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Health care services and facilities at Public hospitals in India and Singapore

By
Santosh Chourpagar
Student No: 1209675

Dissertation Project submitted as a mandatory requirement for the completion for the
award of:

MASTER OF BUSINESS ADMINISTRATION-5002
UNIVERSITY OF BOLTON

Supervisor: Dr. Ron Smith
Marking Tutor: Dr. Mathew Shafaghi



Word counts: 15073 words
Date of submission: 30
th
August 2014






2
ABSTRACT

Parasuman (1985) suggested that service quality is compared with what patients
actually want in the services, which is provided by any healthcare providers. Today
competitive atmosphere service quality is the most important part of the public and
hospital.

In this research author chooses reputed public hospital in India (two) and Singapore
(two), which is representing his own country in a public hospital sector. The research
aim is to find about service quality and facility standard in both country public
hospital and which country public hospital is giving excellent service quality. The
research is performed on 440 responded peoples in the hospital.

In this research In chapter-one author give overview of healthcare with India and
Singapore hospital detail and problem in service quality, author mention according to
problem research question, and research question develop a strong objective which
inspired author to research, in this research author careful about the ethical guideline
which is mention in chapter-one and more detail attach in APPENDIX-7, In chapter-
two about literature review author mention all service quality model which is suitable
for improving the service quality with conceptual framework for research. In chapter
four is the strong pillar for research in which the author is using. Saunders
Research onion and evaluate each and every layer to evaluate the service quality
in both country hospital according to patient, doctors and nurses respected view.
Chapter-five author analysis data from a primary and secondary sources and
according to this data analysis arises in which author found there is the gap between
India and Singapore public hospital service quality especially in Indian public hospital
because of this gap patients are getting poor service quality. Depending on finding
in the research Singapore hospital is giving excellent quality in his services. In the
conclusion author explains the service quality in India and Singapore and lastly
author suggests some useful recommdation for Indian public hospital.

Keywords- Service quality, Public hospital, Patient satisfaction, Gaps model

3
Contents Pages

CHAPTER-ONE

1.1 Introduction 11
1.2 Healthcare industry profile 12
1.4 Hospitals Profile 16
1.5 Reasons Why Health Care Sector was Chosen 17
1.7 Research Contribution / Significance of the Research 19
1.8 Research Questions 19
1.9 Hypothesis 19
1.11 The Outline of Dissertation 20
1.12 Conclusion 22

CHAPTER-TWO

2.1 Introduction 24
2.2 Literature Review 24
2.2.2 Theories of customer satisfaction 25
1.3 Research background 13
1.6 Research Objectives 18
1.10 Research Ethics 20
2.2.1 Patient satisfaction and its Dimensions 24
4
2.2.4 Measuring customer satisfaction 25
2.3.1 Statement of the Problem in Hops-A and B 26
2.3.2 Drawbacks of the Indian public hospital
(Hosp-A and Hosp-B)

28
2.4.1 Singapores Healthcare Expenditure in public
hospital
30
2.5 Measuring service quality models 36
2.5.1 Service Quality Models 38
2.5.3 Hospital Technical, Functional and Image Quality
Model

40
2.5.4 Service Quality, Patients Value and Patients
Satisfaction Model
41
2.5.5 The service-marketing triangle 43
2.6 Conceptual framework 45
2.7 Conclusion 46

2.3 Health care in Indian Public hospital 25
2.4 Health care in Singapore Public hospital 29
2.5.2 Gap model 38

CHAPTER-THREE


3.1 Introduction 48
5
3.2 Methodology 48
3.3 Methodological consideration 49
3.3.1Research Philosophy 52
3.3.2 Research Approach 55
3.3.3 Research Strategy 55
3.3.4 Research Choice 55
3.3.5 Time-horizon 55
3.3.6 Research purpose 56
3.3.7 Rejected methods 56
3.4 Research procedures 57
3.4.1 Data Collection Methods and Triangulation 58
3.4.2 Semi structured Interviews 59
3.4.3 Survey Questionnaire 60
3.5 Ethical Considerations 61
3.6Analysis of Data 61
3.7 Sampling 61
3.8 Conclusion 62

CHAPTER-FOUR


4.1 Introduction 63
4.2 Demographic Analysis 63
4.2.1 General Questions about Health Care Services
Taken Recently
67
6
4.3 Quantitative research 72
4.4 Qualitative Research 88
4.5 Environmental analysis 91
4.6 Conclusion 93

CHAPTER-FIVE


5.1 Introduction 94
5.2 Critical evaluation of adopted methodology 95
5.2.1 Discussion of objective -1 96
5.2.2 Discussion of objective -2 100
5.2.3 Discussion of objective -3 96
5.3 Conclusion 97
5.4 Research limitations 98
5.5 Recommendation 98
5.5.1 Recommendation -1 98
5.5.2Recommendation-2 100
5.5.3Recommendation-3 100
5.5.4 Recommendation-4 101

5.5 Conclusion
105
Reference 106
Bibliography 111
7
































Appendix-1 113
Appendix-2 129
Appendix-3 136
Appendix-4 137
Appendix-5 138
Appendix-6 139
Appendix-7 143
Appendix-8 148
Appendix-9 149
8

LIST OF FIGURE

Pages

CHAPTER-ONE


1.1 Healthcare industry profiles
13

1.2 Health expenditure graph (GDP %) India and Singapore
16

CHAPTER-TWO


2.1 Health and Family welfare at Central level by Govt. of India,
26

2.2 KEM hospital rooms
27

2.3 Statement of problem in Hosp-A and B
28

2.4 Subsides plane in Singapore public hospital
30

2.5 Singapore public hospital rooms
31

2.6 Singapores Healthcare Expenditure in public hospital
32

2.7 Comparison with other country service treatment
33

2.8 Finance expenditure on healthcare, Singapore
34

2.9 Controlling cost in Singapore healthcare.
35

2.10 Service quality model
37

2.11 Essential service quality 22 articles in healthcare system
38
9

2.12 Gap Analysis Model
39

2.13 Gap model (1-5)
40

2.14 Hospital Technical, Functional and Image Quality Model.
41

2.15 Service Quality, Patients Value and Patients Satisfaction
Model
42

2.16 Service marketing triangle
43

2.17 Service quality and profitability
45

2.18 Conceptual framework
46

CHAPTER-THREE


3.1 Research onion
49

3.2 Differentiate diagram Exploratory, Descriptive and Explanatory
50

3.3 Deductive and Inductive Approach
53
10

3.4 Quantitative and Qualitative analysis
54

3.5 Sampling group structure
57

3.6 Sampling group structure hospital
57

3.7 Analysis of data
59

3.8 Primary and secondary data collection model
60

3.9 Secondary data source
60

CHAPTER-FOUR


4.1 Demographic analysis
63

4.2 General Questions about Health Care Services
65

4.3 Expectations of patients from the behavior of medical
assistants
66
11

4.4 Expectations of patients from the quality of the administration
69

4.5 Expectations of patients from the services and facilities
provided by the hospitals.
70

4.6 Expectations of patients from the behavior of doctors
71

4.7 Perceptions of patients from the behavior of medical assistants
72

4.8 Perceptions of patients from the quality of the administration
73

4.9 Expectations of patients from the services and facilities
provided by the hospitals
74

4.10 Satisfaction level of patients for the behavior of doctors
75

4.11 Satisfaction level of patients from the behavior of medical
assistants
76

4.12 Satisfaction level of patients for the behavior of doctors
77

4.13 Satisfaction level of patients for the behavior of doctors

79

4.14 Access to medical care Hosp-A & B and Hosp-C & D
80

4.15 The time you spend in waiting room for doctor Hosp-A & B
and Hosp-C & D.
82

4.16 The staff willingness to help you
83

4.17 Cleanliness in both country public hospitals
84

12
4.18 Public hospital behaviour of administrator 85

4.19 According to you which hospital is best?
86

4.20 Which hospital is economical to you?
87

4.21 The Public Hospital provides proper authority, Responsibility,
and accountability to its health workers Hosp -A & B and Hosp- C&
D
88

4.22 Doctors, nurses and technicians are recognized and
rewarded suitably by the hospital
88

4.23 factor analysis
91

4.24. PEST Analysais

92

CHAPTER-FIVE


5.1 Implanting Enterprise Resource Planning (ERP)
99

5.2 Human resource implantation

100











13
ACKNOWLEDGEMENT

I would be sincerely thankful to my supervisor and adviser Dr.Ron Smith and Dr.
Mathew they always give his valuable time to give feedback and guidance to my
dissertation, because of his valuable guidance I complete my dissertation on time .

I would like to express my gratitude to my school United world school of
business,Singapore especially Dawn gan (Head of department,United world school
of business,Singapore) ,Mr. Lee ( professor), Pixie koh (professor) and Mr.David toh
( Head of Student support department,Singapore) for his help and support at the
time of writing a dissertation.I would also like to thanks my parents and my
friend's.They were always supporting me and encouraging me with best wishes.

Singapore 30
th
August ,2014













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CHAPTER-ONE

1.1 Introduction :-

Health care is one of the most important factors in life and patients always need and
demand for quality health care for healthy living. The purpose of patient health care
centric patient satisfaction of consumers becomes the basic necessity for the health
care provider (Desai, 2011).

The role of the Indian and Singapore government in the accountability of hospitals
for quality of care involves shaping the community of those interested in

Quality developing methods and infrastructure,
Standardizing information providing information and technical assistance and
patient care.

Healthcare industry has witnessed an increase in demand for quality health care
after globalization. Urbanization has improved the service quality of health care.
Service quality has been selected as a key element of the consumer to choose the
best hospital (Dr.Vanniarajan & Arun, 2010) although the development of health care
industry and health care organizations are fighting to provide quality health care in
the competitive environment (Avgar et al., 2011).
In recent year service quality restructured its now patient centric (Desai, 2011).
Furthermore, in this research author showing there is necessary to improve
customer service (Padma et al., 2009). In recent service quality is now become
essential factor to achieve competition to defeat the reveals (Rashid & Jusoff, 2009)
Healthcare service has superior position apart from other services because there is
nature of the risk involved. Therefore the patient satisfaction and service quality in
healthcare always are sating more essential and complex (Taner & Antony,
2006,quoted by Rashid & Jusoff, 2009).
As per Shaktivel et.al (2005) customer (patients) satisfaction is the important
variables that judges the patient toward the service quality given by provides
15
(Shaktivel et.al (2005); cited by Ooi et al, 2011) for the hospitals service quality
research, shown that the relationship between patient satisfaction and service quality
in healthcare impact on patient satisfaction (Kessler & Mylod, 2011). Woodruff in
1991 has shown that health providers consider the loyalty toward patients and this
will give the competitive advantage to the health provider. Many research has shown
that increasing the customer satisfaction increase profit of organizations (Woodruff,
1991), cited by Wang and Wu, 2012) on the other side Strasser et.al 1995 expressed
that negative publicity by patient word of mouth can give in a loss of hospital
incomes USD$ 6,000 to USD$ 400,000 approximately (Naidu, 2009).

According to Lim and Tag (2000) public awareness and a rising proficiency rate of
populous build is the procurement of healthcare services to quality treatment for
patients. Hospital should pay attention and give the excellent service quality for
narrowing the gap between the patients really expects and what service is really
getting by hospital (Lim and Tag (2000); quoted by Suki et al, 2011).

In this research, the authors will assess the quality of services is a decisive factor for
patient satisfaction. First of all authors start with the profile of both country public
hospital then the authors discuss the research goals and objectives then the author
has to say about the reasons for the choice of topic for this research the company's
platform and eventually ended by the entire research summary.

1.2 Healthcare industry profile: -

Health care Industry in India and Singapore offers broad and intensive forms of
services, which are related to patients treatment and satisfaction on his treatment.
In India public health care sector control by state level with the help of the Indian
central government and in Singapore its control by the ministry of health, Singapore,
both countries covers a following services and basic facility.
16

Figure-1.1, Source -Self made for research Healthcare industry profile

1.3 Research background-

In the healthcare industries, both country public hospitals serve the same kind of
service but they do not provide the same quality of service with the patient
satisfaction. In the developing world healthcare industry has driven a huge worldwide
development in the field of health care services.

In the worldwide research of health care industry, as patients began to require and
need forethought better drugs, services and excellent quality of healthcare for
treatment (Naidu, 2004). As per Pricewaterhouse Coopers (2007), in the
administration part, the health care industry one of India's and signature biggest
segments regarding income and is developing quickly.

Health care industry covers
Insurances in hospital healthcare and patients
Medical develop software
Medical equipment
Pharmacy
Different types of health care services
Hospitals
Hospital pathology clinics
Blood Banks
Centers of meditation
Emergency services like (Ambulances, etc.)
E-healthcare services
Telemedicine
Yoga Clinic
Gym
Spas clinic
!
!
!

Year wise
Health Budget


Central government
Budget *


State government
Budget **
2009-2010 Actual USD $ 3197.188
Million
Actual USD $
529.5 Million
2010-2011 Revised USD $ 3809.68
Million
Revised USD $
704.21 Million
2011-2012 Budget USD $ 4397.8
Million
Budget USD $
820.96 Million
!
!
17
In the recent decades Indian government have trying to improving the service quality
in the public hospital not only for the domestic patient but also in its efforts to
become a preferred destination for health care for foreigners due to the lower cost
treatment is available on the other hand public hospitals of Singapore has
established itself as a health care destination and can access and affordable for
domestic patients and also the, attracting about 400,000 foreign patients each year
for medical treatment (Patients beyond borders. com, 2014) .

As compare to Singapore public hospital In Indian public hospital the service quality
of health care is hopeless and by and large the health conclusion is a long way from
palatable (Bajpai and Goyel, 2004). In the health care system patients fulfillment is
additionally an imperative issue as in other service quality segments (Tuu & Olsen,
2012). A health care conglomeration can attain patient fulfillment by furnishing
quality administrations; keeping in perspective patients' desire and nonstop change
in the health care industry (Zeithmal, 1990) in Chapter 2, 3 and 4 author will explain
and demonstrate research and provide evidence regarding both country hospital
healthcare system.

In this research author choose two reputed hospitals in each country. Which is
represent hospital
1. Indian public Hospitals
I. kem hospital, Mumbai,India(Hosp-A)
II. Lokmanya Tilak Municipal General Hospital, Mumbai, India (Hosp -B)

2. Singapore public Hospitals
I. Singapore general hospital ,Singapore (Hosp-C)
II. Alexender hosptal,Singapore(Hosp-D)

India and Singapore have seen an increase in demand for quality health care after
globalization has enhanced the quality of life so has demanded health care quality.
In the Indian public hospital, the number of Indian doctor working in 2012 increasing
rate is approx. 270 and private hospital approx. 327 (Ministry of Health, 2013
statistics books, page 13).
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The bed capacities of Indian public hospitals are not sufficient to meet the current
needs of the patient requirement especially Hosp B after this issue ministry of
health continues to build new buildings to enhance the bed capacity (Ltmgh.com,
2014).
Indian public hospital (Hosp- A & B) also facing a problem which they have a
shortage of people and specialist those have lack of knowledge and handling of
advanced technologically equipment. Specialize doctors shortage for major disease
like Vessels, heart surgery and cancer, over an over years the disease increase
because of no effective treatment (Ministry of Health, 2013 statistics books, page
14). In this case lack of services for patients they transfer the patient to private
hospital to receive the necessary treatment for their illnesses on the other hand
Singapore (Hosp-C and D) has become the most preferable destination for quality
healthcare to the patient they have proper specialist for giving the proper treatment
in major disease, patient are preferred public hospital as compare to private for
better and effective treatments.

According to vanniarajan & Arun, 2010 service quality is the major element to
selecting hospital for treatment therefore Singapore has become medical hub for the
domestic patient and other parts of the world European as we can see in figure-1.2
the Singapore spent almost 31.4 % for healthcare expenditure as compare to Indian
which is 28.2 %. According to KGMP report 2012 its showing the healthcare in
Singapore will booming USD 79 billion (2012) and it will defiantly increasing up to
280 Billion (2020) (KMPG, 2012) this is because the Singapore hospital giving
effective with excellent patient centric service quality (Desai, 2011).
19

Figure-1.2, Health expenditure graph(gdp %) India and Singapore,-Source- http://kff.org/global-
indicator/ government-health-expenditure-as-percent-of-total-health/.
1.4 Hospitals Profile: -

INDIA-
I. KEM hospital (Hosp-A) are attach with medical college (Seth Goverdhan
das Sunderdas Medical College) provides training to about 2000 students
for the undergraduate medical courses, postgraduate and super specialty
courses. The institute also offers undergraduate courses and postgraduate
physical therapy and occupational therapy in addition to doctoral courses
in various specialized alliances and Master. Organize and maintaining a
school and hospital there is approximately 390 employees, 550 resident
physicians are appointed by state government about 1.8 million
outpatients and 78,000 inpatients annually comes for treatment and
hospital provides both basic care and advanced treatment facilities in all
fields of medical and surgical (Kemhospital.org, 2014) more detail in
APPENDIX -2

II. LTMGH, (Lokmanya Tilak Hospital City) (Hosp-B) locally known as
"Hospital Sion", is a general hospital situated in the city of Sion, a region
Mumbai. It began in 1947 with 10 beds initially, but has now turned into a
20
multi-specialty hospital with over 1,400 beds. In the same campus, it is
appended to the Lokmanya Tilak Medical College City (LTMMC) is a
teaching hospital for post-graduate studies and postgraduate medical
hospital sciences. This in a unique situation and most large tertiary
hospital serving first and all injuries and disasters of both major highways.
Start a subclass fifty hospitals and OPD only, at a military hospital, has
developed more than 1,400 beds, and planning to expand faster in a few
years (Ltmgh.com, 2014) more detail in APPENDIX-2

SINGAPORE-

I. Singapore General Hospital (Hosp-C) Singapore public hospitals (Hosp-C
& D) are one of the centers for emergency medical care at the prestigious
Singapore, and receive referrals from the most complex to another hospital.
The management and medical team of highly qualified based on education
and training (Sgh.com.sg, 2014) The hospital is equipped with high-tech
tools to provide the most advanced best treatment (Sgh.com.sg, 2014) The
hospital has a highly experienced staff nurses served basis hospital has 22
rooms with experienced doctors and the most famous of Singapore, please
refer to APPENDIX-1)

II. Alexandra Hospital, Singapore Hospital (Hosp-D) is 400 beds the
hospital is located at the southwest of Singapore in a land of 110,000
square meters. The hospital is a picture of a peaceful setting, lined with style
mansion bordering assembled from the late 1930s (Ah.com.sg, 2014) (More
detail please refers APPENDIX-1).

