect, consideration, and friendliness of contact personnel. Does the front office executive have a pleasant demeanor? Does my doctor or nurse refrain from acting busy or being rude when I ask questions? Are the telephone operators in the hospital consistently polite when answering my calls? Credibility: Trustworthiness, believability, honesty of service provider. Does the hospital have a good reputation? Does my doctor refrain from influencing me for unnecessary diagnostics? Are the rates/fees charged by my hospital consistent with the services provided? Security: Freedom from danger, Is it safe for me to use my credit card with risk, or doubt. the hospital? Does my hospital staff know where my record is? Is my fact sheet safe from unauthorized use? Access: Approachability and ease of contact. How easy is it for me to talk to senior doctors when I have a problem? Is it easy to get through to my doctor over the phone? Does the hospital have a 24-hour, toll-free telephone number?
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Communication: Keeping customers informed in language they can understand and listening to them.
Can the doctor explain clearly the various medications administered? Does my doctor avoid using technical jargon? When I call my hospital, are they willing to listen to me?
Understanding the Customer: Making the effort to know customers and their needs.
Does someone in my hospital recognize me as a regular customer? Does my doctor try to determine what my specific health objectives are?
Source: Zeithaml, Parasuraman& Berry, (1988), Delivering Quality Service, New York, NY: Free Press, p. 21-22 (Modified)
Further, the customer was told to give their perceptions of the service being delivered by the service provider. An additional rating scale was used to corroborate the results.
Table 3.2: Definition of Modified SERVQUAL Dimensions
Dimension Tangibles
Definition Appearance of physical facilities, equipment, personnel, and communication materials
Reliability
Ability to perform the promised service dependably and accurately
Responsiveness Willingness to help customers and provide prompt service. Assurance Knowledge and courtesy of employees and their ability to convey trust and confidence Empathy
26.
Caring, individualized attention the firm provides its customers
Source: Zeithaml, Parasuraman& Berry, (1988), Delivering Quality Service, New York, NY: Free Press, p.
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Figure 3.1: Correlation between Modified SERVQUAL Dimensions and Original Ten Dimensions
Original Ten SERVQUAL Dimensions
Modified SERVQUAL Dimensions
Tangibles
Tangibles
Reliability
Reliability
Responsiveness
Responsiveness
Competence
Courtesy Assurance Credibility
Security
Access
Communication
Empathy
Understanding The Customer
Source: Zeithaml, Parasuraman & Berry, (1988), Delivering Quality Service, New York, NY: Free Press, p. 25
The
modified
SERVQUAL
dimensions
are
tangibles,
reliability,
responsiveness, assurance, and empathy which Zeithaml, et al (1988)3
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determined to be the best determinates for measuring service quality. Not unexpected, SERVQUAL received critiques from several marketing researchers, such as Babakus and Mangold (1992)4 who had serious reservations about the ability of SERVQUALs scales, reliability, and discriminant validity. They noted that the measurement techniques called into question a substantial potential for error and left a number of unanswered questions relating to its validity. Teas (1993)5 also found serious objections to SERVQUAL. He felt that the interpretation of the expectations standard was flawed. Additionally,
operationalization of the expectation standard was not a workable option. He had problems with the evaluation of alternative models specifying the SQ construct as set out in the SERVQUAL instrument. His concerns were similar to Brown et al (1993)6 with regard to whether the five key dimensions capture all of the possible determinants of service quality. Cronin and Taylor (1992)7 stated that perceptions of service quality more closely approach customer evaluations of service provided. Parasuraman, et al (1994)8 disagreed with the Cronin and Taylor (1992)9 perceptions, feeling that disconfirmation is valid since it allows providers of service to establish gaps in the provided services. Dabholkar, et al (1996)10, Spreng and Mackoy (1996)11, and Taylor and Baker (1994)12 were among the few to use multi item measures to ascertain overall service quality, which was accomplished with factors as antecedents. In all cases they only tested using a single-item measure that would prove unreliable in looking at factors as components versus factors as antecedents.
The different schools of thought on quality service would seem to agree on the basic premise that customer preferences of service quality are based upon a comparison between expectations and actual service performance.13 (Howcroft. 1992: page 126)
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Interestingly enough Howcroft (1992)14 concluded that most researchers would agree customer preferences can best be measured on the basis of comparing expectations to actual service. He found that outcome and process as a holistic approach best served the measurement process. A slightly different approach was taken by Dabholkar, et al (2000)15 who found that perceptions and measured disconfirmation are more advantageous than computed
disconfirmation, but they suggest further study to determine their studys ability to predict the power of service quality and customer satisfaction evaluations.
They also recommend measured disconfirmation if gap analysis is used, and noted that cross sectional design for service quality measurement would be more advantageous than longitudinal design. Bahia and Nantel (2000)16 in a Canadian organizational study devised a measurement system modifying SERVQUAL to examine the specific service context on a six dimension scale called BSQ. BSQ by admission of the authors was limited in that its scale construction was based entirely upon expert opinion, published literature, and a small sample. They felt it would have more validity if the sample were larger. In another recent study, Oppewal and Vriens (2000)17 noted that the use of integrated conjoint experiments to measure the perceived level of service quality provided a method of hierarchical information integration theory, which in their judgment avoids some of the measurement pitfalls of SERVQUAL. Unfortunately for the study, they noted:
It is therefore unclear whether in this study the substitution and replacement of terms that underlies the derivation of one overall utility function was valid at all.18 (Oppewal and Vriens. 2000: page 169)
Perhaps, the study may have raised more questions than the answers it yielded; however, it did give some food for thought about another means of measurement through conjoint experiments to measure service quality
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perceptions. Beckett, et al (2000)19 approached consumer behavior from a different concept. They utilized a consumer behavior matrix developed through focus group discussions to determine what impact electronic based delivery systems will have on service and consequently, the quality of service.
Their consumer behavior matrix plotted consumer confidence against the factor of involvement, using four quadrants. Those quadrants representing what the researchers termed four ideal types of consumer behavior were repeatpassive, rational-active, no-purchase, and relational-dependent. This section has shown a number of different studies of service quality measurement. It could be noted that there is no one study that fully and completely measures service quality and that there is a need to fill knowledge gaps with additional studies such as this one that might modify one of these studies.
DIMENSIONS IN MEASURING SERVICE QUALITY
After a thorough examination of the research in the areas of service quality and customer satisfaction, it would be in order to examine the variables that impact the measurement of service quality. In the initial research relating to SERVQUAL, Parasuraman, et al (1985)20 established ten dimensions for measuring service quality.
Those original dimensions defined in Table 3.1 above were tangibles, reliability, responsiveness, competence, courtesy, credibility, security, access, communication, and understanding the customer. This ten dimension
breakthrough approach to measuring service quality was criticized by Cronin and Taylor (1992)21 who not only did not agree with the measurement issue, but also criticized the conceptualization of SERVQUAL, and reported that the perceptions aspect of SERVQUAL was a much better measurement device that SERVQUAL itself.
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Parasuraman, et al (1991)22 revised their SERVQUAL instrument by conducting a new study, which in its refined form changed some scale measurement elements and changed wording relating to those scales. They provided a direct measurement relating to the importance of each dimension reported by the respondents. After substantial research and an evaluation of various critical reviews of SERVQUAL, the modified dimensions as defined in Table 3.2 above are tangibles, reliability, responsiveness, assurance, and empathy23 (Parasuraman, et al, 1988 and 1994)
THE SERVQUAL GAP ANALYSIS MODEL As previously set out above, a number of researchers (Bateson, 197924; Berry, 198025; Bowen & Cummings, 199026; Groonoos, 1983, 199027; and Karwan & Rosen, 198828, among others) suggest that the various strategic opportunities for services management, including quality assurance, differ substantially from those in manufacturing management. Other researchers (Langevin, 197729; Levitt, 197231; Reukert, et al, 198532; Walker and Reukert, 198733) found that there was no essential difference and viewed marketing management as a function or a task, and did not embrace the services marketing approach across the organization. Those who noted a substantial difference saw the severe limitations of the usual manufacturing concepts in dealing with intangibles such as service. They also noted that you could not separate the customer from the process of delivering service.
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Figure 3.2: Service Quality Gap Model by Zeithaml et al.
Source: Zeithaml, Parasuraman& Berry, (1988), Communication and Control Processes in the Delivery of Service Quality, Journal of Marketing, 52 (April), p. 36.
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Following the concept that service quality could be measured utilizing customer perceptions, Zeithaml, et al (1988)33 in their model provided for the customer to judge the process of quality throughout the delivery of service and then, examined product quality after the service delivery. He noted that the intangible, such as a friendly greeting or smile, during the delivery of service is a part of process quality, and the proper handling of the patient grievance constitutes remedy quality. The model by Zeithaml, et al (1988)34, as shown above in Figure 3.1, seeks to examine the amount and direction of the discrepancy between expected levels of service and the customers perception of a delivered service noted as Gap 5 in Figure 3.2. In order to eliminate the discrepancies between expectations of service and the perception of the delivered service, the provider of the service must close the four gaps (Gaps 1-4). To close Gap 1, the management must know what the customers expect and Zeithaml, et al (1988)35 noted this is, in all likelihood, the most important gap to close. It was also noted that in service companies the absence of well defined cues may cause Gap 1 (see Figure 3.3 below) to be larger in service companies than in manufacturing firms.
Additionally, a lack of adequate marketing research can cause Gap 1 to be more difficult to close. Translating the customer expectations into service quality can close gap 2 specifications. An inadequate management commitment is the single largest cause for widening Gap 2. From Figure 3.4, it can be noted that perception of infeasibility, inadequate task standardization, and absence of goal setting are also major factors in widening Gap 2. Hax and Nicolas (1984)36 observed that most U. S. firms suffer significantly from short-term accounting driven measures of performance used to establish the reward mechanisms for high level administrators, who are mainly responsible for implementing strategic actions. It was also noted by Zeithaml, et al (1988)37 when administrators are not dedicated to providing service quality from a customers point of view, their entire
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focus is to bottom line objectives without any consideration to improve service quality.
Figure 3.3: Key Factors Contributing to Gap 1
Customer Expectations
Key Contributing Factors 1. Lack of Marketing Research Orientation Insufficient marketing research Inadequate use of research findings Lack of interaction between management and customers
2. Inadequate Upward Communication 3. Too Many Levels of Management
Management Perceptions of Customer Expectations