1.5 Reasons Why Health Care Sector was Chosen: -

Service quality is an imperative component to assess the triumph of any industry,
meeting the success of patient desires is characterized targets of the business.
Patient satisfaction has been considered as an imperative achievement considers
ready to go is the soul of the day, when good conditions to hold clients and keep up
21
a piece of the overall market share. It is the same applicable scenario for the hospital
industry. It is a compulsory benchmarks used to measure the satisfaction of the
patient in attaining devotion to the public hospital because all of the services of the
hospital to the patient's input on the way it is for the patient and the satisfaction
derived output.
The acceleration of patient satisfaction is basic to client reliability. Service provider
ought to constantly figure out how to enhance patient satisfaction is one of the
elements that measure by the hospital for the patient's service quality. Therefore, an
attempt was made to speak to evaluate service quality is a decisive factor for patient
satisfaction, for which a case research was done on Health care services and
facilities at public hospitals in India and Singapore.
1.6 Research Objectives-

I. Comparative analysis between Singapore and Indian public hospitals & find
out the significant difference.
II. To find the level of patients satisfaction and perception towards Singapore
and Indian public hospitals.
III. To find out & suggest the solutions, tools, methods, facilities for improvement
in service level in public hospitals, which will be suitable to each country.

1.7 Research Contribution / Significance of the Research-

Author of particular interest in this research, he also works as a physiotherapist at
XXXX, in the public hospital. The author is amazed by the speed and quality of
health care in public hospitals in Singapore. This research will provide readers with
some useful information about patients implementation and management of public
hospitals. Paper extra effort to research and propose solutions to improve the level
of service in public hospitals, which would be appropriate and beneficial for each
country. In terms of health care services are few public studies have been touched
on the bench. Through this research, the author will be available to see and find out
if both countries provide better health care and if Singapore hospital for the excellent
service, the Indian hospital can take the example of Singapore public hospitals and
22
to follow his path.
1.8 Research Questions:

1) How long do patients have to wait for in the Out Patients Department?
2) Where are the patients coming from?
3) How many critical patients are being admitted to the public hospital in India
and went to Singapore Public Hospital for further treatment?
4) What sorts of preparing about formal quality change systems are offered to
health professionals?
5) What evidence is the matter about the best techniques for preparing clinicians
in quality change?
6) Are both country partnerships giving improvement in public healthcare
industries?

What is the difference between the service qualities of both public hospitals?
To address this research question the following hypothesis were developed.

1.9 Hypothesis: -
H1:The singapore hospitals are more empathetic than Indian public hospitals

H2:The singapore hospitals are better in tangibles as compared to indian
public hospital
H3:The singapore hospitals provide more assurance to patients than Indian
public hospitals
H4:There is significant difference in the level of timeliness in both public
hospitals
H5: At a health care organization gives standard quality of services and make
profits by the help of successful uses of HRM.
H6: There is an association between hospital facility staff's (doctor's and
nurses)Job satisfaction and quality forethought outfitted to patients
through client supplier relationship guided by sound system of the HR
organization.

23

1.10 Research Ethics-

Politics and Beck (2010), analysts are required to manage ethical issues when
investigators determine their plans with others. The lesson of the legislature would
be required in writing by the chief medical officer (CMO) and the Ethics Committee of
the hospital clinics participate in the research (See APPENDIX-3, 4,5 and 6). At the
time when the CMO, healthcare department must be made mindful of the research
organizations participating in the entire feasibility of monitoring all such tasks are set.
They will likewise need to be convinced of the quality and partial exploration of the
analyst (Lee, 2005). The ethical standards will be recognized principles in the use of
this problem are the admiration for people, beneficence and security /
standardization.

I. Respect for persons-
As individual as you have the legal right to choose for them whether they were
reflected in the present survey. This will be illustrated in the present document
(see APPENDIX 3,4,5 and 6). Support should be considered for membership test
(Parahoo, 2006). Experts agree ahead of time will give the delicate components
of the nature and motivation behind this exploration, potential crowd will come out
information and findings suggest checking. Complete the request of the members
will be taken as consent to be incorporated in the poll. The member will be
equipped with enough time to think about their concerns.
As different as you have the right to choose for them whether they were included
in this research. This will be shown in the present document requirements (See
APPENDIX-3, 4,5 and 6). Agreed to be considered for membership probe
(Parahoo, 2006). Analysts agree ahead of time will give additional points of
interest about the nature and reason for the research, potential crowd will be able
to obtain information, the proposed test findings. The member will be equipped
with enough time to think about their thought and opinion.


24

II. Confidentiality-
The investigation is appropriate for your organization to be able to ensure the
confidentiality and security help answer responses. To ensure confidentiality
guaranteed real inquiry will not be numbered.
III. Beneficence/non-maleficence
While the request is deemed to be less intervention meetings, or cognitive test
they can now envision harm (Parahoo, 2006). It is feasible to be answered is
a particularly emotional person and depression. In case they cause
unpleasant memories or feelings of blame when the defendant is far from
other people and not have the supporters. Pilot research of the survey will be
tried to test requirements can cause damage. Parahoo (2006) recommends
that the request for information, experience and conduct or could undermine
the security experts if their executives can get information. An insurance cover
will be given to the members that the information collected will be kept and
only the expert classification and details used by the researcher will be able to
make it.

1.11 The Outline of Dissertation-


Chapter 1 Introduction
- Introduction
- Healthcare industry profile
- Research background
- Company Profile
- Reasons Why Health Care Sector was
Chosen
- Critics of Health Care Industry
- Research Objectives
- Research Contribution / Significance of
the Research
- Research Questions
25
- Hypothesis
- Research Ethics
- Conclusion

Chapter 2 Literature Review
- Introduction
- Literature Review
- Dimensions of Service Quality-
- The service-marketing triangle
- Measuring service quality models
- Health care in Indian Public hospital
- Statement of the Problem in INDIA
- Health care in Singapore Public
hospital
- Conceptual framework
- Conclusion

Chapter 3 Research
Methodology

- Research Onion

Chapter 4 Data Analysis
- Research finding and Analysis
- Environmental analysis
- Conclusion

Chapter 5- limitation and
Recommendations
- Introduction
- Achievement of objective
- Research limitations
- Recommendation



1.12 Conclusion-
The dissertation divided into Five-chapters. In Chapter -one the authors give an
overview of the entire research, including research purpose and objectives, a brief
background on the industry and health care hospital choice, In chapter -two author
used journal, magazine, book and website for research as a secondary data
26
analysis. In chapter-three author discuss the framework of research in which author
mention the research onion all essential layer and the data taken from public
hospital Hosp-A, B, C & D in chapter -Five the author draw a conclusion with
recommendation to the hospital which can improve service quality in public hospital
in India.






















27

CHAPTER-TWO
2.1 Introduction-
Firstly the author begins with the reviewing the literature by discussing the service
quality after that author had also discussed the various models for service quality.
Finally the author focused on India (Hosp- A and B) and Singapore Public hospital
(Hosp-C and D) service quality and facility drawback, which affect the public hospital
service and facility standard.
2.2 Literature Review-
Due to booming in the healthcare industry, hospital is providing good quality service
at the lowest feasible cost. According to Morris and Bell (1995) from the ancient time
the patient is addressed to get service quality and monitoring health issue with
valuable and effective services to solve the issue (Morris and Bell, 1995; cited by
Sivakumar & Srinivasan, 2010).

According to Hess link and Wiele patient satisfaction is the key determinant of
healthcare and it's will come from the all parties (Akbar & Parvez, 2009). Zeithaml
and Bitner (2003) if the patient is satisfied with the service given by the clinic patient
is automatically evaluated the service and make the conclusion in his mind. If
satisfactory services they definitely come again but if they feel it's not up to the mark
they dont come and visit the clinic. Jackson et al., 2001 also demonstrated that
patient satisfaction is strongly influenced the communication between patient and
doctor. As per Jackson et al 2001 patient satisfactions can use for four purposes
a) "Changed medicine services modified"
b) "To assess nature of consideration"
c) "To distinguish the part of administration required"
d) "To support the association to recognize consumer ".

2.2.1 Patient satisfaction and its Dimensions-
As per Conway and Willcock (1997) treatment are essential desires of public
28
hospital. Linde (1982) is in the developing world patient fulfillment is an evaluation of
human services model. Tucker and Adams (2001) expressed that patient fulfillment
is expected by components identified with consideration, sympathy, unwavering
quality and reaction (Naidu, 2009).
2.2.2 Theories of customer satisfaction-
As indicated in the hypothesis of buying life-Disconfirmation Oliver (1980) the
customer purchases product and administration desires before buy expected
execution. Once items or administrations are utilized the results are contrasted and
expectation. At the point when predictable with the results affirm the normal
happened. Disconfirmation happens when there is a contrast in the middle of
conclusion and desires. Fulfillment because of positive affirmation or disconfirmation
of desires and fulfillment is because of negative disconfirmation of purchaser desires
(Oliver, 1980, cited by Padma et al, 2010).
2.2.3 Measuring customer satisfaction-
According to Evenhaim (2000) said customer satisfaction is extremely difficult
challenge to the healthcare industry, measuring the satisfaction of the customer is
important for patient issue to resolve, improvement of service quality. Ford et al.,
1997 said hospital staff will measure the patient regarding service problem order to
identify and improve patient satisfaction, the qualitative and quantitative analysis is
used for measuring satisfaction level which will author discuss in Chapter -4

2.3 Health care in Indian Public hospital

In the Indian Constitution, healthcare is an every state subject; central government of
India to help the state government is required in the zones of

Correspondence control and destroy substantial and non-transmittable
infections
They help in approach improvement, Universal wellbeing, training, insurance,
Para-restorative and administrative measures,
Medication control and avoidance of sustenance altering notwithstanding
29
exercises identified with the counteractive action of populace development,
including safe parenthood, life youthful child and immunization program
(Mohfw.nic.in, 2014)

The efforts of the State Government and the Centre tries, the national health care in
India is in the worst conditions in the light of a few components of the rapid
development of the country and measures Hanging corruption in government and
non-government health gathered mind and do not understand the appearance of
those around (Welfeld Diedling , 1995).In figure-2.1 the health budget in every year
is increasing ,but its not spending in proper way to give the service quality.


Figure- 2.1,Sources-Health and Family welfare at Central level by Govt. of India,
* Revenue expenditure on Health and Family welfare **Revenue expenditure on Medical, Public health
and Family welfare

The disease is an issue circumstances and common phenomena, in which patients
frequently visit a doctor in a public hospital or a private hospital. A few sicknesses
are so severe that they could be cured just in the hospital. Hospitalization of patients
relies on upon the sort of disease in which the patient endures. In a few cases,
patients need to stay in the clinic for a long day or months (Mohfw.nic.in, 2014)

2.3.1 Statement of the Problem in Hops-A and B

Authors choces hospital Hops-A and B in the research because it is representing
public hsopital in ,Mumbai (India) region

Health care industry covers
Insurances in hospital healthcare and patients
Medical develop software
Medical equipment
Pharmacy
Different types of health care services
Hospitals
Hospital pathology clinics
Blood Banks
Centers of meditation
Emergency services like (Ambulances, etc.)
E-healthcare services
Telemedicine
Yoga Clinic
Gym
Spas clinic
!
!
!

Year wise
Health Budget


Central government
Budget *


State government
Budget **
2009-2010 Actual USD $ 3197.188
Million
Actual USD $
529.5 Million
2010-2011 Revised USD $ 3809.68
Million
Revised USD $
704.21 Million
2011-2012 Budget USD $ 4397.8
Million
Budget USD $
820.96 Million
!
!
30

Figure-2.2, Source-http://www.kractivist.org/tag/kem-hospital/.,KEM hospital rooms
In Hospital Hosp-A and B, every year thousands of people came from all over India
most of the patients are basically middle class working people cannot afford their
hospital bills in a private hospital (Mohfw.nic.in, 2014).In Hosp -A and B mostly
treatment is free or at minimal cost with the cost benefits derived from the annual
allocation from the Central and the state government (Mohfw.nic.in, 2014), In this
hospital they are providing free of charge drugs and advance medical facility.
(Dowser.org, 2014).
In the hospital they have a consistent basis but they do not know how to manage
(failure of human resource management) and provide the appropriate services to
patients (Dowser.org, 2014). Primary healthcare is the major issue for the hospital to
improve good healthcare services the major issue the hospital is facing is showing in
figure-2.3and APPENDIX-6

31

Figure:-2.3 - Self made for this research,Statement of problem in Hosp-A and B


2.3.2 Drawbacks of the Indian public hospital (Hosp-A and Hosp-B): -

There is a divided methodology since the idea and arranging of all
projects that are centered and particular needs of the territory is not
considered.
The capacity to learn how to, utilize and acknowledgement of the
project is low in light of the fact that the framework was set up by the
administration focused around populace standards instead of living
arrangement (The wall street journal India, 2011).
There is a crevice in the middle of interest and supply of human assets
to individuals squandering time sitting tight in line for treatment or
advising.
Regardless of executing base yet the service quality is not the proper
level.
32
Fees are performed in the public hospital that is very low and the
demand for places is at a fairly high rate (The wall street journal India,
2011).
When the income of the hospital staff is not enough they are employed
overtime to earn extra money. Especially the Indian hospitals (Hosp-A
and B) are equipped with advanced equipment and technology, but the
equipment is not required properly.
Indian hospital rooms are in a pretty bad situation due to lack of
inappropriate care (The wall street journal India, 2011).
Since there are no panel sanctions in hospitals lacking discipline and
coordination.
Hospital has advance medical equipment but it's not working properly,
because of lack of knowledge of handling medical equipment

2.4 Health care in Singapore Public hospital-
Singapore began under the human services framework as its starting government
sponsored social insurance through the individuals in general society part and
government charges. In view of the contrasts, India continues to be a great deal
more setup issues. In India, not all individuals living with a medicinal insurance,
particularly for somebody not fit to advertise government protection plan
(Sgh.com.sg, 2014). Singapore accomplishes higher social insurance productivity
than India. In the most recent WHO health framework standing report, Singapore
involves the Number 6 out of 191 countries; while India with the biggest extent of
GDP just ranks at the 37th (Who.int, 2014). In Singapore government, they are
giving so many subsides benefit for the domestic a patient as well as foreign patient
sees figure-2.13
33

Figure-2.4, Source-http://www. moh.gov.sg /content/moh_web/home/our_ healthcare
_system/Healthcare_Services/Hospitals.html .Subsides plane in Singapore public hospital

The nature of forethought in broad public hospital in Hosp-C and-D has been there a
standard transformation from a customary concentrate on an organized methodology
for multi-dimensional idea more extensive including the checking of clinical fault and
medical error (Sgh.com.sg, 2014) .Solid political responsibility and institutional limit is
the basic element to perform the transformation process. What is needing, in any
case, is a society of a thorough system assessment, open interest, and engage
patients. Notwithstanding these inadequacies, Singapore Hosp-C and D has made
huge advancement and their experience may hold lessons for other developing
nation in the normal quest for quality tend to patients (Who.int, 2014).
34

Figure-2.5, Source-http://www. moh.gov.sg /content/moh_web/home/our_ healthcare
_system/Healthcare_Services/Hospitals.html,Singapore public hospital rooms

The impulse for change, notwithstanding, is not originating from public pressure for
public hospital facilities to be considered responsible for the nature of forethought
they convey, yet from a paternalistic government that strives to be proactive in many
matters (Sgh.com.sg, 2014) .The administration as the controller, patients, and
significant open supplier is pushing for change in the interest of Singapore's non-
vociferous, well behaved subjects. Despite the fact that it has not been deliberately
sought after all things considered, the evolutionary way brought by the to a great
extent ''top quality healthcare services (Sgh.com.sg, 2014).
2.4.1 Singapores Healthcare Expenditure in public hospital-
Good healthcare is major point in developed country they are spending lots of
revenue for maintain and develop their healthcare sector Singapore is the one of
them Singapore as a percentage of GDP is as high as the average for low income
countries like India, (Data.worldbank.org, 2014) but the country has the world's
highest income equal to the supply level of health outcomes. It's clearly showing in
figure-2.6 every year Singapore health budget is increasing and improving the health
care quality in an effective way for his country.
35

Figure-2.6, source-http://data.worldbank.org/indicator/SH.XPD.PUBL.ZS, Singapores Healthcare
Expenditure in public hospital




36

Figure-2.7, Source--http://www. moh.gov.sg /content/moh_web/home/our_ healthcare
_system/Healthcare_Services/Hospitals.html, Compersion with other country service treatment

Public healthcare spending in Singapore Hosp-C and D up to about 65 percent of the
total national budget (2012) (Data.worldbank.org, 2014) .The includes medical bills
and payments from Medi-shield program, management, government insurance
programs concerned, Medi-saving fund, and employer- provide health care benefits
(Health Care in Singapore, 20012).
37

Figure-2.8, Source-http://www.moh.gov.sg/content/moh_web/home/statistics/Health_Facts
Singapore/Healthcare_Financing.html,, Finance expenditure on healthcare, Singapore.