Source: Zeithmal, Parasuraman & Berry, (1988), Delivering Quality Service, New York, NY: Free Press, p. 52
Management Perceptions of Customer Expectations
Key Contributing Factors 1. Inadequate Management Commitment 2. Perception of Infeasibility 3. Inadequate Task Standardization 4. Absence of Goal Setting
Service Quality Specifications

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For Gap 3 to be closed, Zeithaml, et al (1988)38 model indicated that it would be necessary as set out in Figure 3.5 the key elements necessary to close Gap 3 are elimination of role ambiguity, role conflict, poor employee-job fit, poor technology job fit, inappropriate supervisory control systems, lack of perceived control and lack of team work. Care must be taken to ensure when evaluating the elements that too broad an interpretation does not distort the evaluation.
Service Quality Specifications
Key Contributing Factors 1. Role Ambiguity 2. Role Conflict 3. Poor Employee Job Fit 4. Poor Technology Job Fit 5. Inappropriate Supervisor Control System 6. Lack of Perceived Control 7. Lack of Team Work
Service Delivery
Of all the gaps, it is Gap 3 that relies on actual employee performance and training which would imply that managements role in closing the gap is proper training and supervision of the staff. In discussing their model, Zeithaml, et al (1988)39 found that service provided by employees played a major role in customers / patients selecting a firm / hospital.
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Service Delivery
Key Contributing Factors 1. Inadequate Horizontal Communication Inadequate Communication between advertising and operations Inadequate Communication between sales
people and operations Inadequate Communication between human
resources, marketing and operations 2. Propensity to Over promise
External Communication to Customer

Gap 4 entails management ensuring that employees do not promise more than can be delivered and that everything promised in oral and written communications, advertising, and selling is delivered.
Some of the pitfalls to closing Gap 4 as noted in Figure 3.6, revolve around inadequate horizontal communication, namely between the advertising function and the operations function; inadequate communication between sales personnel and operations; inadequate communications between human
resources, marketing, and operations; and difference in policies and procedures across branches or departments. Another major area of concern in Gap 4 is the propensity to over promise what the firm will or can deliver to the customer.
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The advantage of Zeithamal, et als (1988)40 model is the logical process by which organizations can measure and improve service quality: determine customer needs, translate needs to service standards, provide service that measure up to specified standards, and communicate accurate service information to customers.
USING SERVQUAL TO EVALUATE SERVICE QUALITY
Regardless of the conflicting research evidence presented above, the SERVQUAL determinants have been widely accepted in the areas of service quality and customer satisfaction. Since the original ten determinants (Zeithaml, et al, 1988)41 have been modified into five determinants, only the current five will be addressed. A discussion of the five revised determinants developed by Parasuraman, et al (1991, 1994)42: tangibles, reliability, responsiveness, assurance, and empathy are set out below:
Tangibles
Tangibles would include those attributes pertaining to physical items such as equipment, buildings, and the appearance of both personnel and the devices utilized to communicate to the consumer. Bitner (1992)43 presented her conceptual framework for examining the impact of physical surroundings as it related to both customers and employees. Berry and Clark (1991)44 provided validation of the physical appearance on the consumers assessment of quality. With the research by Bitner (1990)45, it was noted that physical appearance might influence the consumers level of satisfaction. Tangibles was one of the original dimensions that was not modified by Zeithaml, et al (1988)46.
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Reliability
Reliability relates to the personnels ability to deliver the service in a dependable and accurate manner. Numerous researchers, including Garvin (1987)47 found that reliability tends to always show up in the evaluation of service. Parasuraman, et al (1988)48 indicated that reliability normally is the most important attribute consumers seek in the area of quality service. It was also determined by Parasuraman, et al (1991)49 that the conversion of negative wording to positive wording as suggested by Babakus and Boller (1991)50 and Carman (1990)51 increased the accuracy of this dimension. Negative wording in the request for a customer response caused the customer to misinterpret this particular determinant. Walker (1995)52 found that if there is an adequate delivery of the basic level of service, then peripheral performance leads consumers to evaluate the service encounter as satisfactory. Reliability was one of the original dimensions not modified by Zeithaml, et al (1988)53.
Responsiveness
The desire and willingness to assist customers and deliver prompt service makes up the dimension of responsiveness. Parasuraman, et al (1991)54 include such elements in responsiveness as telling the customer the exact time frame within which services will be performed, promptness of service, willingness to be of assistance, and never too busy to respond to customer requests. Bahia and Nantel (2000)55 disregarded responsiveness in their research, claiming a lack of reliability even though they recognized SERVQUAL and all of its dimensions as the best known, most universally accepted scale to measure perceived service quality. Responsiveness was also one of the original dimensions not modified by Zeithaml, et al (1988)56.
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Assurance
Knowledgeable and courteous employees who inspire confidence and trust from their customers establish assurance. In studies by Anderson, et al (1976)57, it was determined that a substantial level of trust in the organization and its abilities was necessary to make the consumer comfortable enough to establish a relationship. Parasuraman, et al (1991)58 included actions by employees such as always courteous behavior instills confidence and knowledge as prime elements of assurance. Assurance replaces competence, courtesy, credibility, and security in the original ten dimensions for evaluating service quality (Zeithaml, et al, 1988)59.
Empathy
Empathy is the caring and personalized attention the organization provides its customers. Individual attention and convenient operating hours were the two primary elements included by Parasuraman, et al (1991)60 in their evaluation of empathy. The degree to which the customer feels the empathy will cause the customer to either accept or reject the service encounter. Empathy replaces access, communication, and understanding the customer in the original ten dimensions for evaluating service quality (Zeithaml, et al, 1988)61.
VALIDITY OF SERVQUAL IN MEASURING SERVICE QUALITY
Much has been written in support of SERVQUAL, and conversely, much has been written critical of various aspects of the instrument or the measurement obtained. It seems appropriate to present challenges to and arguments for SERVQUAL as discussed in general and as it relates specifically to hospitals.
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CHALLENGES IN GENERAL AREAS CONCERNING VALIDITY
Since the introduction in 1988 of SERVQUAL by Parasuraman, et al (1988) , there have been numerous revisions to the original format, but most researchers who have been frequent critics of this measurement device (e.g., Brown, et al; 199363, Teas, 199364; Dabholkar, et al, 200065) accept and recognize the determinant roles of expectations and perceptions in service quality evaluation. The area that is most troublesome for the critics of SERVQUAL revolves around whether the five key dimensions capture all of the possible determinants of service quality. Brown et al, (1993)66 would agree that SERVQUAL is the most popular measure of service quality, but they have taken exception with using a scoring method to conceptionalize service quality. Their empirical investigation indicated that the problems they found with SERVQUAL manifest itself empirically in that it failed to achieve discriminant validity for all of its various components. When they utilized non-difference score measures they did not manifest the same problems as SERVQUAL. In fact, their measures allowed for direct comparison of expectations and perceptions without linear difference. They also had serious doubts that modification of wording to fit conceptualization had validity and felt that it should be studied further. Teas (1993)67 found serious objections to SERVQUAL. He felt that the interpretation of the expectations standard was flawed. Additionally,
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operationalization of the expectation standard was not a workable option. He had problems with the evaluation of alternative models specifying the SQ construct as set out in the SERVQUAL instrument. His concerns were similar to Brown et al (1993)68 with regard to whether the five key dimensions capture all of the possible determinants of service quality. Dabholkar et al, (2000)69 also was critical of SERVQUALs five dimensions. They also found that perceptions and measured disconfirmation are more advantageous than computed disconfirmation, but they suggest further
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study to determine their studys ability to predict the power of service quality and customer satisfaction evaluations. They also recommend measured
disconfirmation if gap analysis is used. Carman (1990)70 in his study found from six to eight dimensions, while Babakus and Boller (1991)71 determined that a two-dimension approach offered the most efficient and effective measurement device. Cronin and Taylor (1992)72 came to the conclusion that the five dimensions did not hold for perceptions measured against performance, but did very well if only performance was measured. Their study concluded that utilizing the consumers assessment of performance was adequate by itself to determine perceptions of service quality. Their non-difference score measure evaluated service quality without relying on the disconfirmation paradigm. They found that the perceptions component of SERVQUAL was able to outperform SERVQUAL itself, which caused them to conclude that the disconfirmation paradigm is not appropriate for perceived service quality. They observed that perceived quality should be reflected as an attitude, and as a result their criticism of Parasuraman et al for failing to define perceived service quality as an attitude in spite of their (Parasuraman et al, 1988)73 stating that service quality was similar in many ways to an attitude. Parasuraman, et al (1994)74 responded to specific concerns raised by two of the researchers (Cronin and Taylor, 199275; and Teas, 199376) relating to the SERVQUAL instrument as well as the perceptions without expectations. In addressing the criticism by Cronin and Taylor (1992)77, Parasuraman, et al (1994)78 noted:
In short, every argument that Cronin &Taylor make on the basis of their empirical findings to maintain that the SERVQUAL items form a one-dimensional scale is questionable. Therefore, summing or averaging the scores across all
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items to create a single measure of service quality, as Cronin &Taylor have done in evaluating their structural models is questionable as well.79 (Parasuraman, et al. 1994: page 113)
They further noted that it would be important to determine the practical value of SERVQUAL to Cronin and Taylors (1992)80 SERVPERF from the standpoint of asking if administrators who measure service quality are seeking accuracy in determining service shortfalls or explaining variances. Parasuraman, et al (1994)81 agreed measuring variances is the only area in which SERVPERF performs better than SERVQUAL, but indicated that SERVQUALs superior ability to be diagnostic more than outweighs any loss in predictive power. Parasuraman, et al (1994)82 noted that the three issues raised by Teas (1993)83 were (1) interpretation of the expectations standard, (2)
operationalization of this standard, and (3) evaluation of alternative models specifying the SQ construct. While they acknowledged that his conclusions have merit, there was in their judgment a need to reexamine his results before several of the assumptions would provide any true evaluation of SERVQUAL. Validity of SERVQUAL in hospital utilizes studies by Carman (1990)84, Brensinger and Lambert (1990)85, Babakus and Boller (1991)86, Finn and Lamb (1991)87 and Parasuraman, et al (1991)88 to compare and assess the validity of the refined SERVQUAL instrument. Of special note is the part of the study by Parasuraman, et al (1991)89 which involved two organizations. Additionally, each of these studies further reinforced SERVQUAL as a reliable instrument, albeit with slight modifications.
As a concluding note, we can understand that the firms management needs to be aware of the relative importance of each of the service quality dimensions in satisfaction formation of customers, which varies across different firms utilization groups, and use this in strategic considerations.
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QUALITY ISSUES IN HOSPITALS