I. High Quality, Low Cost
Singapore has a world-class healthcare system and is ranked sixth in the world,
according to WHO (World Health organization) Singapore achieved all areas of
healthcare issue. In Hosp-C and D, the waiting time for a bed is 3 -hours (maximum)
(Sgh.com.sg, 2014) hospital give the low cost with good service quality health care
to the patient as compare to India which still suffering from the healthcare they spend
almost 4.7 percent of budget to the health sector as compare to the Indian health
budget which is still 4.0 (Data.worldbank.org, 2014).
II. Helping Patients Pay-
In Singapore government always follow the effective guidelines and rules toward the
38
health care to his people they helps patient in healthcare for their treatment in terms
like Medi-save plane it's a mandatory saving account for all Singapore citizens, CPF
(central provident fund) for employers which can make easily to pay the hospital bill
(Mycpf.gov.sg, 2014). The government set the contribution rate to employees of his
salary for saving which is used for healthcare and personal care and this is effective
in Hosp-C and D public hospital.

III. Controlling Costs-
Singapore government keeps an eye on the Hosp-C and D to give effective and
excellent service, but it's not mean that it will be costly. Government always develops
quasi-free market to health care service become affordable (Health Care in
Singapore, 2008) In Singapore micro-management in healthcare and gives
affordable insurance as compared to other country see figure-2.9.


Figure-2.9.source,http://www.moh.gov.sg/content/moh_web/home/statistics/Health
_Facts_Singapore/Healthcare_Financing.html., Controlling cost in Singapore healthcare


39

2.5 Measuring service quality models-
In the past decades, most of the method introduces to calculate the service quality,
which is belong to medical staff, patients questionnaire and the paradigm to collect
the data, (Sliwa & Okane, 2011) which the author explains in a further chapter. In
this chapter, the author is explaining a different type of method of service quality,
which is, affect the quality and service in both country hospital (Hosp-A, B and C, D),
which is described below.
2.5.1 Service Quality Models-
Parasuraman created SERVQUAL service model in 1988 and is used for measuring
the service quality (Parasuraman et.al in 1988; referred by Mengi, 2009). In service
quality model author wants to explain the multidimensional scale which measure:
40

Figure-2.10, Source-self made for research, Service quality model

To above model there is 5 dimensions is most important to develop and give
excellent service quality in a hospital. In Hosp-A-B the service hospital is not
following this essential models, there is not a proper equipment, staffing and
empathy toward the patient because of this patient are not satisfy and forced to

Assurance


Alludes to patients view and trust toward the
medical staffs how they feel with them and giving
consideration.
As per Lee and Lin in 2008 demonstrated that a
decrease in patient trust toward the caregivers
could prompt the post release resistance, which
causes moderate or inadequate recuperation.


Empathy



Refers to the degree of forethought and
consideration is given to each individual patient.
(Lee and Lin, 2008; called Karl et al, 2010).
Similarly Spigelman and sensors (2008) have
been proposed that patients are always looking
for specialty care services.

Responsiveness


Staffs attentiveness and response toward
patients complaint and handling issue is very
important in health care industry (Anderson et.al
(2006), Roszak (2007); cited by Karl et al., 2010).


Tangibles

Include doctor, nurses and medical equipment or
staffs

Reliability

Include providing good service with accuracy
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!
41
moved to private hospital (Nagral, 2014) on other hand the Hosp-C and D the
service quality model perfectly used its most accurate example the Hosp- C and D is
the patient in world wide favorite destination for treatment is Singapore
(Patientsbeyondborders.com, 2014).

In this model, there are 22 articles in figure- 2.11 which is showing the patient
expectations toward the service quality and hospital.

Figure-2.11, Source-Joanna lee, 2011, Essential service quality 22 articles in healthcare system
2.5.2 Gap model-
In 1985 Parasuraman et .al created mode called as Gap model, its an operational
model, which demonstrated the major factor, which is involved in service quality gap,
which will affect patient satisfaction in hospital in figure-2.12 (Parasuraman et.al,
1988, cited by Nassab et al, 2011).

42

Source- Figure -2.12, Gap Analysis Model, Source- (Alin et al., 2009)
43

Figure -2.13,Source-Alin et al., 2009,Gap model (1-5)

The gap model is the most important model in service quality in a hospital because
of a gap in service patient is afraid to come in Hosp-a and B, they consider Hosp-C
and D for further treatment (Padma, 2010).

2.5.3 Hospital Technical, Functional and Image Quality Model-
Hospital staffs remember the ultimate goal is tantamount to understand the service
quality management and quality benefits for the patient. Monitoring quality
management is expected service quality to compete and follow the Hosp-C and D
public hospital which to carry out the patient's needs. In 1984, Gronroos identified
three components of service quality, namely: technical quality, functional quality,
image (Figure-2.15) which improves the service quality.
44

Figure-2.14, Source: Gronross, C. (1984), A service quality model and its marketing implications ,
2.5.3 Hospital Technical, Functional and Image Quality Model
I. Technical quality patients actually get services from the public hospital, as
an after effect of the result the hospital is critical for quality of service.
II. Functional quality after getting technical outcome from which patient
received services and express his point of views which is very important
III. Image To build a strong image of hospital is very important to build a strong
pillar of technical and functional service quality like Singapore public hospital
qualities build by
- Patients Word of mouth
- Personal needs with satisfaction
- Previous healthcare experience
- Healthcare service product content

2.5.4 Service Quality, Patients Value and Patients Satisfaction Model-
Oh (1999), have proposed an integrated model (Figure -2.15) for quality
management, patient values and perform patient. The proposed model centers
primarily on buying all selection procedures. Arrows show the model suggests causal
bearings. Models participating in important variables, for example, observations,
quality of service, perform patient, persistent values and aims acquisition. Length
45
corresponding to the final proposal is defined as immediately joined recognition
capacity, self-esteem, and implementation objectives and acquisitions (Oh, 1999).).


Figure-2.15, Source: Sweeney et al.,(1997), Service Quality, Patients Value and
Patients Satisfaction Model
This model allows patients to confirm the value is a significant part of the post-
purchase method of patient selection. It is a precursor to patients quickly to
implement the acquisition and aims. The results show that costs are clearly
negatively impact the perceived value of the patient and are not related to quality
management saws (Oh, 1999).





46
2.5.5 The service-marketing triangle: -


Figure-2.16, Source-Self made for research, Service-marketing triangle
Company: Hospital is the company, which innovate the idea of services
(treatment), which will give patient satisfaction (cured) (Rust, 2002).
Patients: patient is the customer who come to hospital for getting service
from the hospital and seek to gets cured and pay for services
Provider: Doctor is the provider, which directly contact with the patient and
doctor is directly responsible with responsibility of hospital reputation if they
satisfy the patient with his services, A satisfied patient is the important
sourced of word of mouth promotion of hospital (company) (Rust, 2002).
The above triangle mention the three interlinked between groups, which provide
services, promote services and develop order to the hospital. In this the provider can
be an employee of hospital, doctors, nurses and medical staffs apart from the three
triangles there are three marketing services, which give benefit to the hospital, which
is
I. External Marketing: Deliberations that the firm takes part into set up its
patient need and expectation and makes guarantees to patient in regards to
what is to be conveyed (Kotler, 2009). Anything or anybody that conveys to
the patient before service conveyance might be seen as a external marketing
function.
47
II. Interactive Marketing: This is additionally called actual marketing in which
the guarantees are kept or broken by the staffs. Individuals are basic at this
crossroads. (Kotler, 2009) . If the promises are not kept clients get to be
disappointed and eventually reach.
III. Internal Marketing: In this services providers deliver the service promises:
recruitment, preparing, persuading, remunerating, and giving gear and
innovation. Unless staffs are capable of conveys the promise, which actually
made if the firm won't be successful the administrations triangle will crumple
(Kotler, 2009)

Healthcare is the combination of tangible and intangible in which tangible dominating
the intangible aspect .In other way the service giving by the doctor are intangible and
tangible things which is include hospital beds, decors etc. Its is very helpful for giving
Service quality and profitability to hospital see figure- 2.17

However at some point it is a synthesis of intangibles and tangibles.

48

Figure-2.17 Service quality and profitability, Source-Self made for research

2.6 Conceptual framework-

The conceptual framework evolution in planning of research, analysis of data and
conclusion is obtained (Bryman, 2001). To evaluate the healthcare in Singapore and
India public hospital patient satisfaction, in the healthcare patient satisfaction is
playing the crucial role to provide excellent service (Desai, 2011).

The conceptual framework is used to enable the present performance of health care
in both country public hospitals. In this research author used the research onion for
research and explore every layer for research, Author used primary and secondary
research for this they used face to face interview, survey, hospital websites, articles
49
and journals after that compare and make conclusion lastly author give some
valuable recommdation for improvement the public hospital and provide excellent
service quality


Figure-2.18 .Conceptual framework,Source :- Auther self-made








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Healthcare
Service quality,
Technology,
Patient
satisfaction
Concept of
SERVQUAL service
quality model
Dimension of
effective service
quality
!
Theoretical framework of Hospital A,
B, C and D
Objectivist
Constructivist
Patient satisfaction
in service quality
and facility
!
Research onion
model
Basis of analysis data
available in public
Hops-A, B, C and D
Recommdation and
conclusion
Survey
questionnaire
Face to face
Interview
50
2.7 Conclusion-
Service quality is the major and most important determinant to meet the patients
expectation in achieving the service quality. Service quality play important role in
make repo of any hospital toward patients loyalty, in the health sector will be aware
of patients cannot always be taken into account when they lack knowledge of the
technical aspects of the hospital.












51
CHAPTER-THREE
3.1 Introduction

In this chapter author disuses about the research philosophy then move to research
strategy with include research approach with the data collection method after that
author move to discuss about the sample size in sampling techniques for the
research and technique and adopted to make the research and finally the conclusion
of chapter.

3.2 Methodology-

As indicated by Burns (1997) research could be characterized as an arrangement of
a request to discover an answer for an issue (Burn, 1997 referred to by Kumar,
2011). Saunders et.al (2009) said: "The examination methodology is an arrangement
of connected stages and gives the presence of being a direct association" (Saunders
et al., 2009). Dr.C.Rajendra Kumar (2008) is the idea that "an examination strategy
is a deliberate approach to take care of exploration issues" (Kumar, 2008).

3.3 Methodological consideration

Methodological consideration is the research plan of all research general plans.
Sunder et al in 2009 has demonstrated research onion with six layers in which every
layer has value in researching this layer divided into research philosophies, research
approach, strategy, research choices, time horizon research technique and last
research procedure. Saunders "Research onion every layer has developed for
particular reason for research. Research philosophies, approach and time horizon for
guide the author desired process on Research onion and help in answering the
question wherever research design is useful for research question, Research
strategy depend upon the collection of data in research, research topic and time
factors, research design are also subdivided into Exploratory, Descriptive and
Explanatory.
52

Figure: - 3.1,Source: -Saunders et.al, 2009,Research onion
I. Exploratory research-
It is based on the understanding and initial develop of the new aspect (Babbie,
2010). Difference in Various research show in figure-3.2
II. Descriptive Research
It is a valuable measurement and data describing for measurement of populace. It
can be also helpful for analyzing the existent data (Babbie, 2010).
III. Explanatory Research
Is a research in which different type of phenomenon involve and establishment of
effective relationship of different aspect (Babbie, 2010) .
53

Figure: - 3.2,Source: - Saunders et.al, 2007, Differentiate diagram Exploratory, Descriptive and
Explanatory

Justification for Methodological consideration -
The author has used methodological consideration in research onion because the
author is trying to find the relationship between diverse parts of the phenomena
contemplated.

3.3.1 Research Philosophy -

Research Philosophy" studies have essential assumptions including the essential
research will conduct. "It gives the basics of strategy and research affected by the
real consideration.
I. Positivism-
The author proposes receiving a comparative methodology to the common
researcher then experimental exploration systems. In the positivism hypothesis
being investigated to create a speculation. It is an observational investigation of
liberal values, for example, quantitative analysis and detail, which could be
actualized (Wilson, 2010). On the off chance that the author is seeking after a
positive methodology for research than accept that it is a free analyst and exploration
objectivity. Prove in perspective of the exploration is expected to be done in an
experimental way. This is a demonstration research, led under the strict rules of the
approach prepared researchers. This examination is usually done in a deductive
methodology moves from hypothesis to perception. All in all acknowledgment need
their discoveries could be connected to the entire populace (Wilson, 2010).
54
II. Realism
This is a development of the scientific approach of similar knowledge, which is
similar like positivism
In the direct Realism in realism research not only directly observe and record
what author knowledge done by senses.

Critical realism author show the whole research is a part of a bigger picture
Critical realism author can two ways experience the world. The first
is the case that self and feeling it transmits and the second is the mental processing
that goes on sometimes feeling after meeting our senses. On the other hand direct
say realism that the first step is only enough (Saunders et al, 2009).
III. Interpretivism-
In this research, the author has a dynamic part in the execution of the research. This
sort of research stresses the need to direct research on individuals and not on the
objects. Author takes a look at a specific issue in profundity. The motivation behind
this research is not intended to sum up however to heartily partake in the
participation state of investment and cooperation (Wilson, 2010).
Interpretivism has 2- intellectual traditions-
a) Phenomenology: -The author can make knowledge about the world around
us.
b) Symbolic Interactions: - The author continues explaining other actions and
make new meaning by combining our views and their actions (Saunders et al.,
2009).

IV. Ontology-
It accords with the, at least in principle and can be classified. Ontology is able to
understand in an understandable manner or at least partially (Poli, 2010). According
to Saunders et al., 2009 ontology is concerned with the nature of reality. It is divided
into.
55
a) Subjectivism -
In subjectivism here is a interaction contumely with changing world regularly.
b) Objectivism -
In objectivism everything has its individual character.
V. Axiology
Axiology is concentrated on the judgment of the quality. It is a more valid type of
exploration. Theory is concentrated around the estimation of scrutinizes
regarding gathered the information. In the event that we need our examination to
be dependable we keep our qualities in each one phase of exploration
methodology (Saunders et al., 2009).
Justification of research philosophy
Author has applied empirical approach because it does not insist on the interest of
the people and aims to analyze quantitative data in the statistical analysis.
3.3.2 Research Approach-

As mention Saunders in 2007 approaches are two types Deductive and Inductive In
a deductive approach was created speculations and exploration method were
intended to test the theory. Figure -3.3 demonstrates that the deductive technique is
an organized way to high. In autonomous exploration of what is constantly
contemplated. In its deductive technique clarifies the relationship between the
diverse variables. There is a situated of quantitative information.

While an "inductive approach" "gather information and hypothesis created as a
consequence of information examination" (Saunders et al., 2009). Figure 3.3
demonstrates that the inductive strategy concerning human comprehension
connected with this occasion. There is a situated of qualitative information. The
research is a piece of the exploration process.
56

Figure: -3.3, Source-Saunders et.al, 2009, Deductive and Inductive Approach

Justification of research approach
The author will apply a deductive technique for experimental research reasoning. It
additionally relies on upon the calculated skeleton and hypothesis before being
secured a lot of quantitative data. It additionally analyzes current hypothetical
discoveries, which could be summarized.
3.3.3 Research Strategy-
As a research method used to collect data, which is divided into: -



57

Figure-3.4, Quantitative vs. Qualitative. Source-http://www.knowledge-communication
.org/coursesandevents.html.


I. Quantitative data-
It accentuates the production of summed up and exact factual finding. Qualitative
data is utilized when we need to check whether a reasonable delivers an impact
(Rubin & Babbie, 2011).
II. Qualitative data-
Author has to choose the best technique to answer the healthcare research
question. This qualitative technique had created from a philosophical point of view
(Issel, 2009). In qualitative information, the author will be getting the inward
implications of people through perception, which is planned to generate hypothetical
perception and is not effortlessly lessened to numbers (Rubin & Babbie, 2011).
Justification of Research Strategy-
The author selected quantitative research strategies. Author will use the research
questionnaire served basis will be examined and theoretical hypotheses with data.
58
The author consider qualitative researchers the most important to address
hypotheses and theories to test the data to see if they are supported.

3.3.4 Research Choice-

Research choice is the fourth layer of research onion (Saunders et al, 2009). It is a
mixed method research it can use to for both quantitative and qualitative research.
3.3.5 Time horizon-
In the research onion Saunders et al, 2009 time horizons are to research, used to a
crossed sectional research design for a snap shot of the present level of patient
satisfaction in a public hospital
3.3.6 Research purpose-
The research purpose is to investigate the factor influence the patient in both country
hospitals Hosp-A, B, C and D, within the manufacturing environment
3.3.7 Rejected methods-

In determining the appropriate methodology to use for this research, some initial
research design was considered, and then rejected one.
3.4 Research procedures-
Its a procedure in which the research makes idea and framework to collecting the
data for the research.
3.4.1 Data Collection Methods and Triangulation-
Triangulation is demonstrated the use of data collection technique. Saunders et al.,
(2009) qualitative research data gather from the semi structured interview and the
semi structure interview follows by survey questionnaires. This questionnaire
distributed and handles out to the appropriable hospital people to gather the collect
information for further research
3.4.2 Semi structured Interviews-
The author is viewed as proper to direct semi-structured interviews were viewed as
59
a suitable technique for introductory information gathering, giving chances to
investigate and semi-structured interviews were led with doctors, nurses and
patients of both country public hospital To balance potential wellsprings of
predisposition and to upgrade the unwavering quality of the qualitative information
gathered, an institutionalized data sheet was delivered to interview persons to
peruse, 24 prior hours the meeting. Furthermore, members were additionally called
upon to sign an assent structure in keeping with the moral contemplations of the
research. An open inquiry style was utilized all through the meeting, which swayed
members to react unashamedly to the inquiries. At the point when leading semi-
structured interviews, exercises and methodologies emulated by "have been utilized.
Related methodology obliges members to present open-finished inquiries focused
around the fundamental topic of the model idea, emulated by inquiries to push
further gives investigation and a center of provincial criticalness (Saunders et al.,
2007).

3.4.3 Survey Questionnaire-

To gather information from the doctors, nurses and patients focused around a poll
survey of patients was produced. A survey was viewed as proper for this research.
On the grounds that it will permit the information from both gatherings of examples,
were gathered rapidly and proficiently. The utilization of the survey, as proposed by
Saunders et al. (2009), for the investigation of quantitative information utilizing
expressive facts and induction. The information gathered can likewise be used to
show connections between semi-structure interviews. The survey inquiries are
intended to contain all the information sets of variables, in spite of the fact that the
information viewpoint is predominant variables. Saunders et al. (2009), has been
nearly checked to guarantee legitimacy and dependability of the inquiries in the poll
survey. To enhance the reliability of quantitative information and lessen wellsprings
of inclination, a data sheet ready for every one of the individuals who partook in the
survey for perusing, 24 hours priority being put into inquiry.




60
3.4.3.1 Pilot of Questionnaire

Before utilizing a questionnaire survey to primary data, Saunders et al. (2007) exhort
that the inquiry is expected to be steered. The motivation behind the survey was
judged to check whether the respondents had no inconvenience in understanding or
finishing the survey. Criticism got from respondents in the pilot stage empowers
enhanced poll proposes being carried out before executing the data accumulation
period of the research. A survey of the data gathered pilot additionally gave an
evaluation of the legitimacy and reliability of inquiries that may happen in the data
gathered (Saunders et al., 2007).

3.4.3.2 Sampling Group

To answer the research question, important examination data was gathered
surprising. A survey, which gathers data from all cases or a part of the gathering, a
rebate in this research because of time demands. Distinctive testing systems were
inspected until the methodology is the capability to choose the most proper
alternative see figure-3.5 and 3.6

Figure-3.5, Source-Self made for research, Sampling group structure
61
Author using collecting Sample from the giving public hospital see detail figure-3.6

Figure: - 3.6,Source: - Author self-made, Sampling group structure hospital

3.4.4 Standardized Questionnaire

Standardized questions, taken from Cooper et al. (1987) Occupational anxiety list
(OSI), have been included in the survey to measure the satisfaction of the
respondents. Robertson et al. (1990) pointed out that measures of satisfaction inside
adequate values. As depicted by Arnold et al. (1998), questions and proclamations
from analysts asked respondents to rate how they think and/ or feel of
administrations and their hospital.

3.5 Ethical Considerations
The ethical standards will be recognized principles in the use of this probe is the
admiration for people, beneficence and security / standardization. Ethical
consideration include
Respect for persons
Confidentiality
Beneficence/non-maleficence
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3.6 Analysis of Data
Author can detach information as discretionary information starting now exists in a
couple of structures; for instance, payroll and fundamental information have been
accumulated in the midst of the examination handle by (Burt et al., 2009).


Figure: -3.7, Source-Burt et.al, 2009, Analysis of data

i. Primary Data Collection: Questionnaire
"Primary data" is the data in Figure 3.8 were collected during for this research. Data
can be gathered in many different ways by, observations, questionnaires, and
personal interviews, telephone interviews. Primary data can be gathered by
quantitative research and qualitative research. Quantitative techniques including
surveys, experiments, observation. Qualitative techniques including in-depth
interviews with projective techniques and focus groups. (Wiid and Diggines, 2009) it
is shown in figure below
63

Figure: -3.8, Source-Wiid & Diggines, 2009, primary and secondary data collection model
3.6.2 Secondary Data Source
"Secondary data" could be classified into a few sorts most vital one is interior
information found inside a hospital. Extrinsic information might be again isolated into
that is consistently publisher and we get the data free of charge for instance,
enumeration data, statics and that are published by diverse business associations
and offer the data (Churchill Jr & Iacobucci, 2010).
64

Figure: -3.9, Churchill Jr & Lacobucci, 2009,secondary data source
Justification for secondary Data-
Author will collect secondary data from the websites of public hospital and additional
data will be collected from both country central government healthcare statistics,
local newspaper, articles, journals and books

3.7 Sampling-
According to Lohr, 2010 sampling is the subdivision of the population its include 2-
types: -
3.7.1 Probability Sampling or Representative sampling-
Both country population, author collect probability sample for demonstrated and is
equivalent for same country (Saunders et al., 2009).
3.7.2 Non -Probability Sampling-
In the non-probability sampling in research probability, in each one case being
chosen for the populace not known and cannot answer questions or unravel
research objectives require factual derivation of the human character of the
individuals "(Saunders et al., 2009).

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Justification of sampling
Author will utilize a sample of probability. The author utilized straightforward regular
sampling research. Author will be done question to a public hospital in India and
Singapore (Hosp-A, B, C and D).

3.8 Conclusion-
This chapter discusses the research methods primary research. The authors
explained through research are designed in the light of this research. Author applied
methods of inference and evidence philosophical research. Author distributing
questions to 440 patients for the secondary research and books, magazines and the
hospital web site can be utilized to and primary research. Simple random sampling,
probability sampling will be invoked as the sampling technique.
















66
CHAPTER-FOUR

4.1 Introduction-
In this chapter author will first, take the survey and it was conducted using
questionnaires from public hospital; will be analyzed and illustrated with the help of
tables and charts to answer the research questions related to public hospitals are
comparable in both countries and how to improve and what expectations for hospital
patients, employees are considered to be factors affecting the quality of customer
service. (Lewis, 2007)
Finally, the author's evaluation will be addressed after data analysis. In the field of
health care is important in order to both countries. In this research, the authors have
negative aspects and positive health care in both countries. The questions and the
survey were conducted in the country responded 440 patents; doctor and medical
staff's to the survey and the questions are all citizens of Singapore and India.
Including doctors, nurses, patients, housewives and retired persons.
4.2 Demographic Analysis-
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Frequency (N) Percentage
(%)
Gender-
Men 300 75%
Women 100 25%
TOTAL 400 100%
Age Groups-
18-20 8 2%
21-30 90 25%
31-40 90 25%
41-50 32 9%
51-60 70 19%
61-70 60 17%
71+ 9 3%
TOTAL 359 100%
Education Level-
Primary school gradate 2 1%
Secondary school 45 11%
Higher secondary school 50 13%
Master/PhD/doctor 300 75%
Others 3 1%
TOTAL 400 100%

Doctor 80 20%
Nurses 89 23%
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Figure .4.1 Demographic Analyses, Source author

In the survey carried out by including gender distribution, the reply is that survey
75% of men and 25% women. In this survey, in this survey all are above 18 years
ages. The main reason for choosing age restriction because of cultural difference in
people and country. The highest score gets by in 21-40 years people. The education
level of the survey focused mainly on the doctor / nurse / patients

4.2.1 General Questions about Health Care Services Taken Recently-
Author asked in general questions to the patient, doctors nurses and following
responded in in figure-4.2
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Patient 150 38%
Teacher 40 10%
Housewife 20 5%
Retired 10 3%
Others 5 1%
TOTAL 394 100%
Marital Status-
Married 250 63%
Single 150 38%
Total 400 100%
Region of residences-
Singapore 100 25%
India 300 75%
Total 400 100%
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Frequency
(n)
Percentage
Distribution (%)
Do you receive any health care services in
India (Hosp-A & B) and Singapore (Hosp-B &
C) in the past six months:

Yes 250 63%
No 150 38%
Total 400 100%
From where:
Singapore Hospital (Hosp-c & Hosp-D) 180 43%
Indian Hospital (Hosp-A and Hosp-B) 90 21%
Others 32 8%
Both country public Hospital 120 28%
Total 422 100%
Who paid this service fee:
Myself 223 51%
Insurance 152 35%
Both myself and insurance 48 11%
Other 14 3%

Total 437 100%

(A) Do you recommend the hospital that you
had received health care to other people India

Yes 75 21%
Maybe 125 34%
No 165 45%
Total 365 100%
(B) Do you recommend the hospital that you
had received health care to other people
Singapore

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Yes 280 67%
Maybe 125 30%
No 15 4%
Total 420 100%
(A) Have you faced any problems: Hosp-C &
Hosp-D


Yes 30 9%
No 280 86%
I Didnt receive any treatment within the last six
months
15 5%

Total 325 100%
(B) Have you faced any problems: Hosp-A &
Hosp-B

Yes 270 73%
No 90 24%
I Didnt receive any treatment within the last six
months
10 3%

Total 370 100%
(A) Satisfaction From Hosp-A &Hosp-B
Very satisfied 25 7%
Satisfied 25 7%
Dissatisfied 140 40%
Very Dissatisfied 160 46%
Total 350 100%
(B) Satisfaction From Hosp-C &Hosp-D
Very satisfied 180 47%
Satisfied 190 49%
Dissatisfied 12 3%
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Figure.4.2 General Questions about Health Care Services, Source-author
The request and response is shown in the figure above is determined with
discernments of respondents about the nature of health care in Singapore and India
One of the questions to gain any health benefit services in the most recent six
months in India from the hospital (Hosp-A & B) and Singapore (Hosp-C & D), 63%
said yes and then after the response from countries including surveying, and 38%
say No, what's more includes 43% of the respondents admitted that management
will benefit Hosp-C & D and the rest 21% to the public hospital Hosp-A & B and also
the 8% to various points. Responding to this survey is 440.
4.3 Quantitative research-
In this research author patient and doctor expectation and perception toward the
hospital, author used 440 people for this research and takes a survey to analysis the
data.
4.3.1 Expectations of Patients from the Behavior of Doctors-
In the research patients expectations of Hosp-A and B, C and D from the doctor
behaviour toward the patient point of view. Author asked patients to rate their
Very Dissatisfied 5 1%
Total 387 100%

(A) Would you get Health Care Service from
the Hosp-A & Hosp-B

Yes, certainly 25 7%
Maybe 65 17%
Absolutely no 290 76%
Total 380 100%
(B) Would you get Health Care Service from
the Hosp-C & Hosp-D

Yes, Certainly 190 49%
Maybe 180 47%
Absolutely no 15 4%
Total 385 100%
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expectations in size of 1-9 average ratings for each attribute is given in this figure-
4.3.



Figure-4.3 Expectations of patients from the behavior of medical assistants

The attribute mean score is availability of medical assistants is 9, which mean all the
patients had given rating 9 to this attribute i.e. they consider this factor very
important and their level of expectations for this attribute are very high. Politeness,
maintenance of records and cooperation with patients are given the mean scores at
8.79, 8.71 and 8.65 respectively which means that patients also consider these
factors very important. Attribute experience has the mean score 7.45. So this shows
that patients think this attribute important but not as much as the above-mentioned
attributes and the mean score for the attribute dress have medical assistants is
lowest among all the other attributes, which are 6.9. This explains that patients do
not consider this attribute very important, but they had not rated this attribute low. So
this is also an essential attribute. The overall mean score for the factor behavior of
medical assistants is 8.33 and this is high.
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Attributes Expectations
(Mean Value)
Availability 9
Knowledge 8.56
Cooperation 8.65
Politeness 8.79
Impartial attitude 8.49
Maintenance of Record 8.71
Handling of Queries 8.44
Experience 7.45
Dress 6.9
Average 8.33
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4.3.2 Expectations of Patients from the Quality of hospital Administrations-

In the expectations of patients from the quality of hospital administration, patients
were asked to rate their expectations on the scale of 1 to 9 for the various attributes
given below in the figure 4.4 for this factor. The mean rating for each attribute is
given in this figure.


Figure 4.4 Expectations of patients from the quality of the administration

The mean score for all the attributes for this factor is 8.17. So it is accurate to say
that patients consider the Quality of Administration an important aspect of the
hospitals and their level of expectation from this factor is also high. Expectation level
for the attribute behavior of clerical staff is the highest among all the other attributes
with the mean score 8.89. Check up procedure, behavior of security staff, checks out
the procedure, billing procedure was also considered very important by the patients.
The mean scores for these attributes are 8.85, 8.85, 8.78 and 8.78 respectively.
Attributes Expectations
(Mean Value)
Convenient Office Hours 6.53
Check Up Procedure 8.85
Over Crowding 8.26
Welcome Your Ideas 7.31
Fee 7.10
Grievances Handling System 8.45
Billing Procedure 8.78
Check Out Procedure 8.78
Behavior of Clerical Staff 8.89
Behavior of Security Staff 8.85
Average 8.17
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Patients said that these procedures must be simple i.e. they are not really complex.
Grievances handling system i.e. how the complaints of patients are handled was
also given a high rating of 8.45. Mean score for the attributes welcome your ideas,
which mean that whether the hospitals listen their ideas carefully or not and fee is
7.31 and 7.1 respectively. Convenient office hours had been rated lowest among all
the attributes with the mean score 6.53. This means that patients did not consider
this attribute as important as additional attributes.

4.3.3 Expectations of Patients from the Services/ Facilities provided by the
hospitals-



Figure 4.5 Expectations of patients from the services and facilities provided by the hospitals.

In the research the expectations of patients from the services and facilities provided
by the public hospitals figure-4.5 shows that expectation level of patients for the
attributes bedding arrangements, dust boxes and flies and mosquitoes is highest
among all the other attributes as all the three attributes has a mean score of 9. Here
it is also evident that all the patients had rated these attributes with a score 9. Mean
score of 8.98 for the proper sitting arrangements also shows that patients consider
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Attributes Expectations
(Mean Value)
Proper Sitting Arrangements 8.98
Bedding Arrangements 9
Staff Appearance 6.55
Natural Light 8.36
Dust Boxes 9
Flies & Mosquitoes 9
Outer & Inner Appearance 7.44
Parking 8.71
Well Equipped Units 8.33
Marking On Walls 8.07
Eating Places 8.69
Average 8.37
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this attributes as important as the above mentioned three attributes. Patients also
thought that parking, eating places, natural light, well-equipped units and marking on
walls are other essential attributes. Mean scores for these attributes are 8.71, 8.68,
8.36, 8.33 and 8.07 respectively. Outer and inner appearance of the hospital has an
average score of 7.44, which is quite lower than other attributes. Attribute staff
appearance has got the lowest mean score of 6.55 among all the attributes.

4.3.4 Perceptions of the Patients for various Factors-

4.3.4.1 Perceptions of Patients for the Behavior of Doctors-


Figure- 4.6 Expectations of patients from the behavior of doctors

Above figure shows that attribute thorough check-up have the maximum mean score
7.88. It is quite high score, which means that patients''s perception about this feature
is good. Then this attended by attributes availability of doctors, examination comfort
and impartial attitude of the doctors. The mean scores for these attributes are 7.78,
7.76 and 7.46 respectively. Knowledge has the average score 7.11 which shows that
Attributes Perceptions
(Mean Value)
Availability 7.78
Knowledge 7.11
Handling of
Queries
6.60
Cooperation 6.75
Politeness 6.86
Impartial attitude 7.46
Examination Comfort 7.76
Thorough Check-Up 7.88
Empathy 5.85
Individual Consideration 6.10
Experience 6.80
Average 6.99
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patients perception about this factor also tends to be quite good. Mean scores for
the politeness, experience, cooperation with the patients and handling of queries are
6.86, 6.80, 6.75 and 6.60 respectively which means that perception of the patients of
the attributes is not so good. Individual consideration and empathy have moderate
scores in 6.10 and 5.85 respectively among all the attributes. So it says that
perception of the patients regarding these attributes is neither good nor bad. The
overall mean score for all these attributes is 6.99, which means that perception of the
patients of the factor behavior of doctors is not very good but it is mildly good.