The health care industry presents a very dynamic, unexpected, ambiguous and uncertain environment in which quality issues have occupied a central position. Quality of care is related to all issues vital to health care reform to the question of access and to the problems associated with ineffective and inappropriate care, patient preferences and patient choice is inseparable from the issue of efficiency (Koeck, 1997)90.
Quality literature in health care abounds with implementation of various quality management practices including TQM in the developed countries (Potter et al., 199491; Kohli et al., 199592; Moody et al., 199893; Yang, 200394). As health care organizations are becoming more and more complex, old models of quality assurance, relying on provider-based preset standards are insufficient to solving quality problems. Concepts of total quality management (TQM) and continuous quality improvement (CQI) have taken a central role in the health care quality management (McLaughlin and Simpson, 1999)95. According to Lakhe and Mohanty (1994)96, TQM is a solution for improving quality of products in developing economies so that they can compete in the global market. By adopting the concepts of TQM or CQI, a health care institution can move away from an inspection-oriented quality improvement system to one that orients itself to a systematic transformation of an organizational culture through a roll-out plan involving customer focus, key-process monitoring, data-driven tools and techniques, and team empowerment (Klein et al., 1998)97. In order to determine an organizations level of quality management and continuous improvement, many studies have used MBNQA (Counte and Meurer, 200198). Health care organizations in India are undergoing major changes like in any other developing nations and making sincere efforts to establish quality management practices. This thesis is taken up to work and analyze the quality management initiatives in the selected 5 hospitals in Hyderabad and to illustrate the importance of quality in the present context.
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QUALITY INITIATIVES IN INDIAN HOSPITALS
As hospitals in India are not only growing in number but in size, complexity and the types of services provided, there is an ever-growing need for professional management of hospitals (Tabish, 199699; Sharma, 1998100). A number of private and corporate hospitals are constantly innovating and improving the technical/clinical and service aspects like never before in order to provide world-class quality. In the absence of an accrediting body for hospitals, leaders in the industry are looking at different approaches like accreditation from organizations abroad and hospital grading by commercial organizations in India to improve quality and attract new markets. Nandaraj et al. (2001)101 examined the feasibility of introducing accreditation in Mumbai hospitals, though different stakeholders supported such a system, financing the process was judged to be a major hurdle.
Many Indian hospitals are getting ISO certification and Apollo Group of Hospitals in its efforts to position itself as an Indian MNC in global health care is undergoing the US Joint Commission on Accreditation of Healthcare
organizations (JCAHO) certification process. However, external reviews rarely generate wholly new knowledge, are found to be more confirmatory than revelatory, and do not usually lead to major changes in policy, strategy or practice (Walshe et al., 2001)102.
Industry leaders in India are also voicing their concerns about the usefulness of ISO and JCAHO certification for Indian hospitals. In general, ISO certification helps achieve consistency in production of a product or service and providing assurance to customers that the specific practices are in providers stated quality systems. ISO certification does not address the people issues specifically employee motivation, leadership style, social concerns and what should be improved in order to gain a competitive position.
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Therefore, models of TQM based on quality awards and empirical research for identifying critical factors have provided better framework to implement quality practices and measure performance of hospitals. Mohanty et al. (1996)103 have argued that although health care systems have some unique factors, they bear many similarities to other industrial systems and can be subjected to the same forms of analysis, evaluation and improvement. Improvement in quality has become essential in the health care sector in order to enhance efficiency and effectiveness of services. Process management (Varghese, 2001104; Reddy and Acharyulu, 2003105),
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patient
satisfaction/expectation surveys (Mahapatra et al., 2001
; Bhardwaj et al.,
2001107; Verma and Sobti, 2002108), reducing hospital infection rates (Vij et al., 2001109; Gupta and Kant, 2002110) and TQM (Reddy et al., 2002111; Arya et al., 2003112) are some of the reported quality improvement strategies implemented by hospitals in India.
While the TQM philosophy has its roots in manufacturing and industry, it is based on many techniques, which could easily be transferred to the health care setting. In the US Malcolm Baldrige National Quality Award (MBNQA) was instituted for the health care organizations on similar lines of the manufacturing industry, recognizing the importance of quality (Baldrige National Quality Program, 2003)113. The MBNQA has evolved from a means of recognizing and promoting exemplary quality management practices to a comprehensive framework for world-class performance, widely used as a model for improvement (Flynn and Saladin, 2001)114.
Currently, there are newly established criteria for performance excellence that have been specially tailored for the health-care providers. Meyer and Collier (2001)115 empirically tested the Baldrige Model of quality management for the health care industry using data from 220 US hospitals and determined the causal relationships among the Baldrige Health Care pilot criteria. The seven criteria are: leadership, strategic planning, customer and market focus, measurement,
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analysis and knowledge management, human resource focus, process management and business results. As such, its underlying theoretical framework is of critical importance, since the relationships it portrays for the different criteria convey a message about the route to competitiveness. It was therefore judged that the MBNQA health care criteria would provide a good framework to analyze quality management practices in the case hospital that has obtained ISO certification and strives for continuous improvement based on TQM principles including committed leadership, customer focus and satisfaction, process improvement, service design, human resource management and social responsibility.
QUALITY MANAGEMENT PRACTICES & HOSPITALS PERFORMANCE
Quality management (QM) has received a high degree of attention in extant literature. Several research papers attribute superior firm performance to adoption of QM practices. The availability of a large number of research papers that investigate the impact of QM practices on performance provide an ideal setting for theory extension and refinement using meta-analysis techniques which is as well applicable to hospitals. In his paper, Meta-analysis of the relationship between quality management practices and firm performance, implications for quality management theory development Anand Nair (A. Nair / Journal of Operations Management 24 (2006) 948975)116, a study is presented that fulfills two objectives.
First, his paper formalizes performance implications of adopting QM practices and present hypothesized relationship between QM practices and performance. Second, a meta-analysis of correlation (Hunter and Schmidt, 1990)117 approach is used to examine the empirical research in QM to determine which QM practices are positively related to improved performance. His study also examines the presence of moderating factors in the association between QM practices and performance. The results of his study support many
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hypothesized relationships and also point towards the presence of moderating factors in almost all QM practiceperformance relationships. A discussion of the findings was presented and directions for further development of QM theory were proposed in his paper.
ANALYSIS OF QUALITY IMPLEMENTATION ISSUES IN THE SELECTED HOSPITALS
The selected five hospitals were analyzed deeply considering all the available factors / information. Subsequently all the five hospitals were assessed based on three parameters and presented here to facilitate a common platform for understanding their existing situation. The history and profile of these hospitals helped in arriving so. The three parameters considered are as under. 1.Level of implementation of quality 2.Usage of management techniques in bringing the quality for patient satisfaction and 3.Implementation of quality initiatives
Accordingly the information is presented here in Table 3.3 related to all the selected five hospitals.
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Table 3.3: Comparative Analysis of Quality Implementation Issues in the Selected Hospitals Hospital Apollo Hospital Parameter Level of implementation of quality Observations / Remarks The implementation level of quality in Apollo is very remarkable. As shared by few of the top executives of this Hospital in Hyderabad, every employee in Apollo Hospital is committed to their best to serve the customer to their expectations. Special training programs regularly scheduled to provide the awareness to the employees of all categories including Administrators, Doctors, Nurses, Paramedical staff and Supporting staff. Usage of management techniques Implementation of quality initiatives Care Hospital Level of implementation of quality Over the years, Apollo has created a healthcare powerhouse that has significant presence in every sphere of healthcare across the nation. Its integrated business model, scale, national footprint and presence across multiple disease and delivery segments with various management techniques including organic and inorganic expansion in healthcare services. All these techniques are focused to bring / increase the patient satisfaction. All the efforts are targeted to approach the patient problems and provide qualitative remedial measures. Keeping the intense competition in view and necessary marketing tactics required by multiple commercial corporate organizations, CARE has carved a niche for itself by garnering the best reputation amongst the local masses. Equipped with the best of the facilities in areas of Education, Research, patient care and highly qualified professionals, CARE portrays the quality implementation levels to match global benchmarks and conquer healthcare market. Usage of management The management techniques practiced at CARE roots from the ideology of to put patients interests first. The ideology dictates every aspect of the clinical governance, patient care,
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techniques
satisfaction and the work culture. The great heights achieved in delivering medical care with exceptional quality have been a result of these values-based and the sense of patient satisfaction in health services.
Implementation of quality initiatives