4.3.4.2 Perceptions of Patients for the Behavior of Medical Assistants-


Figure-4.7 Perceptions of patients from the behavior of medical assistants

It is clear from the above figure-4.7 that attribute dress is the highest rated attribute
with mean score 9. From this, it is clear that patients''s perception about the dress of
medical assistants is very good i.e. they think medical assistants wear neat and
clean dresses. Mean scores of the attributes maintenance record and availability are
7.99 and 7.89 respectively. These are very good score on a scale of 9 which means
that patients had perceived these attributes of medical assistants as good. Impartial
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Attributes Perceptions
(Mean Value)
Availability 7.89
Knowledge 6.46
Cooperation 6.71
Politeness 6.88
Impartial attitude 7.04
Maintenance of Record 7.99
Handling of Queries 6.10
Experience 6.35
Dress 9.00
Average 7.16
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Attributes Perceptions
(Mean Value)
Convenient Office Hours 8.26
Check Up Procedure 6.35
Over Crowding 7.95
Welcome Your Ideas 6.23
Fee 5.48
Grievances Handling System 6.01
Billing Procedure 7.66
Check Out Procedure 7.80
Behaviors of Clerical Staff 7.15
Behaviors of Security Staff 8.48
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attitude has the average score 7.04 which is not bad. Politeness and cooperation
have the scores 6.89 and 6.71 respectively. This means that medical assistants
dealing with patients is not very good. Mean scores of 6.46 and 6.35 for knowledge
and experience show that medical assistants are lacking on these attributes.
Handling of queries has the least score among all the other factors and it is quite.
Less, which means that medical assistants do not properly handle the queries of
patients. Overall average score for all the attributes comes out to be 7.16. So it can
be concluded that patients perception about the behavior of medical assistants is
moderately good i.e. there is need for medical assistants to improve their behavior.

4.3.4.3 Perceptions of Patients for the Quality of Administration-



Figure 4.8 Perceptions of patients from the quality of the administration

In the above figure show the average scores for the behavior of clerical staff and
convenient office hours are 8.48 and 8.26 respectively, which are very high and so it
can be concluded that hospitals are doing well on these two attributes. Over
crowding and check out procedure have the scores, 7.95, 7.80 and 7.66, which
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Attributes Perceptions
(Mean Value)
Availability 7.89
Knowledge 6.46
Cooperation 6.71
Politeness 6.88
Impartial attitude 7.04
Maintenance of Record 7.99
Handling of Queries 6.10
Experience 6.35
Dress 9.00
Average 7.16
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Attributes Perceptions
(Mean Value)
Convenient Office Hours 8.26
Check Up Procedure 6.35
Over Crowding 7.95
Welcome Your Ideas 6.23
Fee 5.48
Grievances Handling System 6.01
Billing Procedure 7.66
Check Out Procedure 7.80
Behaviors of Clerical Staff 7.15
Behaviors of Security Staff 8.48
Average 7.14
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Attributes Perceptions
(Mean Value)
Proper Sitting Arrangements 8.54
Bedding Arrangements 8.66
Staff Appearance 7.66
Natural Light 7.24
Dust Boxes 8.55
Flies & Mosquitoes 8.43
Outer & Inner Appearance 7.41
Parking 8.05
Well Equipped Units 7.09
Marking On Walls 7.78
Eating Places 8.43
Average 7.99
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means that patients perception about these attributes, are good. 7.15 are the score
of attribute behavior of clerical staff, which is less than the above-mentioned factors.
So hospitals need to strengthen on this. Mean scores for the check up procedure,
welcome your ideas and grievances handling system are 6.35, 6.23 and 6.01
respectively. So we can say that perception of patient's there is moderately good.
The lowest mean score 5.48 is scored by the attribute fee which is not good and this
shows that patients thought the fee of the hospitals is high. It is clear from the figure
that the overall mean score for all the attributes is 7.14, which shows that perception
of the patients towards the quality of administration tends to be good.

4.3.4.4 Perceptions of Patients for the Services/ Facilities provided by the
hospitals-

Figure-4.9 Expectations of patients from the services and facilities provided by the hospitals

Author calculate in figure-4.9 the mean score for the bedding arrangements, dust
boxes, proper sitting arrangements, flies & mosquitoes, eating places and parking
are 8.66, 8.55, 8.54, 8.42, 8.42 and 8.05 respectively which means that perception of
the patients about these attributes are very good. So we can say that hospitals are
providing these facilities to the patients in a proper way. Marking walls, staff
appearance, outer and inner appearance and natural light scores are 7.78, 7.66,
Average 7.14
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Attributes Perceptions
(Mean Value)
Proper Sitting Arrangements 8.54
Bedding Arrangements 8.66
Staff Appearance 7.66
Natural Light 7.24
Dust Boxes 8.55
Flies & Mosquitoes 8.43
Outer & Inner Appearance 7.41
Parking 8.05
Well Equipped Units 7.09
Marking On Walls 7.78
Eating Places 8.43
Average 7.99
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7.41 and 7.24 respectively and it shows that patients perceptions about these
attributes are good. 7.09 is the lowest score scored by the attribute well equipped
units but this score is not bad and we can say that perception of the patients toward
this is generally good. 7.99 are the overall mean score for perception of patients
about the services/facilities offered by the hospitals.

4.3.5 Satisfaction Level of the Patients for the various Factors-
4.3.5.1 Satisfaction Level of the Patients for the Behavior of Doctors-

To measure the satisfaction level of patients from the behavior of doctors, the
differences between the mean scores of expectations and perceptions for each
attribute is calculated and then t-test is applied to see whether the difference
between the two mean values is significant or not at 5% level of significance. The
calculated values are given in the figure.


*There is significant difference at 5% level of significance (t-critical =1.66)
Figure-4.10 Satisfaction level of patients for the behavior of doctors

In the figure 4.10 shows that the difference between the mean values of expectations
and perceptions for the attributes handling of queries, politeness, experience,
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Attributes Expectations
(Mean Value)
Perceptions
(Mean
Value)
Difference T-value
Availability 8.99 7.78 1.21 6.48*
Knowledge 8.98 7.11 1.83 7.11*
Handling of Queries 8.51 6.60 1.91 8.41*
Cooperation 8.54 6.75 1.79 10.01*
Politeness 8.71 6.86 1.85 10.05*
Impartial attitude 8.39 7.46 0.93 5.48*
Examination Comfort 8.79 7.76 1.03 7.92*
Thorough Check-Up 8.98 7.88 1.10 9.25*
Empathy 7.31 5.85 1.46 5.93*
Individual Consideration 6.98 6.10 0.88 5.04*
Experience 8.64 6.80 1.84 8.31*
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knowledge, cooperation and empathy is 1.91, 1.85, 1.84, 1.82, 1.79 and 1.46
respectively. The t-values for these attributes at 5% level of significance show that
there is significant difference in the mean values of expectations and perceptions for
these attributes. For the attributes availability, thorough check up and examination
comfort differences between their mean values for expectations and perceptions are
1.21, 1.1 and 1.02 respectively. Their corresponding t-values indicate this is a
noteworthy difference. 0.93 and 0.88 are the differences in the impartial attitude and
individual consideration respectively and t-values for these attributes also show that
there is significant difference between the means scores of expectation and
perceptions. So, it is clear that the highest difference is for the handling of queries
and lowest for the attribute individual consideration.

4.3.5.2 Satisfaction Level of the Patients from the Behavior of Medical
Assistants-

Author measure the satisfaction level of both country patients from the behavior of
medical staffs, the differences between the mean scores of expectations and
perceptions for each attribute is calculated and then t-test is applied to see whether
the difference between the two mean values is significant or not at 5% level of
significance. The calculated values are given in the figure.


*There is significant difference at 5% level of significance (t-critical =1.66)
Figure 4.11 Satisfaction level of patients from the behavior of medical assistants

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Attributes Expectations
(Mean Value)
Perceptions
(Mean
Value)
Difference T-value
Availability 9.00 7.89 1.11 5.90*
Knowledge 8.56 6.46 2.10 8.98*
Cooperation 8.65 6.71 1.94 9.43*
Politeness 8.79 6.89 1.91 9.93*
Impartial attitude 8.49 7.04 1.45 5.93*
Maintenance of Record 8.71 7.99 0.73 4.94*
Handling of Queries 8.44 6.10
2.34
11.11*
Experience 7.45 6.35 1.10 3.99*
Dress 6.90 9.00 -2.10 -13.23*
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It is clear from the figure that the difference between the mean values for
expectations and perceptions is highest for the attribute handling of queries, which is
2.34, and its corresponding t-value is very large and it shows that this difference
between the values is significant. This implies that patients had not received what
they have expected from this particular attribute. Differences for the knowledge,
cooperation and politeness are 2.1, 1.94 and 1.91 respectively and their respective t-
values indicate that these differences are quite significant which means that
perceptions of these attributes are less than the expectation of Singapore patients
from these attributes. 1.45, 1.11 and 1.10 are the differences between the mean
scores of expectations and perceptions for the attributes impartial attitude,
availability and experience respectively and t-values corresponding to these
attributes are larger than the t-critical at 5% level of significance. This means that
differences are significant. The difference for the attribute maintenance of record is
0.73 and t-value for it shows that the difference is quieting significant i.e. patients
perception about this factor is lower than their expectations. Dress has the difference
-2.1, which shows that patients perception for this attribute is higher than their
expectations.

4.3.5.3 Satisfaction Level of the Patients for the Quality of Administration-

Author measure the satisfaction level of patients from the quality of administration,
the differences between the mean scores of expectations and perceptions for each
attribute is calculated and then t-test is applied to see whether the difference
between the two mean values is significant or not at 5% level of significance. The
calculated values are given in the figure.

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*There is significant difference at 5% level of significance (t-critical =1.66)
Figure- 4.12 Satisfaction level of patients for the behavior of doctors

This figure show that differences between the mean values of expectations and
perceptions for the check up procedure and grievances handling system are 2.50
and 2.44 respectively, which are quite big differences. So we can say that
expectations of Indian patients from these attributes are higher than their
perceptions. For attributes behavior of clerical staff and fee difference between
expectations and perceptions are 1.74 and 1.63 respectively, which are not small. So
it is accurate to say that expectations are higher than perceptions of these attributes.
1.11, 1.08 and 0.98 are the differences for the billing procedure welcome your ideas
and check out procedure respectively. Behavior clerical worker and over crowding
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Attributes Expectations
(Mean Value)
Perceptions
(Mean
Value)
Difference T-value
Convenient Office
Hours
6.53 8.26
-1.74
-7.27*
Check Up
Procedure
8.85 6.35
2.50
9.84*
Over Crowding 8.26 7.95 0.31 1.92*
Welcome Your
Ideas
7.31 6.23
1.08
4.99*
Fee 7.10 5.48 1.62 4.49*
Grievances
Handling System
8.45 6.01
2.44
11.19*
Billing Procedure 8.78 7.66 1.11 7.47*
Check Out
Procedure
8.78 7.80
0.98
7.08*
Behaviors of
Clerical Staff
8.89 7.15
1.74
7.88*
Behaviors of
Security Staff
8.85 8.48
0.38
3.10*
!
!
!
!
!
!
!
!
!
83
has the difference 0.38 and 0.31 between the mean values for expectations and
perceptions. Attribute convenient office hour has the negative difference between
mean values of expectations and perceptions, which mean that patients perception
about the attributes is higher than their expectations.

4.3.5.4 Satisfaction Level of the Patients for the Services and Facilities
Provided by the Hospitals-

Author measure the satisfaction level of patients from the services and facilities
provided by the hospitals, the differences between the mean scores of expectations
and perceptions for each attribute is calculated and then t-test is applied to see
whether the difference between the two mean values is significant or not at 5% level
of significance. The calculated values are given in the figure.


*There is significant difference at 5% level of significance (t-critical =1.66)
Figure-4.13 Satisfaction level of patients for the behavior of doctors
!
!
!
!
!
!
!
!
!
!
!
!
!
Attributes Expectations
(Mean Value)
Perceptions
(Mean Value)
Difference T-value
Proper Sitting
Arrangements
8.98 8.54
0.44
5.04*
Bedding
Arrangements
9.00 8.66
0.34
4.48*
Staff Appearance 6.55 7.66 -1.11 -4.44*
Natural Light 8.36 7.24 1.13 4.52*
Dust Boxes 9.00 8.55 0.45 5.07*
Flies & Mosquitoes 9.00 8.43 0.58 6.13*
Outer & Inner
Appearance
7.44 7.41
0.03
0.10
Parking 8.71 8.05 0.66 3.80*
Well Equipped
Units
8.33 7.09
1.24
5.63*
Marking On Walls 8.08 7.78 0.30 1.56
Eating Places 8.69 8.43 0.26 2.70*
84

This above figure shows that largest differences between expectations and
perceptions are 1.24 and 1.12 for the attributes well equipped units and natural light
respectively among all the other attributes. This means that expectations of Indian
patients are higher than Singapore patients and their perceptions for these attributes.
0.66, 0.58, 0.45 and 0.44 are the differences for the parking, flies & mosquitoes, dust
boxes and proper sitting arrangements respectively. The attributes bedding
arrangements, marking on walls and eating-places have small differences of 0.34,
0.30 and 0.26 respectively between the mean values of expectations and
perceptions. For inner and outer appearance, the difference is.0.25, which is very
small, and it can be concluded that patient's perception and expectation for this
attribute are approximately same. But attribute staff appearance has negative value,
which is -1.11, and it is true to be able to say that patients expectations are lower for
this attribute than their perceptions.


4.4 Qualitative Research-

4.4.1 Survey questionnaire to hospital patient-

Rate your satisfaction (RYS), see APPENDIX-8
Indian Public hospital-
I. kem hospital Mumbai,India(Hosp-A)
II. Lokmanya Tilak Municipal General Hospital, Mumbai, India (Hosp-B)

Singapore public hospital-
I. Singapore general hospital, Singapore (Hosp-C)
II. Alexander Hospital, Singapore (Hosp-D)





85
1. Access to medical care Hosp-A & B and Hosp-C & D-


Figur-4.14, Source- author

Analysis: Out of 418 patients, 119% responded as excellent for Hosp-C & D but
other side 0% responded excellent to the Hosp A & B this is because at the time of
taking services by the hospital they suffer a lots, 77% responded good for the easy
access to medical care of Hosp C & D but again the no of responded for Hosp A &
B only 2 %, 13 %gave the average response to the Hosp C & D and 8 % responded
to Hosp-A & B, 0 % gave poor response to Hosp C & D but when we goes to Hosp
A & B No. Of responded 39% it likes in very poor the No.of responded by Hosp A &
B is 51% which is too much high score but for Hosp C & D got 0% response.











86
2. The time you spend in waiting room for doctor Hosp-A & B and Hosp-C & D.


Figur-4.15, Source- author

Out of 418 patients, 23% responded as excellent for Hosp-C & D but other side 0%
responded excellent to the Hosp A & B this is because at the time of taking services
by the hospital they suffer a lots, 59% responded good for the time spend in waiting
room in both the hospitals of Hosp C & D but again the no of responded for Hosp A
& B only 0 %, 12 %gave the average response to the Hosp C & D and 14 %
responded to Hosp-A & B its little good in comparison, 3 % gave poor response to
Hosp C & D but when we goes to Hosp A & B No. of responded to 67% it likes in
very poor the No. Of responded by Hosp A & B is 3% which is too much high score
but for Hosp C & D got 19% response.











87
3. The staff willingness to help you-



Figur-4.16, Source- author


Out of 418 patients, 46% gave excellent response for the staff willingness to help for
Hosp-C & D but in mean while the Hosp-A & B 1% responded, 39% gave good
response for Hosp C & D but in Hosp- A & B 3% and 66% gave average response
to Hosp-A & B well in this case 11% responded for average to the Hosp-C & D. The
patients were quite satisfied with the helping nature of staff.











88
4. Cleanliness in both country public hospital-


Figure-4.17, Source- author

Out of 418 patients, 0% gave excellent response to the cleanliness of the hospital
Hosp A & B while the Hosp-C & D 47%. 28% gave a good response to Hosp-C & D,
but for Hosp A & B is 12% only. This is the reason patients cure so easily and early,
as hygiene plays an important part in both hospitals in Singapore.

5. Public hospital behaviour of administrator


Figur-4.18, Source- author
89

Out of 418 patients, 48% gave excellent response for the behavior of the staff
members with them in Hosp C & D while in Hosp A & B it is 0%, 36 % gave good
response to same Hosp C & D and for 0% for Hosp A & B, But in the case of
average the no. of responded miracle, 97% for Hosp A & B and the 15% for the
Hops C & D gave an average response.


6. According to you which hospital is best? -


Figur-4.19, Source- author

The survey was conducted in both hospitals and out of 418 patients different patient
gave different viewpoint regarding the best hospital according to their need. Most of
patient responded as Hosp- C & D to be the best hospital as they gave different
reasons for it, according to the facilities which they get from hospital, the care,
concern of doctors, they get attention of doctor whenever it is needed.