Various quality initiatives were implemented by Care Hospital, including having the single largest team of Cardiologists and Cardiac Surgeons in the country, building multi specialty hospital, providing a base for many national and international clinical researches, creating an Institution with strong ethos and unflinching devotion to Ethical medical practice, converting to an institute par excellence and becoming an enviable solution and a role model to the ever demanding patient satisfaction through its physician-cooperative model.
NIMS
Level of implementation of quality
In case of NIMS, the level of quality implementation is visible by their efforts in bringing out as many services as possible. Having 25 clinical departments, 6 diagnostic departments and 7 supporting departments permit NIMS to show up good levels of quality implementation. Further, staffing particularly maintaining the doctors to patient ratio of 1:3 also allows NIMS to strengthen their efforts in implementing permeable levels of quality.
Usage of management techniques
Certainly the management techniques like having a firm Academic Council with strength of 35 members to advise and approve the academic programs, Ethical Committee to funnel the research projects are to bring in the quality for patient satisfaction. The efforts of management in starting courses of bachelors and masters in physiotherapy just at the time of necessity is a clever move which is to be appreciated and obviously focused to provide qualitative healthcare delivery to patients and to work to their satisfaction.
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Implementation of quality initiatives
It can be observed that NIMS effectively chalked out the implementation of quality initiatives. Whether it comes in creation of centers of excellence, educational and research facilities, or making the plans of super specialties existent, or teaching or training etc are all the initiatives which were implemented efficiently and functioning to the satisfaction of patients. Further, having medical audit sessions and regular training programs which are being conducted regularly shows the enthusiasm of the management in making their efforts to become successful and to pass on the positive benefits to patients while implementing the quality initiatives planned off.
Gandhi Hospital
Level of implementation of quality
All through, it is quite evident that Gandhi Hospital is striving hard to introduce the comfort levels to patients. It can be observed that majority of the Principals and administrators put up their efforts to introduce better facilities to patients. The same can be witnessed in the efforts they have put up to move the premises from Basheer Bagh campus to the Secunderabad campus. Similarly, their efforts to introduce the number of specialties are to increase the service levels to patients. The contributions from the administrators, doctors and nurses can be strengthened if government looks at the immediate replacement of equipment wherever necessary.
Usage of management techniques
The management initiatives are visible in bringing more and more facilities in order to provide more and more services to patients. The technological innovations like equipping the operation theaters accessible online is a best example to show the commitment of management to bring the best quality of experts advise to provide the better service to
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patients. Implementation of quality initiatives OGH Level of implementation of quality It is to be agreed that being a government owned hospital the scope to implement the quality initiatives takes more time than in a private environment. It is imperative to see the level of assurance being extended by the government and the administrators is to be appreciated. OGH has witnessed many of the renowned doctors, expert surgeons, highly trained specialists bringing in their highly experienced and carefully crafted patient treatment skills. Every one of them added with the pool of proved perfectionists topped the administrative positions in OGH, always tried to put in the best quality levels to be implemented while serving the patients. Usage of management techniques Without a second thought everybody has to agree that the management techniques being thought of were meant for the patient satisfaction. Despite working in an environment where the immediate possibility of using these management techniques is less, the efforts put up by the administrators, doctors, well trained and certified nurses, paramedical and supporting staff are all directed towards the patient satisfaction. A permeable delay in bringing the management techniques can always be understood by the patients keeping the realty in view. Implementation of quality initiatives A very practical training given to the junior doctors, a focus on contemporary research in the medical & healthcare delivery and practicing pioneering medical innovations were all part of implementation of quality initiatives in OGH. Undoubtedly, name either the administrators or the doctors; the dedication to implement the quality initiatives is to be understood particularly keeping the constraints like government control, incomplete & not regular replenishment of the resources including personnel and consumable medicines, in view.
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MARKETING MIX IN THE SELECTED HOSPITALS
The study of 7 P s itself is very enterprising. When it comes to the presentation of services, every organization must and will take care of the 7 P s in order to satisfy the customer. Once we've developed your marketing strategy, this "Seven P Formula" should be used to continually evaluate and reevaluate the business activities. These seven are: product, price, promotion, place, people, physical evidence and process. As products, markets, customers and needs are changing rapidly, we must continually revisit these seven Ps to make sure that we're on track and achieving the maximum results possible in today's marketplace.
Hospitals too are not exempted from this and need to work towards satisfying their customers i.e., the patients. Marketing in Hospitals is unethical was the frequent refrain in the eighties, when very few hospitals realized that it was necessary to incorporate marketing as an integral function in the hospital operations. Many hospitals started having eminent personalities from the industry on their Boards. Private hospitals can attract their shareholders by offering discounts. Hospitals have long-term understanding with PPOs (Preferred Provider Organization), which further have understanding with Corporates. Some hospitals by means of their past track record have created a niche market for themselves. Hospitals can also promote medical colleges. For example, Apollo Hospital and Care Hospital have nursing schools. Following to this, lets look at the native theoretical strength of 7 P s in brief and their application to the hospitals which are under study. THE FIRST P PRODUCT
Originally to be understood and contain both intangible and tangible type of products in any business, seeking to satisfy the new wants and demands of the consumer. The services are the type of products which are mostly intangible. 150
The hospital services include certain percentage of tangibility in terms of clinical services associated with the treatment using diagnostic tools (like X-Ray reports, Scan reports, Blood test reports etc,). The offerings include treated ailments which may be tangible and intangible. The treatment provided by doctors may be intangible whereas the tools that the doctors use in this process of treatment may be tangible. Usually the corporate hospitals specially the top management undergoes a tremendous mind work to begin with, and in that process, develops the habit of looking at their current products as an outside marketing consultant brought in to. Their thought process must help the hospital to decide whether or not it's in the right business at this time. Spinning further, they can ask critical questions such as, "Is our current product or service, or mix of products and services, appropriate and suitable for the market and the patients of today?" Whenever we're having difficulty selling as much of our products or services as we'd like, we need to develop the habit of assessing our business honestly and asking, "Are these right products or services for our patients today?" Is there any product or service we're offering today that, knowing what we now know, we would not bring out again today? Compared to our competitors, is our product or service superior in some significant way to anything else available? If so, what is it? If not, can we develop an area of superiority? Should we be offering this product or service at all in the current marketplace? The Table 3.4 is compiled to show the extent of the first P, Product, related to the selected 5 hospitals.
Service products of the hospitals normally have the following features. Quality Level Accessories Packaging (Bundling) like offering full health checkup. Product line Brand name 151
Table 3.4: Comparative Analysis of Product Information in the Selected Hospitals Apollo Hospitals Serving Patients in Cardiology, Oncology, Orthopaedics, Cosmetic & Plastic Surgery, Critical Care the areas of Medicine & Emergency and Trauma Care Facilities Health checkups, Complementary and alternative medicine, Corporate health programmes, Apollo life magazine, Disease management, Number of beds 4000 Services provided Nursing, Hospital management, Pharmacies, Diagnostic clinics, Medical transcription services, Third party administration and Telemedicine. Serving Patients in Cardiology, Cardiothoracic Surgery, Neurology, Neurosurgery, Urology, the areas of Gastroenterology, Surgical Gastroenterology, Orthopedics, Endocrinology, General Surgery, Critical Care, Radiology, Internal Medicine, Pulmonology, ENT, Pathology, Dermatology, Facilities Personal Nursing, Stent, Telemedicine, Robotic Surgery, Electro Anatomical Heart Mapping System Number of beds 1912 Services provided Catheterization Laboratory, Hospital management, Pharmacies, Diagnostic clinics, Medical Transcription Services, TPA Serving Patients in the areas of Facilities Number of beds Services provided Cardiology, Cardiothoracic Surgery, Neurology, Neurosurgery, Nephrology, Plastic Surgery, Urology and CP&T Teaching in Graduate and Post Graduate Specialties, Fellowship programs, 1012 Oncology surgeries, Laparoscopic Surgeries, Nephrectomy, Oophrectomies, Abdominoperineal resection, Excision of pelvic tumours, Intra-arterial regional chemotherapy, Isolated limb perfusion for extremity melanoma/ sarcomas, Diagnostics,
Care Hospitals
NIMS
Gandhi Hospitals
Serving Patients in General medicine, Pediatrics, Anesthesia, Cardiology, Dermatology, Leprosy, the areas of STD, Radiology, Casualty, Endocrinology, Dental, Obgyn, ENT, Ophthalmology,
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Facilities
Number of beds Services provided
Orthopedics, Urology, Neurology, Nephrology, Psychiatry and Hospital Administration General surgery, Orthopedic surgery, Cardio-thoracic surgery, Neurosurgery, ICCU, Mobile ICCU, Pediatric surgery, Neurosurgery, Gastroenterology, Cardiothoracic surgery, and Plastic surgery 1600 Cardiac Catheter Lab, Blood bank, TB clinic, Diagnostics, CT Scan, MRI, Pathology, and Nursin
OGH
Serving Patients in Medicine, Surgery, Radiology, Anesthesiology, Orthopedic surgery, the areas of Neurosurgery, Neurology. Facilities Teaching in Graduate and Post Graduate Courses, Research, ICU, Number of beds 3800 Services provided Ventilators, Diagnostics, CT Scan, Nursing, MRI, Pathology, and TB Clinic
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THE SECOND P PRICING