90
7. Which hospital is economical to you? -


Figur-4.20, Source- author

This was also a controversial question, a rational person will prefer that hospital
which is reasonable, or its free of cost, but when the survey was conducted it was
found that 418 responded patient doesnt go for price, but prefer quality which they
got from the hospital, where they come certain i.e. Hosp-C & D. But when it comes to
economic wise then Hosp- A & B government hospital is preferred as compare to
Hosp C & D.


8. The Public Hospital provides proper authority, Responsibility, and
accountability to its health workers Hosp -A & B and Hosp- C& D-

91

Figur-4.21, Source- author

Out of 418 patients, 90% gave strongly agree with the cleanliness of hospital Hosp
C & D while the Hosp-A & B 0%. 27% Disagree for the Hosp A & B while the Hosp-C
& D is 0% but for Hosp A & B is 0% only. This is the reason patients preferred
Singapore hospital.


9. Doctors, nurses and technicians are recognized and rewarded suitably by
the hospital-

Figur-4.22, Source- author
92

Out of 418 doctor, Nurses and attended in both the country hospital Hosp -C & D
responded 79% is strongly agree and they are happy but in the case of the Hosp A
& B 0% which is very bed score because of this they are not dedicated regarding
about work. Rest of the score is not good for Hosp A & B.

4.3 Factor analysis-
Factor analysis elements is a necessity in light of the fact that it will give a focused
intention to the required size is a measure, which is two-dimensional measurement
requirements, etc., and the distinguish investigation did not realize stimulus size
information (Asubonteng, 1996 Chapter 3., p. 87). The investigation is not well
defined size was evacuated. To check the age of the material, all the components
are 21. Author analyses by using Ms-Excel Tool. The survey measures if the 21
components in each set of conditions, and the meetings are shaped according to the
research requirement.
93

Factor Loading
TANGIBLES (=0.74)

T1 Hospitals (Hosp B & C) will have excellent equipment and modern
looking.
0.839
T2 Facilities at the hospital (Hosp- B & C) are excellent visually
appealing.
0.819
T4 Documents relating to this service will be attractive in the hospital
usually excellent.
0.488


RELIABILTY (=0.82)
R4 Hospital will provide excellent service at the time they promise to
do so.
0.717
R1 As excellent hospital will tell customers exactly when services will
be performed.
0.686
R3 Hospital will provide excellent service at first time. 0.655
R2 When customers have problems, excellent hospitals will show a
sincere interest in solving them.
0.646
R5 Hospitals will insist on excellence profile error free. 0.599
T3 Staff at an excellent hospital will be neat attractive. 0.536

RESPONSIVENESS (=0.77)
R4 Employees of excellent hospitals will never be too busy to meet
the needs of patients.
0.686
R3 Employees of excellent hospitals will always be willing to help
patients.
0.588
R2 Employees of excellent hospitals will provide services to patients
quickly.
0.538
R1 Workers of brilliant doctor's facilities will tell patients precisely 0.519
94

Figure 4.23,-factor analysis, Source -author

In this analysis, author is calculating the factors in public hospital they are empathy,
responsiveness, assurance, and reliability tangible/significantly. Two elements are
stacked in different sizes. Factor 3 has been set up on the unmistakable views were
stacked on reliability and extending the range in size from 1 point to parts of
compassion was stacked on the corner confirmed, see APPENDIX-9.

4.5 Environmental analysis-

Francis J. Aguilar develops PEST in 1967 for the company to ensure that they cover
large areas of political, economic, social, technological, environmental, and legal and
culture so that they can compete in the market (Scholes and Johnson, 2005). In this
author is using PEST analysis for explaining the environmental analysis in both
county public hospitals.
when administrations will be performed.

ASSURANCE (=0.86)
A2 Patients of superb healing facilities will feel protected in their
transactions
0.727
A1 The behavior of the hospital staff will emphasize excellence
confidence in the hospital.
0.72
A3 Patients of excellent hospitals will always polite with patients. 0.703
A4 Employees of excellent hospitals will have the knowledge to
answer patients' questions.
0.699
E1 Hospital will provide excellent patient personal attention 0.502
EMPATHY (=0.67)
E5 Employees of excellent hospitals will understand the specific
needs of their customers.
0.767
E4 Hospital will provide excellent patient personal attention. 0.731
E2 Hospital staff excellence will give customers personal attention. 0.628

95

Figure-4.24. PEST Analysais, Source: http://www.businessballs.com/pestanalysis
freetemplate.htm.

1) Singapore and India public hospital Hosp-A, B, C and D.

i. Political Factors

Both the country is a democracy country in the world. In this Singapore public
hospital has to work on the rule and regulation according to Singapore government
(Moh.gov.sg, 2014). In political factor, the increased in the political pressure and tax
policy is the important factor in healthcare services. In India political analysis, the
central government is now reducing the hold on subsides (Anon, 2010). Private
sector also influences the public hospital.

ii. Economic Factors

Singapore must target the healthcare market national GDP by increasing as
compare to Indian GDP. The current rate of this industry is about 3.6 precent annual
(the digital living hub, 2012). As compare to India public hospital the patients
expectation changes they are comparing with other hospital due to not improving in
quality of service in a public hospital they are moving to another option.

96
iii. Social factors

In the social factor in Singapore public hospital they are providing quality services,
advance healthcare equipment, they doing survey every year from the patients
feedback for improving the healthcare services. As compare to Indian public hospital,
IS (information system) is not a proper way establish in Hosp-A and B, well feedback
of patient and survey is available but not taking seriously for improvement.

iv. Technological factors-

The use of is the right direction for Singapore hospital to take for its long-term
objectives. It is equally a source of revenue for future expansion (Somvanshi, 2011).
In advance technology in healthcare is the main factor in Hosp-C and D, which will
give excellent services. As compare to Indian hospital the equipment is there but
lack of knowledge to handle
4.6 Conclusion-
The findings of this chapter shows that the patient were disappointed with the
cleanness in the hospital and it has caused an increased waiting time in all the
departments of the hospital in Hosp A and B as compere to Hosp-C and D of the
doctor's facility administration ought to give careful consideration to this gap in
healthcare services Patients surveyed the tangible assets of the association,
including the offices and staff. It is evident from the research of this chapter is that
patient satisfaction is not up to the level of the presence of the picture of the public
hospital. Now in chapter , five authors will give some recommendation as a
suggestion which will give support the service quality graph of Hop-A and B will
increase.





97
CHAPTER-FIVE
5.1 Introduction-
In this chapter author had presented a general conclusion for the entire research
with achieving in objective in research, author also presented recommendation
especially for Indian public hospital (Hosp -A and B) so they can take follow
Singapore hospital (Hosp-C and D) path and make patient satisfaction with excellent
service quality.
The author begins this chapter by stating the goals and objectives of the research,
followed by a discussion of how the goal was achieved.

5.1.1 Discussion of objective -1: -

The author analyze the quality of existing services comparison with Hosp-A and B
and C and D and they found in achieving objective one is

Similarities- Hosp-A, B and C, D -

Both public hospital has insurance plan give by government to the patient
Public hospital are major healthcare provider in both country
Both country public hospital have high tech technology
Management under state government
Less completion in public healthcare sector

Differences in Hosp-A, B and C, D

Health system Singapore (Hosp- C and D)-

Allow and in courage the medical staff to make Hosp C and D
efficient and effective
Medical bill are pay by the CPF, Medi-save scheme
Government full control on hospital finance issue as well as
98
management
Health system India (Hosp-A and B)-

Hospital has best technology but lack of knowledge to handle the
medical equipment
Cleanness is the major issue
Hospital is control by government but the effectiveness of control is
not proper way.

Hospital financing Singapore (Hosp- C and D)-

Payment under the Medi-save scheme, with progressive co-
payment for high class of services

Hospital financing India (Hosp- A and B)-

Free of charge healthcare or minimal charges in hospital by the
government

Public hospital governance Singapore (Hosp-C and D)-

Corporation owned by the government managed by hospital boards
of directors

Public hospital governance India (Hosp-A and B)-

Hospital managed under the state government but not in
Proper and effective policy.

Human resource Singapore (Hosp-C and D)-
No longer public employees, flexibility in effective management

99
Human resources (Hosp A and B)

Still mainly government officers

After analyzing the primary data and compare with secondary data in chapter-4
author achieve the objective one in which author public hospital Hosp-A and B has a
certain gap between the patient service expectation which will hospital must give
attention to narrow this gap and improve the service quality. The finding in chapter-4
the medical staff is not cooperative and work willingness toward the patient is too
low. Hospital has high technology equipment but they dont know how to use them
as well as human resource implantation is .The finding in the research also shows
the cost effectiveness as compare to Hosp-C and D Indian Hospital Hosp-A and B is
minimal costly but the treatment is not good. The time spent in Hosp-A and B is too
much as compare to Hosp C and D. The management of the Hosp- A and B should
give attention in high technology IS (Information system) in hospital for upgrading
medical equipment for give fair completion to other hospital. Above result, it's clearly
shown that patient is not satisfied with the doctor attitude toward the patient
management should give the proper attention the service quality and fulfilled the gap
between the patient satisfaction.
5.1.2 Discussion of objective -2: -
The author shall consider the existing literature on service quality, patient
satisfaction, in which the author clearly give evidence about Indian hospitals are not
up to mark and not providing patient satisfaction, on the other hand Singapore
hospital for the best quality and services according to data in Chapter-4 and
suggestions are put forward by the authors in the introduction. From these results, it
is clear that "hospital cleanness" is the first level of the respondents to the Hosp-C
and D, in which the other replied Hosp- C and D are given priority for rapid diagnosis
delivered at the right time. People are asking for effective service in the proper way
of the hospital in India. "T -Test" display value is negative relationships in the ranks
of Hosp-A and B as compare to Hosp-C and D. Al andaleeb (1998) stated that
hospitals that do understand the importance of customer satisfaction to be invited to
a possible extinction. (Andaleeb 1998; cited by Padma et al, 2010)
100

5.1.3 Discussion of objective -3: -

In chapter 4 is clearly showing that the Indian hospital (Hosp-A and B) must be follow
the path of Hosp C and D for improving the hospital service quality after
conclusions the objective -3 author suggest that hospital should improved in
The resources required to enable the provision of quality care infrastructure,
equipment, drugs and supplies
Care provided by appropriately trained and supervised providers; numbers of
staff adequate to meet the demand for care
Care consistent with scientific knowledge, internationally recognized good
practice.
Patient/Provider satisfaction high
Aspects of Quality Improvement
According to finding the Hosp A and B central government can give proper attention
to improve the hospital, which they are not giving, proper (as per the data). The
Indian government should fill the shortage of specialists including surgeons,
physicians, gynecologists, pediatricians and public hospitals. Government should
open drug stores everywhere, which can help patients with medication affordable.
Public hospitals in Singapore and India should arrange training and development
program for their staff to close the gap in responsiveness, assurance and empathy.
Each hospital must keep the box to receive feedback from patients about their
experiences, which can help hospitals for continuous improvement in their
operations. In the current scenario comparing the patient satisfaction is the first
priority to improve the healthcare sector also customer satisfaction is the old time
concept has encouraging the strategic of marketing culture in the healthcare industry
in both the develop as well as developing countries (Wisniewski, 2001). Wear else
Public hospital aware of and attentive to give good healthcare services because of
the rapidly increasing healthcare competition in the healthcare business. Along this
all this to maintain in hospital patients to give and provide better administration of
hospital to the patients, The various factor which are affected the implementation of
good healthcare in India except Singapore for implementation and give proper
healthcare give easy access to hospital management, give better quality
101
management, Good information technology which will boot the health care growth.
As well as in public hospital give proper and good medicine facility to the patient.
5.2 Conclusion-
The author analyzing the data and writes about the achievement of the objective of
the research, which is compared with the chapter-four analysis with the comparison
of the both hospital. In order to realize the objectives of the research, the primary
data was collected.


5.3 Research limitations-
This research has constraints. It is a public hospital facility based on research
instead of a universal one. In future, notions of administration suppliers and strategic
producers ought to be looked for on the elements where an administrative quality
gap was discovered furthermore on the suggestions that have been considered in
this research. Such work would help draw legitimate profit from this research. The
research endeavored to recognize the particular elements of the nature of
administration in the Indian public hospital services division that ought to be
enhanced from the viewpoints of Singapore Public hospital center. This future
research has demonstrated that-availability of physicians, assurance/competence of
physicians, empathy of physicians, responsiveness of nurses, empathy of nurses,
availability of drugs, tangibility (amenities of care), and perceived cost were certain
factors in which significant differences existed among the Indian public hospital and
Singapore public hospital .The actual administration suppliers ought to, hence,
attempt the important steps to relieve this crevice to offer better human services
administrations to patients. Such steps would help the rational development of the
human services division in India.
5.4 Recommendation-
5.4.1 Recommendation 1 -
Author is highly recommendation for the Hosp- A and B to implant the ERP system
(Enterprises resource planning) to the hospital. It can help in the day-to-day activity,
102
help in information flow and restore data regarding staff, medical equipment,
management, discipline and cash flow, by the execution of ERP, it is trim down the
admission process, billing process and patient file quickly by registration number. If
the doctor wants further examination of the patient they directly coordinate with the
other department with the ERP system online at save time and access data from any
department easily and get result quickly. Hosp-C and D they already have an ERP
system and they used effectively in his hospital but they are required to update time
to time for more efficient work in service quality. Well ERP is an opportunity to
improve the stock management of the pharmacy more easily it helps the
management in decreasing operational cost. Implantation of ERP is costly before
implanting in hospital, a detailed report of the project sends to the high authority of
the hospital and needs the approval by management, after that gives advertisement
in newspaper and hospital websites for bid for implanting ERP system. Before
implanting training should be given to the employees is completed 10-15 days as
well as the ERP system can be implanted in 5 weeks without affecting the hospital
business work.


Figure-5.1 Implanting Enterprise Resource Planning (ERP)-Self made for research

103
5.4.2 Recommendation 2
Recruitment of HR trainers for motivating the doctors and the staffs of the hospital to
give effect to a patient cantered approach. The manager implanted the effective
policies and procedure in Hosp A and B for involving patient families and patient
care in service quality improvement and patient safety. The manager of hospital Hr
(human resource) department can incorporate the consideration knowledge of
patients they had in the doctor's facility turned in to staff executive evaluation and will
cultivate patient society. Healthcare manager ensures that there is a proper system
in the hospital and regular collection with daily reporting of patient care. The Manger
implanted training strategy to hospital staff to build patient centric approach. The
manager should ensure that after implanting the health service action plan for the
hospital they should consider the feedback of the patient experience clinical and
optional data to consider in his action plan for effective use. There is different
method to use promote patient culture approach daily monitoring hospital, survey
manger should direct chit -chat with patient which they know what problem is going
on in each unit, Motivate the staff for performance and give employee of the month
to which will encourage give best service to the hospital. Manger give the training
programmed to update his work and implanting training to the employees give the
phased manner in 7-week, The primary assessment of the preparation is possible
following 2 weeks of execution office savvy The reappearance of the speculation
might be seen in inside 6 months and the advancement could be assessed by the
input of patient involvement in the public hospital.

104

Figure-5.2, Human resource implantation
5.4.3 Recommendation -3
The Hosp-An and B ought to begin their own particular health care insurance
programmed modified by having tie up with leading insurance operators. By having
this protection framework, the patients will return over and over for profit treatment.
5.4.4 Recommendation-4
In the public hospital (Hosp A and B) should implant the JCI accreditation (Joint
Commission International) in his hospital, which will help in keeping an eye on the
quality stranded in hospital. By using JCI stranded, hospital can attract the more
patient from his own country as well as foreigners. The hospital is located in most
advance and populate a city in India which by having the stranded quality it will
attract more patient and hospital get profit and brand image.
5.5 Conclusion-
The main data were gathered from the respondents patient, nurses and doctors in
the hospital. To select the sample author collects sample according to demographic
which percentage and the conclusion author showing in data analysis, other things
105
the sample taken from the public ward of both the hospital the information with data
collected from the pre-designed, structured questionnaire. A number of samples are
440, which are responded and were selected from the hospital.

The Indian government should fill the shortage of specialists including surgeons,
physicians, gynecologists, and pediatricians at public hospitals. Government should
open drug stores everywhere, which can help patients with medication affordable.
Public hospitals of Singapore and India (Hosp-A, B and C, D) should arrange training
and development program for their staff to close the gap in responsiveness,
assurance and empathy. Each hospital must keep the box to receive feedback from
patients about their experiences, which can help hospitals for continuous
improvement in their operations.

The results of the analysis conducted indicate that public hospitals in India have
rather bigger gaps when compared to Singapore public hospital.
Research data from responded form hospital in hospital suggest a lack of confidence
in service quality improvement that hospital management will solve the problems
identified in the care of patients. Author research data support this of the World
Alliance for patient safety that organizational behavior is important in promoting
patient safety and service quality for public hospitals.