The second P in the formula is price. Develop the habit of continually examining and reexamining the prices of the products and services that we sell to make sure they're still appropriate to the realities of the current market. Sometimes we need to lower our prices. At other times, it may be appropriate to raise our prices. A direct application of this concept might not be appropriate to hospitals. Many companies have found that the profitability of certain products or services doesn't justify the amount of effort and resources that go into producing them. By raising their prices, they may lose a percentage of their customers, but the remaining percentage generates a profit on every sale. Sensing an appropriateness of this argument to hospitals may be a tougher task.
Sometimes we need to change our terms and conditions of pricing. Sometimes, by spreading your price over a time period during the treatment, we can sell far more than asking the patient to pay a lump sum. Sometimes we can combine products and services together with special offers and special promotions. This is more evident in diagnostics where bundling is proved to be attractive. Sometimes we can include free additional tests that cost very little to conduct but make our prices appear far more attractive to our patients.
In the business of hospitals, as in nature, whenever we experience resistance or frustration in any part of our sales or marketing activities, we must be open to revisiting that area. We must be open to the possibility that our current pricing structure is not ideal for the current market, if necessary, to remain competitive, to survive and thrive in a fast-changing marketplace.
Pricing in the service products of the hospitals normally need to consider many factors. The following are some of the parameters to decide the pricing.
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1. Charges vary in corporate hospitals due to the cost necessary for the sophisticated inputs like highly qualified and competent doctors, high precision and updated machinery etc. a. Packages available in corporate hospitals (like Rs. 1 lakh for bypass surgery, Rs. 60000 for Knee replacement etc.) 2. In corporate hospitals, varies from patient to patient and some times may be changed depending on need of patient which includes the severity drawing the attention of specialist doctors. a. Mostly the below three methods of costing can be observed i. Cost based ii. Competition based heart surgeries, knee
replacement etc., iii. Demand based (market) high tech, highly capable doctors, discriminative pricing for certain segments of politicians, cinema people etc., 3. Reasonable return on investment (ROI) in long run can be envisaged. 4. For some hospitals, the prices need to be changed based on market and some other times not a partial one such as NIMS. 5. Always fixed and as per government regulations usually are witnessed in government hospitals a. Free to all poor; nominal fee for others 6. Government hospitals may not have much of leverage as the control is centralized and will be fixed keeping the common and BPL families in view. 7. There are few schemes introduced by government like Rajiv Arogyasri helping the white card holders. 8. A usual phenomenon of trends like higher pricing in corporate and lower in government can be clearly observed.
The Table 3.5 is compiled to show the extent of the second P, Pricing, being applied to the selected 5 hospitals. Table 3.5: Comparative Analysis of Pricing Information in the Selected Hospitals
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Apollo Hospitals
General ward Semi private / sharing room Single room Deluxe room Suite room ICU
Rs. 1500 Rs. 2700 Rs. 5500 Rs. 6500 Rs. 12500 Rs. 5000 Rs.500 Rs.1,200 Rs.1,500 Rs.1800 Rs.2250 Rs. 500 Rs. 2500 Rs. 400 Rs. 800 Rs. 1200 Rs. 1500 Free Rs. 150 Rs. 300 Rs. 500 Rs. 500 Free Rs. 100 Rs. 200 Rs. 400 Rs. 500
Care Hospitals
General ward Twin sharing room Single room Single room AC ICU
NIMS
General ward Mettu Ranga Reddy room Millennium block (A,B,C types) Millennium block Millennium block Non A/C Millennium block A/C General ward Semi private / sharing room Single room Deluxe room ICU
Gandhi Hospitals
OGH
General ward Semi private / sharing room Single room Deluxe room ICU
THE THIRD P PROMOTION
One of the necessary habits in marketing and sales is to think in terms of promotion all the time. Promotion includes all the ways we tell our customers about our products or services and how we then market and sell to them. Small changes in the way we promote and sell our products and services can lead to dramatic changes in our results. Even small changes in our advertising can lead to immediate higher sales. It is observed that
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experienced copywriters can often increase the response rate from advertising by 500 percent by simply changing the headline on an advertisement.
Large and small companies in every industry continually experiment with different ways of advertising, promoting, and selling their products and services. And here is the rule: Whatever method of marketing and sales we're using today will, sooner or later, stop working. Sometimes it will stop working for reasons we know, and sometimes it will be for reasons we don't know. In either case, our methods of marketing and sales will eventually stop working, and we'll have to develop new sales, marketing and advertising approaches, offerings, and strategies.
Word-of-mouth, one of the promotion tools, plays a very important role in promotion of any organization and this is started showing its relevance to hospitals too. As evident, government hospitals by virtue of their existence are far behind catching the reality. The counter fits, corporate hospitals are going in big leaps, and using the promotional concepts innovatively and fully.
The three components of promotion, namely, advertising, publicity and personal selling individually, sometimes combined with others are taken appropriately by the corporate hospitals. Print media like Newspapers, Magazines Journals and Periodicals are helping them to push their prominence to public. Hoardings and wall writings near the markets and recreation centers are also evident. The sence of CSR activities to create awareness among the people is one of the intelligent yet bi-fold advantageous is being best utilized by some of the corporate hospitals. Ex. Aids awareness camp, Blood donation camps etc.
The Table 3.6 is compiled to show the extent of the third P, Promotion, being applied to the selected 5 hospitals.
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Table 3.6: Comparative Analysis of Promotion Information in the Selected Hospitals Apollo Hospitals Social programs for causes Women Health Empowerment, Distance Healthcare Advancement Project, Society to Aid the Hearing Impaired, Cancer Care Initiative, Save A Childs Heart
Care Hospitals
Social programs for causes
Little Hearts, Care Relief Fund, Smile Train, Kidney Care, Care Arogya, Trust Hospitals
NIMS
Free Health Checkups, Regular Programs in Rural areas for under privileged, Regular Cancer Detection and Screening Camps, Special reduced consultation fee for White Card holders
Gandhi Hospitals
White Card, Rajiv Arogya Sri
OGH
White Card, Rajiv Arogya Sri
THE FOURTH P PLACE
The placing is the second P which deals with physical establishment and point of service delivery. We need to develop the habit of reviewing and reflecting upon the exact location where the customer meets the sales person. Sometimes a change in place can lead to a rapid increase in sales.
We can sell our product in many different places. Some companies use direct selling, sending their sales people out to personally meet and talk with the prospect. Some sell by telemarketing. Some sell through catalogs or mail order. Some sell at trade shows or in retail establishments. Some sell in joint ventures with other similar products or services. Some companies use
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manufacturers' representatives or distributors. Many companies use a combination of one or more of these methods.
In each case, the entrepreneur must make the right choice about the very best location or place for the customer to receive essential buying information on the product or service needed to make a buying decision. What is ours? In what way should we change it? Where else could we offer our products or services?
To hospitals marketing, distribution of Medicare services plays a crucial role. Location of the hospital instrumentality works to be a deciding factor especially when there is a strong competition present in the close proximity, geographically. The same may not plays a significant role when the choice is between corporate hospitals and government hospitals. One another instance where this P may not turn to be a key is the case when a patient is referral and need to contact the specific hospital and the specific doctor only. Hence this P proves to be influential when the choice is in the hands of patient.
The Table 3.7 is compiled to show the extent of the fourth P, Placing, being applied to the selected 5 hospitals. Table 3.7: Comparative Analysis of Placing Information in the Selected Hospitals Apollo Hospitals Located in (distance from 7 KM from Central Bus nearest Transport facilities) Station, 8 KM from Railway Station, 30 KM from Air Port Built up area 46,000 Sq. Ft
Care Hospitals
Located in (distance from 6 KM from Central Bus nearest Transport facilities) Station, 5 KM from Railway Station, 30 KM from Air Port Built up area 38,000 Sq. Ft
NIMS
Located in (distance from 4 KM from Central Bus nearest Transport facilities) Station, 4 KM from Railway Station, 35 KM from Air Port Built up area 1 Million Sq. Ft 159
Gandhi Hospitals
Located in (distance from 5 KM from Central Bus nearest Transport facilities) Station, 1 KM from Railway Station, 40 KM from Air Port Built up area 6 Lakhs Sq. Ft
OGH
Located in (distance from 1 KM from Central Bus nearest Transport facilities) Station, 2 KM from Railway Station, 40 KM from Air Port Built up area 50,000 Sq. Ft.
THE FIFTH P PEOPLE
The fifth P of the marketing mix is people. Here we need to develop the habit of thinking in terms of the people inside and outside of our business who are responsible for every element of our sales and marketing strategy and activities. It's amazing how many entrepreneurs and businesspeople will work extremely hard to think through every element of the marketing strategy and the marketing mix, and then pay little attention to the fact that every single decision and policy has to be carried out by a specific person, in a specific way. Our ability to select, recruit, hire and retain the proper people, with the skills and abilities to do the job we need to have done, is more important than everything else put together.
In his best-selling book, Good to Great, Jim Collins discovered the most important factor applied by the best companies was that they first of all "got the right people on the bus, and the wrong people off the bus." Once these companies had hired the right people, the second step was to "get the right people in the right seats on the bus."
To be successful in business, we must develop the habit of thinking in terms of exactly who is going to carry out each task and responsibility. In many cases, it's not possible to move forward until we can attract and put the right person into the right position. Many of the best business plans ever
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developed sit on shelves today because the people who created them could not find the key people who could execute those plans.
In the context of hospitals, it is not a difficult task to list the categories viz., internal customers and external customers. The prior include administrators, doctors, nurses, paramedical staff and supporting staff whereas the later covers predominantly patients. Though media, general public, government etc, also can become part, the significant contributions can be mostly confined from patients.
The power of people in hospitals can also be seen in another distinction. When we look at front office, most of the times, the administrative people, doctors and nurses come in first layer of contact. The patient meets these categories of hospital staff in his or her first point of information and or treatment. Then comes the back office; wherein the special needs providers like ICU, diagnostics, paramedical and clinical staff comes into scenario.
The dominant strategy and the most challenging task to the top management is creating a right culture in the hospital. This is more required as to have an influence on patients. The customers, i.e., patients must have the feel and culture of the organization is the tone for that.
The Table 3.8 is compiled to show the extent of the fifth P, People, being applied to the selected 5 hospitals.
Table 3.8: Comparative Analysis of People Information in the Selected Hospitals Apollo Hospitals Doctors Nurses Administrative Staff Paramedical Staff Other Staff Care Hospitals Doctors Nurses 1500 Consultants, 2000 Supporting Doctors 4500 843 1037 683 220 1000
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Management & 612 Administrative staff Support staff (outsourced) 759 Paramedical staff 1115 NIMS Faculty Doctors Doctors Medical Officers Nurses Administrative Staff Paramedical Staff Other Staff (including Class IV, Consolidated Staff) Gandhi Hospitals Doctors Nurses Administrative Staff Paramedical Staff Other Staff Doctors Nurses Administrative Staff Paramedical Staff Other Staff 139 43 (& 172 Resident Doctors) 14 426 149 304 946
138 342 117 398 518 250 (60 Professors + 190 Civil Assistant Surgeons) 530 202 614 311
OGH
THE SIXTH P PROCESS The next P is processing. We should develop the habit of thinking continually about how we must design better processes to better serve our customers. How do people think and talk about us when we're not process specific? How do people think and talk about our company? What process structure that we have developed, in terms of the specific activities our staff use when our customers describe us and our offerings to others?
A critical determinant of our success in a competitive marketplace is also dependent on how better and how structurally we are able to deliver the services to our customers. Attribution theory says that most customers think of us in terms of a single attribute, either positive or negative. Sometimes it's "service." Sometimes it's "excellence." Sometimes it's "quality engineering," as with Mercedes Benz. Sometimes it's "the ultimate driving machine," as with 162
BMW. In every case, how deeply entrenched that attribute is in the minds of our customers and prospective customers determines how readily they'll buy our product or service and how much they'll pay.
We have to develop the habit of thinking about how we could improve our processes. Begin by determining the process that we'd like to have. If we could create the ideal impression in the hearts and minds of our customers, what would it be? What would we have to do in every customer interaction to get our customers to think and talk about in that specific way? What changes do we need to make in the way interact with customers today in order to be seen as the very best choice for your customers of tomorrow?
When we observe by inspection, we can identify that every hospital specifically corporate hospitals, carefully keep track of activities from beginning of admitting a patient till the final dispatch after complete treatment. To facilitate this, every hospital need to have a process of needs with a clear and transparent order or structure of operations. It is quite obvious that when the flow of activities are planned, the hospital approach towards moving the patient from one layer to another layer can be found to be very quick and seem less. The sequence of operations determines the level of efforts put up by the hospital administration to make the more comfortable stay of patient in their hospitals. Various services including, medical services & auxiliary services need to be knitted carefully and must be designed towards patient centric.
Some of the characteristics / parameters / actions needed from the administrators which would influence the design of effective processes in a hospital include the below. a. Organization structure b. Different tasks that are performed by the hospital efficiently and effectively c. Communication structure within the setup d. Experts and specialists of different disciplines e. Quick and healthy service under all situations from the staff. 163
The Table 3.9 is compiled to show the extent of the sixth P, Process, being applied to the selected 5 hospitals.
Table 3.9: Comparative Analysis of Process Information in the Selected Hospitals Apollo Hospitals Organization structure Comprising Chairman, Managing Director, Executive Directors, Directors, Superintendent, and Chief Doctors Innovative practices Consulting, Aggressive Expansion Plans, Brown Field Expansion, Inorganic Expansion
Care Hospitals
Organization structure Comprising Chairman & Managing Director, Chief Executive Officer, Whole time Director, Directors, Chief Doctor and Medical Officers Innovative practices Clinical Researches & Clinical Trials, VSAT based Public-Private Telemedicine system launched.
NIMS
Organization structure
Innovative practices
Statutory body, viz., Finance Committee, Purchase Committee, Works Committee, Ethical committee, Committee for Academic and Service Accountability Rehabilitation Program for Cancer patients and clinical Research on Immuno-therapy and Molecular treatment, and many Research Projects
Gandhi Hospitals
Organization structure Innovative practices
Directors, Chief Superintendent, Chief Medical Officer and Chief RMO First open-heart surgery in the state
OGH
Organization structure Innovative practices
Directors, Chief Superintendent, Chief Medical Officer, and Chief RMO First time usage of Chloroform, Causative agent of malaria was elucidated by Sir Ronald Ross, each medical specialty has a separate training hospital.
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THE SEVENTH P PHYSICAL EVIDENCE
The last P in this series is Physical Evidence. A quite significant factor which gets imprinted in patients mind is the physical presence of hospital. The first look starts from the front office, the arrangement of facilities in and around, the way that leads to different departments, rooms, the sophisticated equipment that the hospital is using for diagnostics, processing the documents etc., plays very crucial role. From gigantic structures like buildings, to very low rated files that carry the history of patients, the prescriptions given to patients and transferred from one department to another also counts. Some times we can observe the dressing of staff in all categories including doctors, nurses, house keeping staff matters a lot. Though this feature looks to be not so significant, it is very important habit that shows the discipline and importance hospital gives to patients. A recent practice in some of the hospitals especially in corporate hospitals is interiors design and decoration of the office facilities. A feel at home factor is to be created and it is the responsibility of management of hospitals to create and continually maintain the hygiene factors. A pleasant environment needs to be created in the hospital and sometimes may include development and construction of a dignified and green materials like gardens.
In nut shell it can be told that the creation of right ambience is very important factor and necessary responsibility of the hospitals administration. Another interactive tool that is being used by only few hospitals is the presence of website. They are cleverly using this tool to create awareness among the patients and interested communities. They are providing as much information as possible so that the patients are well informed about the service providers.
Some other parameters / points that include part of physical evidences can be, Smart buildings Logos
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Mascots Proper diagnosis and cure of the problem Diagnostic equipments used in the hospitals etc.,
The Table 3.10 is compiled to show the extent of the seventh P, Physical Evidence, being applied to the selected 5 hospitals.
Table 3.10: Comparative Analysis of Physical Evidence Information in the Selected Hospitals Apollo Hospitals Buildings Well built up multi floored buildings spread out with sophisticated facilities, centrally air conditioned administrative offices, lush green gardens, with sprawling parking areas Sophisticated and upto date technology, Internet connected systems for prompt communication, Fully loaded diagnostic facilities, Completely automated operation theaters, very hygienic patient rooms including supporting systems
Equipment
Logo
No. of patients cater to Care Hospitals Buildings
Above 67,455 patients per year
Equipment
Multi floored buildings spread out with sophisticated facilities, centrally air conditioned administrative offices, patient friendly indicator based clinics Technically superior domain knowledge, Internet connected systems for prompt communication, Fully loaded diagnostic facilities, Completely automated operation theaters, very hygienic patient rooms including supporting systems
Logo
No. of patients cater to
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NIMS
Buildings
Equipment
Spread in 30 acres of land in the heart of Hyderabad city. Almost three multi stored buildings. Historical buildings are converted into hospital. Dedicated hostels for teaching hospital. Operation Theaters, Anaesthesiology and IC Unit, CT Scan machines, MRI, Cardio Catheterization, and Digital Subtraction Angiography
Logo
Gandhi Hospitals
Buildings Equipment
Newly constructed buildings, spread into multi floors, spacious rooms and departments Ventilators, Surgical Operation Theaters, Dialysis machines, CT Scan machine, Video endoscope machines, ICU and MRI machine
Logo
OGH
Buildings
Equipment
Relatively old buildings but very spacious, multi stored and can cater to the needs of various departments. Historical buildings are being used in the heart of the city. Hostels buildings for students. ICU, CT Scan machines, MRI units, diagnosis laboratory and dialysis equipment
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Logo
In hospital organizations the need to undertake segmentation in order to simplify their task of creating and stimulating demand is a point of interest on the administrators desk. This facilitates to identify the potential customers, transform them into actual customers and further into habitual customers.
The below are the some of the possible segments and can be of hospitals interest. 1.Non-users: They lack the willingness, desire and ability (income & leisure time). 2.Potential Users: They have the willingness but the marketing resources have not been used optimally to influence their impulse. 3.Actual Users: They are already using the services generated by the hospital. 4.Occasional Users: They have not formed the habit of visiting hospitals. 5.Habitual Users: They have formed a habit and avail of the services regularly.
The discussion of specific quality related issues in the selected five hospitals, a focused narration on marketing mix and comparative discussion of the five hospitals under study provides sufficient lead to discuss the study of patients demographics distribution and study of staff perceptions with respect to service quality.
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CHAPTER 3