106
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117
APPENDIX-1-

1.1 Overview of public hospital in Singapore and India in the healthcare
services industry -

The health awareness administrations organizations could be broken down into two
quality estimations: particular quality and utilitarian quality (Gronroos, 1984). While
particular quality in the social assurance divide is portrayed essentially on the
prelude of the specific rightness of the therapeutic determinations and strategies or
the conformance to ace shares, reasonable quality intimates the track in which the
social insurance administration organization is passed onto the patients (Lam, 1997).
In different revelations, particular quality is about what the patients get,functional
quality is about how they get it. Research has exhibited that particular quality misses
the motivation behind being a sincerely strong measure for delineating how patients
review the way of a medicinal organization experience (Bowers et al., 1994).

Baldrige National Quality Program: Health Care Criteria for Performance
Excellence-
The most renowned quality-of-management award-- Malcolm Baldrige National
Quality Award (MBNQA)in Singapore sets the management framework for
performance excellence, which has been initiated in many other countries. From the
health care perspective, performance excellence means an integrated approach to
organizational performance management that results in
I. Provide continuously improve value for patients and other customers,
contributing to improve the quality of health care;
II. Improve overall organizational effectiveness and capabilities as a provider of
health care; and
(3) Personally learning of organizational
The framework of MBNQA criteria comprises the organizational profile and the seven
categories of criteria as shown in figure. Many interesting features, which can be
summarized for the purposes of, identify the needs for management improvement
118
and designing a management model for hospitals as follow.

Figure-2.14,Source-NIST 2005



1.3.PATIENT CARE IN SINGAPORE PUBLIC HOSPITALS:

Quality of care in Singapore has seen a paradigm shift from a traditional focus on
structural approaches to a broader multidimensional concept, which includes the
monitoring of clinical indicators and medical errors. Strong political commitment and
institutional capacities have been important factors for making the transition. What is
still lacking, however, is a culture of rigorous programmed evaluation, public
involvement, and patient empowerment.

Despite these imperfections, Singapore has made considerable strides and its
experience may hold lessons for other small developing countries in the common
quest for quality care and patient safety.
119

Quality care is by no means a new concept in Singapore, where it has long been
assumed to be an implicit goal of the healthcare system. What is new is the adoption
of a systematic and scientific approach to its measurement and management.1
Likewise, the recognition of medical errors as a systemic problem requiring
systemic solutions2 is a recent and positive development.

The impetus for change, however, is not coming from public pressure for hospitals to
be held accountable for the quality of care they deliver, but from a paternalistic
government that strives to be proactive in most matters. The governmentas the
regulator, major purchaser, and major public provideris pushing for change on
behalf of Singapores non-vociferous, law abiding citizens. Although it has not been
consciously pursued as such, the evolutionary path taken by the largely top down
quality healthcare movement can be described in Donabedian terms.3 Initially
focused on structures, it has recently turned on processes and outcomes.

Singapore inherited a British style, largely tax based, and publicly provided
healthcare system at independence in 1965. Over the years it has evolved under a
pragmatic government bent on eschewing egalitarian welfarism in favors of market
mechanisms to allocate scarce healthcare resources. N Today, health care is
financed by a combination of state subsidies (25%), employer benefits (35%), out of
pocket payments (25%), compulsory medical savings for acute care expenses (8%),
risk sharing for catastrophic illnesses (2%), and private health insurance (5%)
(Ministry of Health, unpublished data, 2000). National health care expenditure has
remained fairly constant at 3% of GDP over the last two decades.23 The WHO 2000
Report ranked Singapore sixth (out of 191) in overall health system performance.

Patients have complete freedom of choice of providers. Primary health care is
easily accessible through private medical practitioners (80%) and government
outpatient polyclinics (20%). There are 26 well-equipped hospitals and specialty
centers providing 11 798 beds (ratio of 3.7 beds per 1000 population). Eight public
hospitals and five-specialty centers (ranging from 80 to 3110 beds) account for 80%
of the beds while 13 private hospitals (from 25 to 500 beds) account for the
remainder. Three private hospital chains are listed on the Stock Exchange of
120
Singapore and Since 1985 every public sector hospital has been restructuredthe
latter term referring to the granting of autonomy in operational matters so as to inject
private sector efficiency and financial discipline, but with the government retaining
100% ownership of the hospitals. Initially managed by a monolithic government
company, the restructured hospitals underwent further reorganization in 2000,
splitting into two competing clustersthe National Healthcare Group and the
Singapore Health Servicesbut ultimately reporting to the MOH. (Ministry of Health)

Singapores doctors enjoy a high reputation, as attested by the steady streams of
well-heeled patients who fly in from the surrounding region for medical care. In 2000
an estimated 150 000 foreign patients sought treatment in Singapore.25 Recently, a
governmental Economic Review Committee has set a target of one million foreign
patients a year in 10 years time, which would bring in an estimated $3 billion
annually and create 13 000 jobs.26 As Singapore strives to become a regional
medical hub of excellence, a major challenge will be to ensure uncompromising
standards in the quality and safety of health care that is both affordable and
accessible to all Singaporeans.


1.6 Expansion of health budget in Singapore: -
SINGAPORE will increase its healthcare spend by 6 per cent a year to reach US$
12.6 billion in 2015 from US$9.27 billion in 2011 Still, the growth in Singapores
healthcare expenditure will be outstripped by the regions expected annual increase
of 8 per cent. From 2011 to 2015, governments across the Asia-Pacific will beef up
healthcare budgets to US$420 billion from US$309 billion. [Sources: - http://
www.Healthchange.com.sg/ News/Pages /healthcare-spending-hit-us126b-
2015.aspx]

121

Sources:-World Bank (2012 Statistics)


Demographics of Singapore, Data of FAO, year 2005 ; Number of inhabitants
in thousands.
5,076,700 - 2010 est. Source: World Bank, World Development Indicators

122

Sources-http://www.singstat.gov.sg/pubn/popn/population2012b.pdf

Exceptional health awareness is costly, and a hefty portion of the most-advanced
countries of the planet is discovering that the constantly climbing expenses for
quality consideration are unsustainable. Singapore, then again, has deftly figured out
how to keep its expenses low without relinquishing quality. Indeed, it has realized
that astoundingly high rating from the World Health Organization while using less for
every capita than whatever viable high-pay economy.

Disregarding climbing expenses all over because of demographic patterns, new and
costly engineering, and altering infection designs, Singapore, I am satisfied to see,
presses on to use less than four percent of GDP for health awareness, by a wide
margin the most minimal figure around all other high-wages nations on the planet.

The United States, by complexity, uses just about 18 percent of GDP yearly an
immense cost to pay that is presently bringing about intense discussions and political
fights as the country civil arguments its anticipated approach to give a second
thought. In the matter of costs of particular strategies, one can instantly see the
distinctions that exist in Singapore's expenses vs. the United States. Case in point,
the expense of an angioplasty in the United States is very nearly $83,000, while in
Singapore the expense is about $13,000. A gastric detour in the United States is
essentially Us$70,000, while in Singapore the expense is $15,000 (these figures are
in US dollars and incorporate no less than one day of hospitalization).11 See Table
2.6a for additional expense correlations.

123
Singapore's sum national health use as a rate of GDP is practically identical to that
of the upper-center (ChinaMalaysia), and easier center livelihood nations (India
Philippines), yet the health results realized are keeping pace with those conveyed by
the most elevated salary nations on the planet.

Singapore's for every capita use was simply over Us$2,000 in 2009. Examination
figures with different areas are accessible for 2008 and show that the United States
used the most for every capita at just over US$7,000. Other advanced nations on
normal used over $3,000, aside from Japan, which used well under $3,000. In the
easier center earnings nations, the figure falls as low as $90, for instance, in
Indonesia. Singapore, conversely, used just over US$1,800.

Government-just use for the planets medicinal services frameworks likewise
indicates Singapore as the pioneer in holding expenses under control. For every
capita studies uncover that in 2008, the administration used over $600 for
forethought, while the United States used practically $3,500, the United Kingdom
over $2,600, Japan about $2,300. Asia Pacific figures go from $274 in Malaysia,
$126 in China, down to $40. The Singapore government consumption as a rate of
sum government use was around eight percent.

Private use in Singapore ended up as around 65 percent of the sum national cost
(2008). Note that this incorporates installments out of the legislature run Med shield
plan and identified protection plots, Medisave accounts, and other private protection
conspires or boss gave restorative profits. The figure for the United States is 52
percent, 17 percent for the United Kingdom, and 18 percent Japan. Singapore's
moderately high private use is an immediate consequence of the administration's
deliberations to movement a greater amount of the expense trouble to shoppers than
do generally different nations. The methodology is an essential procedure for holding
public uses down and controlling unnecessary utilization. I might need to say that the
methodology is living up to expectations. Later in the book, I will examine this
system, and additionally the framework's managing standard of empowering
people's authority regarding their own particular care. I find it fascinating that the
figures for private medicinal services use in more level center livelihood nations are
likewise considerable, yet for an alternate excuse for why. The immature public
124
medicinal services foundation in these nations and a general absence of confidence
in the framework cause nationals to incline toward private health awareness
administrations and to pay for their own particular mind. In India, private use was as
high as 67 percent in 2008; in the Philippines it amount to around 65 percent


1) Singapore General Hospital




The Singapore Health Services healing center includes sprawling grounds at
Outran Park, offering space to four expert medicinal centers, specifically the
Singapore National Eye Centre (SNEC), the National Heart Centre (NHC), the
National Cancer Centre (NCC) and the National Dental Centre (NDC). The
Singapore General Hospital was secured in 1821, when the first General
Hospital was discovered in the cantonment for British troops shut the
Singapore River. It later moved to Pearl's Bank then a short time later to the
Kandang Kerbau zone, before at final settling at Sepoy Lines in Outram Road
in 1882.
On 31 March 2000, going with a major patching up of individuals by and large
territory social insurance organizations began by the Ministry of Health, the
Singapore General Hospital went under the organization of Singapore Health
Services or Sing Health. The Sing Health Group at present serves the eastern
fragment of Singapore through a group arrangement of 4 hospitals, 5 master
centers and 7 polyclinics.



125
Hospital Overview-
With a history and custom of remedial brightness crossing two centuries,
Singapore General Hospital (SGH) is Singapore's lead doctor's facility. SGH
functions as a revamped clinic and is a part of the Sing Health (Singapore
Health Services) Group, an accommodated medicinal services transport
framework joined on 31 March 2000 incorporating hospitals, national strong
point focuses and polyclinics. It is a not-for profit establishment with a long
custom of giving aggressive tertiary medicinal services. As the bedrock of
medicinal preparing, SGH presses onto accept a key part in nurturing pros,
restorative guardians and unified health specialists, and are sure to innovative
translational and clinical exploration. Our social mission and accommodating
legacy have been the driving compel behind the Hospital's consultations and
attainments in organization, direction and research the "three sections" of
SGH.



2) Alexandra Hospital, Singapore.







Alexandra Hospital is a 400-couch hospital placed in the southwestern part
of Singapore. Settled in an 110,000 square meter land, the hospital is a
126
picture of serene setting, lined with generally frontier style edifices assembled
since the late 1930s. Under British guideline, it was reputed to be the British
Military Hospital. It is recollected as the site of a slaughter throughout the
World War II Japanese occupation.
Our Vision, Mission and Values-

Our Vision
Transforming Care-
With our maturing populace and the present arrangement of long-winded
healthcare administrations (mostly centered around intense forethought),
"Transforming Care" is a call for a principal movement in the way we convey
the most proper consideration centered on the necessities of patients.
"Converting Care" is not about bringing about a noticeable improvement at
our specialty. It is about moving far from sickness mind center to positively
keeping patients and occupants sound, and caring for their well-being.

Bringing Health To Every Home-
This explanation highlights our Vision to contact our group in the West.
Straightened with our Mission, "Bringing Health" talks about our goal to
incorporate and improve healthcare with the goal that it may be approachable
to help the solid stay sound, to help the debilitated get well and to enable the
group to administer their well-being.

Our Mission-

Stay Well. Heal. Empower.
Giving combined healthcare by working as one with group accomplices,
patients, parental figures and staff.
Stay Well-
127
Inside the entire domain of healthcare, helping individuals to stay sound is a
necessity. Henceforth, one of our mainstays of our mission is to help the
neighborhood stay well.
Heal
The point when people fall broken down, we will recuperate them to the best
of our capability. This is the accepted part of hospitals and we should press
on to outperform here of consideration.
Empower
For the healthy, we need to engage them with data, assets, outreach
programmers and training to keep living sound lives. For the individuals who
presuppose progressing consideration or are past mending, we need to
enable them to live their lives as agreeably as could be expected under the
circumstances and with poise.

Our Values-
Patients Centeredness

We plan and convey mind around the requirements of our patients and their
guardians.

Honesty
We uphold trust through all we say and do.

Perfection
We give our best, against all odds.

Shared Respect

We treat every single individual with respect.

Openness

128
We grip change and champion enhancement.

































129
APPENDIX-2-

INDIA-

Indian Healthcare Industry: -
Indian Healthcare industry is a wide and intensive form of services, which are related
to well being of human beings. Health care is the social sector and it is provided at
State level with the help of Central Government. Health care industry covers
hospitals, health insurances, medical software, health equipments and pharmacy in
it. Right from the time of Ramayana and Mahabharata, health care was there but
with time, Health care sector has changed substantially. With improvement in
Medical Science and technology it has gone through considerable change and
improved a lot.

In the Constitution of India, health is a state subject. Central governments
intervention to assist the state governments is needed in the areas of control and
eradication of major communicable & non- communicable diseases, policy
formulation, international health, medical & Para-medical education along with
regulatory measures, drug control and prevention of food adulteration, besides
activities concerning the containment of population growth including safe
motherhood, child survival and immunization Program. The plan outlay for central
sector health programmed in the Annual Plans 1997-98 is USD $147.634 million
including a foreign aid component of USD $ 64.175 million. A major portion of outlay
is for the control and eradication of diseases like malaria, blindness being
implemented under Centrally sponsored schemes.

Another major component of the central sector health programmed is purely Central
schemes through which financial assistance is given to institutions engaged in
various health related activities. These institutions are responsible for contribution in
the field of control of communicable & non-communicable diseases, medical
education, training, research and parent -care.
In our project our focus has been the hospital sector, which is the major component
of the healthcare industry.
130
Health Care Some Facts: -
Indias healthcare industry is currently worth USD $11711.856 which is
roughly 4 percent of the GDP. The industry is expected to grow at the rate
of 13 percent for the next six years, which amounts to an addition of USD
$ 1443.927 each year.
The national average of proportion of households in the middle and higher
middle-income group has increased from 14% in 1990 to 20 % in 1999.
The population to bed ratio in India is 1 bed per 1000, in relation to the
WHO norm of 1 bed per 300.
I. In India, there exists space for 75000 to 100000 hospital beds.
II. Private insurance will drive the healthcare revenues. Considering the rising
middle and higher middle income group we get a conservative estimate of 200
million insurable lives
Over the last five years, there has been an attitudinal change amongst a
section of Indians who are spending more on healthcare.
Corporate hospitals mushroomed in the late eighties. The boom remained short-lived
and out of the 22 listed hospital scripts; most are being trading below par.
An increasingly fragmented market, lack of statistics, capital intensive operations and
a long gestation period are all wise reasons to shy away from investing in the
healthcare industry. Government and trust hospitals dominate the scene. Many of
the trust hospitals suffer from poor management. Good corporate hospitals are still
too few to amount to a critical mass.
Corporate hospitals failed a decade ago because they emerged in isolation and
werent part of a larger phenomenon. However, now, there are the insurance
companies, the hospital hardware and the software companies that have come
together to create the boom.


131
Factors Attracting Corporates In the Healthcare Sector-
1. Recognition as an industry: In the mid 80s, the healthcare sector
was recognized as an industry. Hence it became possible to get
long term funding from the Financial Institutions. The government
also reduced the import duty on medical equipments and
technology, thus opening up the sector.
2. The National Health Policy: Since (the policys main objective was
Health For All by the Year 2000) was approved in 1983, little has
been done to update or amend the policy even as the country
changes and the new health problems arise from ecological
degradation. The focus has been on epidemiological profile of the
medical care and not on comprehensive healthcare.
3. Socio-Economic Changes: The rise of literacy rate, higher levels
of income and increasing awareness through deep penetration of
media channels, contributed to greater attention being paid to
health. With the rise in the system of nuclear families, it became
necessary for regular health check-ups and increase in health
expenses for the bread-earner of the family.
4. Brand Development: Many families run business houses have set-
up charity hospitals. By lending their name to the hospital, they
develop a good image in the markets, which further improves the
brand image of products from their other businesses.
5. Extension To Related Business: Some pharmaceutical
companies like Wockhardt and Max India have ventured into this
sector, as it is a direct extension to their line of business.
6. Opening Of The Insurance Sector: In India, approx. 60% of the
total health expenditure comes from self-paid category as against
governments contribution of 25-30 %. A majority of private
hospitals are expensive for a normal middle class family. The
opening up of the insurance sector to private players is expected to
give a shot in the arms of the healthcare industry. Health Insurance
will make healthcare affordable to a large number of people.
Currently, in India only 2 million people (0.2 % of total population of
132
1 billion), are covered under Mediclaim, whereas in developed
nations like USA about 75 % of the total population are covered
under some insurance scheme. General Insurance Company has
never aggressively marketed health insurance. Moreover, GIC
takes unto 6 months to process a claim and reimburses customers
after they have paid for treatment out of their own pockets. This will
give a great advantage to private players like Cigna which is
planning to launch Smart Cards that can be used in hospitals,
patient guidance facilities, travel insurance, etc.