SERVICE QUALITY IN SELECTED HOSPITALS A THEORETICAL FRAMEWORK

Definition Appearance of physical facilities, equipment, personnel, and communication materials

Ability to perform the promised service dependably and accurately

Caring, individualized attention the firm provides its customers

Original Ten SERVQUAL Dimensions

Modified SERVQUAL Dimensions

Courtesy Assurance Credibility

Understanding The Customer

responsiveness, assurance, and empathy which Zeithaml, et al (1988)3

DIMENSIONS IN MEASURING SERVICE QUALITY

Figure 3.2: Service Quality Gap Model by Zeithaml et al.

2. Inadequate Upward Communication 3. Too Many Levels of Management

Management Perceptions of Customer Expectations

Figure 3.4: Key Factors Contributing to Gap 2

Management Perceptions of Customer Expectations

Service Quality Specifications

Service Quality Specifications

Figure 3.6: Key Factors Contributing to Gap 4

people and operations Inadequate Communication between human

resources, marketing and operations 2. Propensity to Over promise

External Communication to Customer

USING SERVQUAL TO EVALUATE SERVICE QUALITY

VALIDITY OF SERVQUAL IN MEASURING SERVICE QUALITY

CHALLENGES IN GENERAL AREAS CONCERNING VALIDITY

QUALITY ISSUES IN HOSPITALS

QUALITY INITIATIVES IN INDIAN HOSPITALS

satisfaction/expectation surveys (Mahapatra et al., 2001

QUALITY MANAGEMENT PRACTICES & HOSPITALS PERFORMANCE

ANALYSIS OF QUALITY IMPLEMENTATION ISSUES IN THE SELECTED HOSPITALS

Implementation of quality initiatives

Level of implementation of quality

Usage of management techniques

Implementation of quality initiatives

Level of implementation of quality

Usage of management techniques

MARKETING MIX IN THE SELECTED HOSPITALS

Number of beds Services provided

THE SECOND P PRICING

THE THIRD P PROMOTION

Social programs for causes

Social programs for causes

Social programs for causes

White Card, Rajiv Arogya Sri

Social programs for causes

White Card, Rajiv Arogya Sri

THE FOURTH P PLACE

THE FIFTH P PEOPLE

Organization structure Innovative practices

Organization structure Innovative practices

THE SEVENTH P PHYSICAL EVIDENCE

No. of patients cater to Care Hospitals Buildings

Above 67,455 patients per year

No. of patients cater to

Above 26,095 patients per year

No. of patients cater to

Above 31,295 patients per year

No. of patients cater to

Above 24,500 patients per year

No. of patients cater to

Above 65,790 patients per year

Health ed., Aspen

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