INDIA-

1) KEM HOSPITAL-




King Edward Memorial (KEM) Hospital and Seth G.s. Restorative College It was
established in 1926 in Mumbai With something like 390 staff M.d.s and 550
inhabitant specialists, the 1800 slept with healing facility treats in the vicinity of 1.8
million out-patients and 78,000 in-patients yearly and gives both fundamental
forethought and propelled medication offices in all fields of solution and surgery
[Sources-http://www.kem.edu/hospital.htm].funded principally by the Mumbai, these
foundations render yeomen administration -practically free of expense -basically to
the underprivileged areas of the social order.
133


2) LTMGH, (Lokmanya Tilak Municipal General Hospital)-



LTMGH, (Lokmanya Tilak Municipal General Hospital), provincially reputed to be
"Sion Hospital", is a general civil healing facility arranged in Sion, a suburb of
Mumbai. It was begun in 1947 with 10 couches at first, which has now developed
into multi-claim to fame clinic with more than 1,400 mattresses. In the same grounds,
it is joined to LTMMC (Lokmanya Tilak Municipal Medical College), which is an
educating organization for undergrad and postgraduate thinks about in therapeutic
sciences.

In fifty years, what was a fifty bunk Indian Military Hospital at Dharavi, has now
turned into a state of the craftsmanship 1,416 mattress cutting edge "Sion Hospital."
This has happened very nearly actually because of the brilliant witticism of the
establishment: "Service through Excellence" -the one family convention emulated by
all staff parts at the healing facility.

The transformation from the armed force military enclosure to a present day healing
facility has been a moderate yet relentlessly dynamic one. The fundamental quality
of the healing facility is the managed magnificence of its crisis territories. We are
reasonably glad that it was L.t.m.g. Recuperating office that started the first Trauma
Care Center in India two decades back. A salvage vehicle equipped with a two-way
134
radio outfitted emergency drug to the patient at the accident site. The Trauma Ward
handles more than three thousand truly hurt patients each year. The Intensive
Cardiac Care Unit has pioneered non-executor schedules in treating patients with
compelling heart ambushes. In Mumbai, L.t.m.g's. Restorative Intensive Care Unit
was in the bleeding edge in treating such emergencies as the chlorine gas radiate in
1985, the sickness torment in 1994 and the Bhiwandi sustenance hurting in 1996.
The Pediatric and the Neonatal Intensive Care Units have been doing exceptional
work in the medication of infants and the energetic youngsters of Mumbai. It won't be
an adulteration to state that L.t.m.g. Recuperating focus is everlastingly in a "state of
alert" for calamities. We have reduced the reaction time of calamities to minutes due
to the being of a disaster organization organize.

The most young of the three major metropolitan teaching hospitals of Greater
Mumbai, our foundation stands today as one of the generally recognized pressing
centers of propelled social protection. All through the past fifty years, the center has
outfitted quality medicinal administrations to the subjects of Mumbai taking after a
committed method for obligation, sensitivity, and competency.


Annual Statistics for 1995-2012-


Annual budget-

Hospital - US $ 8,647,828
College - US $ 1,591,771
UHC Dharavi - US $ 257,457

A Demographic Overview of India-
When we move onto disentangling the health frameworks of Singapore and India, we
outfit a demo-reasonable survey to help speedier an enhanced appreciation of a rate
of the issues and challenge the two countries defy. Singapore and India are the two
for the most part famous countries on the planet. Regardless, their demographic
135
profiles and designs differ unfathomably. India are thorough of the second populated
individuals nation on the planet, with in abundance of 1.21 billion people (2011
enrollment), more than a sixth of the planet's masses. As of late holding 17.5% of the
planet's masses, India is foreseen to be the World for the most part gathered country
by 2025,indian people landed at the billion stamps in 2000.india has more than 50%
of its masses underneath the age of 25 and more than 65% underneath the age of
35. It is typical that, in 2020, the ordinary time of an Indian will be 29 years, India's
dependence should be a little more than 0.4.

Source-http://indiabudget.nic.in/es2006-07/chapt2007/tab97.pdf















136
APPENDIX-3-

1. Letter of Invite to the Participants
XXXXXXX
Date: XXXXXX
Phone: XXXXXXXXX

Dear Participant,

I invite you to participate in a research research entitled Healthcare in public hospital
I am currently enrolled in the Master of business administration, Singapore and am in
the process of writing my Dissertation. The purpose of the research is to determine:
A comparative research of health care services and facilities at Public hospitals in
India and Singapore
The enclosed survey has been designed to collect information on participant opinion
about the service quality and facility in both country public hospitals your
participation in this research project is completely voluntary. You may decline
altogether, or leave blank any questions you dont wish to answer. There are no
known risks to participation beyond those encountered in everyday life. Your
responses will remain confidential and anonymous.

If you agree to participate in this project, please answer the questions on the
questionnaire as best you can. It should take approximately 10-15 minutes to
complete. If you have any questions about this survey, feel free to contact me on my
number, which I mention above in this letter. Thank you for your assistance in this
important endeavor.

Sincerely yours,

Santosh Chourpagar



137
APPENDIX-4-

2. Letter to the Director of Singapore and Indian Hospital-

United world school of business, Singapore,
Date: XXXXXXX
Ph: XXXXXXXX
Re: A research of attitudes, knowledge and experience of patients on priority
measures comfortably in a hospital environment.
I am currently conducting a research in Business administration in the united world
school of business, Singapore and a research proposal must be submitted as a
partial implementation of the course. My point was chosen to test the proposed
psychological, information and knowledge about the measures needed to be in a
hospital setting for patients. Can I request authorization to 440 participants; doctor
working at the hospital was interested in this research. It is attitude survey,
research and knowledge of health professionals in that range will generate data that
will be valuable in improving the service quality in hospital. The data necessary to
complete this research were .Sir you must give permission to the nursing staff to go
along with us; I can confirm in case you give me a rundown of all the staff working in
the facility contemplated intense hospital. Each member will receive a letter
(connected) and inferred consent will receive the completed surveys will be
confidently ensured at all times. Many obligations related to time to check the
contents of this letter. On the off chance that you have any questions or want to
check this issue further before deciding on a choice, please contact me at the above
location or phone number.
Yours Sincerely,
Santosh chourpagar



138
APPENDIX-5-

3 Letters for the Ethics Committee-

XXXXXXXXXXX
XXXXXXXXX
XXXXXX Ethics Committee

Date: XXXXXXX

Re: Ethical approval to conduct a research of the attitude, knowledge and
experience of nurses, doctors and patients on the use of comfort measures and
service provided at public hospital in India and Singapore.

Dear Sir/ Madam,

I am a student currently conducting studies in MBA at United world school of
business, Singapore and a proposed examination is to be presented as a mid-
course satisfaction. The topic I have chosen is pointed in the direction of research on
the knowledge of medical caregivers, physicians and patients on the use of service
quality in public hospital in India and Singapore.

This could be of benefit to what will advance health awareness administrations
healing facility open. Every effort has been made in advancing this research
proposal to be sensitive to all moral questions.

I significantly like your support to carry out this research by auditing the moral
contemplations. Enclosed please find a duplicate of the proposed exploration for
your attention. Any proposal to be recognized and acknowledged. If you have any
questions or concerns, please do not hesitate to contact me at the above location, or
phone number.
Thanking you for your time,
Yours Sincerely,
Santosh chourpagar
139
APPENDIX-6-


S.NO

SERVQUAL
Attribute

Definition


Modified Definition for
Hospital Industry


1

Reliability


Capability to perform
the guaranteed
administration certainty
and correctly

Speed of Service
Speed of enrollment
Accuracy of treatment

2


Responsiveness



Eagerness to help
clients and furnish brief
administration

Speed of reaction to
protests
Concern to patient
Desire for helping

3
Assurance

Information and
kindness of
representatives and
their capability to
motivate trust and
certainty

Doctor concern to
patients
Nurse disposition to
patients

4

Empathy


Minding, individualized
consideration the firm
gives its clients

Simplicity of
correspondence
Attention and
persistence of the
medical caretaker
140

5

Tangibles


Physical offices,
supplies, and
manifestation of staff



Availability of
restorative units
Cleanliness and
serenity of patient
room
Choices of menu and
elixir
Furniture are available
in patient room
Electricity accessible
for crisis
Pathology lab

6.

Competence


Ownership of needed
abilities and information
to perform the
administration

Doctors capability
Qualification of staff in
clinic
Experience of
specialists
Reputation of doctors

7.

Access


Congeniality and
simplicity of contact

No. of hours specialists
sitting in the chamber
No. Of rounds
taken/day

8.

Courtesy


Consideration, regard,
and cordiality

Politeness of the staff
to patient
Behavior of the staff
and doctors
141

9.

Communication


Keeping clients
educated in dialect they
can comprehend and
listening to them.

Counseling facility
Communication and
ITC
Computerized
enlistment office
Computerized charging
facility


10

Credibility


Reliability,
Conceivability,
respectability having
the client's best
diversions.


Trustworthiness
Doctors confidence


11


Security


The opportunity from
risk, hazard, or
mistrust.

Alarm accommodated
Fire evidence
arrangement
Accidental office


12

Understanding
/Knowing the
patient


Attempting to grasp the
Customer's needs


To recognize what sort
of dieses patient
experiencing
What sort of issue rolls
out to patient
Sources Self made for this assigment


142
Health care service quality and information technology-

In this model, the proposed approach to apply IT in improving administration quality
in clinic is dependent upon the standards of proficiency and adequacy. This standard
and it be effectively accomplished in Singapore, the level of administration quality
concerning Communication, Promptness and Availability might be upgraded in the
hospital. As figure shows, when a patient visits a clinic to benefit the health
administrations, the Singapore open healing center could be realized the patient
fulfillment with the assistance of IT-improved administration quality show. The
methodology calls for a center arrangement of IT parts to be interlinked utilizing a
regular World-Wide Web based stage. So as to expedite the scattering of convenient
data and choices from this center framework to all stakeholders included, the
utilization of remote advances, broadband conveyances, Radio Frequency
Identification (RFID) tags and hand-held mechanism must be fittingly sent
conglomeration wide. . [Sources- Shahin and Jamshidian, Information technology in
service organizations, Iranian Journal of Information Science and Technology, vol.4,
pp.67-85, January/June 2006] Demand for quality in human services is coming to be
more basic and is expanding massively with the developing human services needs.
Data engineering can play a crucial part in assembling the healing facility to furnish
better quality administrations and it will improve the administration nature of a
healing center that has set out to think outside of the container. The potential
outcomes are interminable as the healing facilities plan their work environment of the
what's to come. [Sources: -Physical clinical communication systems: An Australian
perspective, Journal of Medical System, vol. 21, no. 2, pp. 99-106, 1997.]. It is the
authority of the top administration then after that all stakeholders in human services
to join and enable the data innovation in healing centers to change the overburdened
manual process into a mechanical establishment. Data innovation will underpin the
doctor, the attendant and the multidisciplinary group at the purpose of consideration
to give the better administration quality to realize the patient fulfillment.

143

Fig 2- IT-Enhanced service quality in hospital





















144
APPENDIX-7-





Page 1 of 5
RESEARCH ETHICS CHECKLIST Form RE1

This checklist should be completed for every research project which involves human
participants. It is used to identify whether a full application for ethics approval needs to be
submitted.

Before completing this form, please refer to the University Code of Practice on Ethical
Standards for Research Involving Human Participants. The principal investigator and,
where the principal investigator is a student, the supervisor, is responsible for exercising
appropriate professional judgment in this review.

This checklist must be completed before potential participants are approached to take
part in any research.

Section I: Applicant Details

1. Name of Researcher (applicant): Chourpagar Santosh
2. Status (please click to select): Postgraduate Research Student
3. Email Address: santosh1achourpagar@gmail.com
4a. Contact Address: C-101,sheetal dhara,Kamothe navi
mumbai,Pin code-410209
4b. Telephone Number: +91-8652880126

Section II: Project Details

5. Project Title: Health care services and facilities at Public
hospitals in India and Singapore



Section III: For Students Only:

6. Course title and module name and
number where appropriate

Department:
Master of Business
administration,Dissertation-5002




7. Supervisors or module leaders
name:
Supervisor: Dr. Ron Smith
Marking Tutor: Dr. Mathew Shafaghi

8. Email address: santosh1achourpagar@gmail.com
9. Telephone extension::



Declaration by Researcher (Please tick the appropriate boxes)

I have read the Universitys Code of Practice
The topic merits further research
I have the skills to carry out the research
The participant information sheet, if needed, is appropriate
The procedures for recruitment and obtaining informed consent, if needed, are
appropriate
The research is exempt from further ethics review according to current University
guidelines
145


Page 2 of 5
Comments from Researcher, and/or from Supervisor if Researcher is Undergraduate
or Taught Postgraduate student:



146


Page 3 of 5
Section IV: Research Checklist

Please answer each question by ticking the appropriate box:

YES NO
1. Will the study involve participants who are particularly vulnerable or
who may be unable to give informed consent (e.g. children, people
with learning disabilities, emotional difficulties, problems with
understanding and/or communication, your own students)?

2. Will the study require the co-operation of a gatekeeper for initial
access to the groups or individuals to be recruited (e.g. students at
school, members of self-help group, residents of nursing home)?

3. Will deception be necessary, i.e. will participants take part without
knowing the true purpose of the study or without their
knowledge/consent at the time (e.g. covert observation of people in
non-public places)?

4. Will the study involve discussion of topics which the participants may
find sensitive (e.g. sexual activity, own drug use)?

5. Will drugs, placebos or other substances (e.g. food substances,
alcohol, nicotine, vitamins) be administered to or ingested by
participants or will the study involve invasive, intrusive or potentially
harmful procedures of any kind?

6. Will blood or tissues samples be obtained from participants?
7. Will pain or more than mild discomfort be likely to result from the
study?

8. Could the study induce psychological stress or anxiety or cause
harm or negative consequences beyond the risks encountered in
normal life?

9. Will the study involve prolonged or repetitive testing?
10. Will financial inducements (other than reasonable expenses and
compensation for time) be offered to participants?

11. Will participants right to withdraw from the study at any time be
withheld or not made explicit?

12. Will participants anonymity be compromised or their right to
anonymity be withheld or information they give be identifiable as
theirs?

13. Might permission for the study need to be sought from the
researchers or from participants employer?

14. Will the study involve recruitment of patients or staff through the
NHS?


If ALL items in the Declaration are ticked AND if you have answered NO to ALL questions in
Section IV, send the completed and signed Form RE1 to your Departmental Research
Ethics Officer for information. You may proceed with the research but should follow any
subsequent guidance or requests from the Departmental Research Ethics Officer or your
supervisor/module leader where appropriate. Undergraduate and taught postgraduate
students should retain a copy of this form and submit it with their research report or
dissertation (bound in at the beginning). MPhil/PhD students should submit a copy to the
Board of Studies for Research Degrees with their application for Registration (R1). Work
which is submitted without the appropriate ethics form will be returned unassessed.

If ANY of the items in the Declaration are not ticked AND / OR if you have answered YES to
ANY of the questions in Section IV, you will need to describe more fully in Section V of the
form below how you plan to deal with the ethical issues raised by your research. This does
147













Page 4 of 5
not mean that you cannot do the research, only that your proposal will need to be
approved by the Departmental Research Ethics Officer or Departmental Research
Ethics Committee or Sub-committee. When submitting the form as described in the
above paragraph you should substitute the original Section V with the version
authorized by the Departmental Research Ethics officer.

If you answered YES to question 14, you will also have to submit an application to the
appropriate external health authority ethics committee, after you have received approval
from the Departmental Research Ethics Officer/Committee and, where appropriate, the
University Research Ethics Committee.
148




Page 5 of 5

Section V: Addressing Ethical Problems

If you have answered YES to any of questions 1-12 please complete below and submit the
form to your Departmental Research Ethics Officer.

Project Title



Principal Investigator/Researcher/Student



Supervisor



Summary of issues and action to be taken to address the ethics problem(s)



Please note that it is your responsibility to follow the Universitys Code of Practice on Ethical
Standards and any relevant academic or professional guidelines in the conduct of your
study. This includes providing appropriate information sheets and consent forms, and
ensuring confidentiality in the storage and use of data. Any significant change to the
design or conduct of the research should be notified to the Departmental Research Ethics
Officer and may require a new application for ethics approval.

Signed: Principal Investigator/Researcher

Approved: Supervisor or module leader
(where appropriate)

Date:

For use by Departmental Research Ethics Officer:

No ethical problems are raised by this proposed study - Retain this form on record

Appropriate action taken to maintain ethical standards

The research protocol should be revised to eliminate the
ethical concerns or reduce them to an acceptable level,
using the attached suggestions

Please submit Departmental Application for Ethics Approval
(Form RE2(D))

Please submit University Application for Ethics Approval
(Form RE2(U))

Signed:

Date:


L:\AQAS\Common\Research\Research Ethics\Research Ethics Checklist Form RE1.doc




Retain this form on record
and return a copy of section V
to Researcher
149
APPENDIX-8-












150












151




















152

APPENDIX-9











153