A Research Project Report

ON

“A study of Service Quality & Customer Satisfaction in Health Care System”

SUBMITTED FOR

APPROVAL FOR COUNDUCT OF RESEARCH PROJECT REPORT

FOR

PARTIAL FULFILLMENT OF THE DEGREE OF MASTER OF BUSINESS ADMINISTRATION FROM

U.P. TECHNICAL UNIVERSITY, LUCKNOW

Batch (2008-10)

UNDER THE GUIDENCE OF: SUBMITTED BY:

Dr. Neeraj Saxena Saurabh Verma ( Director ) M.B.A. IV Sem. Roll no- 0801670063

SUBMITTED TO:

DEPARTEMENT OF BUSINESS ADMINISTRATION

RAKSHPAL BAHADUR MANAGEMENT INSTITUTE

BAREILLY (U.P.)

ACKNOWLEDGMENT

This report incorporates the contribution of many people and without their support

this work would not have come in completion.

So I would like to extend my immense ineptness to all of them who have guided

and motivated me throughout my winter training project. I sincerely thank to all of

them for their valuable contribution without which this project report would have

not reached its goals.

I sincerely wish to acknowledge a deep sense of gratitude to Mr. Abhijeet Das

(Assistant Director RBMI) for giving me this opportunity & to be my supervisor &

guiding my dissertational project to fruitful result.

I am indeed grateful to respected Dr. Neeraj Saxena (Director) for their valuable

support & guidance throughout the research project.

DATE:

(Saurabh Verma)

PREFACE

As markets are Dynamic in nature, so does marketing. Marketing is no longer a

company department consists of a limited number of tasks, managing advertising,

sending out direct mail, finding sales leads, providing customer services, building

relationship with distributors and retailers. Marketing must be a company-wide

undertaking. It must drive the company’s vision, mission and strategic planning.

Marketing is about generating utilities in the customer’s mind and develop a

compatibility between market potential with its product and services and making

strategies for making a Brand image by continuous improvements in Quality of

services provided and taking care of the customers as well as seeking new

opportunities in the untouched areas by developing partnership with other

company’s.

Marketing deals with the whole process of entering markets, establishing profitable

positions, and building loyal customer relationship. This can happen only when all

the departments work together.

DECLARATION

I do hereby declare that the summer research report titled “A study of Service

Quality & Customer Satisfaction in Health Care System” submitted in partial

fulfillment of requirement of the M.B.A. programme 2008-2010 batch offer by

Rakshpal Bahadur Management Institute, Bareilly is based on genuine works

undertaken during the course of the research report.

This report has not been submitted to any other institution or university

to the fulfillment of any other course of the study or any other purpose.

(Saurabh Verma)

CONTENTS

Introduction

Research Objectives

Research methodology

Data Analysis

Conclusion

Limitation

Bibliography

Questionnaire

Introduction

HOSPITAL

A hospital is an institution for health care providing patient treatment by

specialized staff and equipment, and often, but not always providing for longer-

term patient stays.

Today, hospitals usually are funded by the public sector, by health organizations,

(for profit or nonprofit), health insurance companies or charities, including by

direct charitable donations. In history, however, hospitals often were founded and

funded by religious orders or charitable individuals and leaders. Similarly, modern-

day hospitals are largely staffed by professional physicians, surgeons, and nurses,

whereas in history, this work usually was performed by the founding religious

orders or by volunteers.

Service Quality and Customer Satisfaction in Health Care System

Patient perception of the quality of the services offered in hospitals follows latent

patterns, which can not be adequately reduced to a set of variables, but can be

approximated by multidimensional scaling. Thus, hospitals which are similarly

appreciated by their patients cluster close together. By examining what these

hospitals have in common, what are their best practices and quality recipes, one

can indirectly find out what is that which patients look for, in terms of service

quality in healthcare. Our analysis revealed that the profile of the hospital (general

vs. specialized) is related to the way the hospital is perceived, in terms

of quality, and that there are differences, inside the clusters, in the quality

perception, the sample of specialized hospitals being more homogenous than the

sample of general hospitals.

Patient satisfaction is measured with respect to technical and non- technical

characteristics of health care service encounters, categorised into four basic

components: attitude towards doctors, attitude towards medical assistants, quality

of administration and quality of atmospherics. All four factors are closely related to

consumer satisfaction. The study measures the degree of consumer satisfaction

experienced by patients through the tested self-developed five-point Likert scale

and has highlighted the problem faced by them. The impact of age, education level

and gender of the decision maker on satisfaction, dissatisfaction is analysed using

relevant statistical tools. The responses have been integrated into important factors

on the basis of factor analysis after verifying the validity and reliability of the

schedule.

SERVICE QUALITY

The good health of nations is a key to human development and economic growth

and it is important to analyze health systems’ performance and to share what we

knew with governments and the international community .

Large segments of the population in developing countries are deprived of a

fundamental right: access to basic health care. Without an appropriate and

adequate health support and delivery system in place, its adverse effects will be felt

in all other sectors of the economy. In simple terms, an ailing nation equates to an

ailing economy as manifested in lower income earning capacity of households and

significant productivity losses in those sectors that sustain the economy.

According to a World Bank (1987) estimate, ‘only 30% of the population has

access to primary health services and overall health care performance remains

unacceptably low by all conventional measurements.’ A subsequent study (Sen and

Acharya 1997) notes some improvements but indicates that ‘the poor qualities of

health services . . . are persistent concerns.’ The poor performance of the health

care sector was attributed to the following: critical staff are absent, essential

supplies are generally unavailable, facilities are inadequate, and the quality of

staffing is poor. The problems of supervision and accountability exacerbate the

problems; and if corrupt practices are added to the list, it is not difficult to imagine

the predicament of the patients. In fact, these conditions and a general perception

of poor and unreliable services may explain why those who can afford it have been

seeking health care services in other countries. In a country where the population

growth rate will place additional demands on the health sector, its preparedness to

serve its constituencies effectively is particularly troubling as the future begins to

catch up. To address the impending problems, consideration has been given to the

privatization alternative. Thus, the Medical Practice and Private Clinics and

Laboratories Ordinance was promulgated in 1982 to encourage the growth of

private health-care service delivery. By June 1996, a total of 346 private hospitals

and clinics with more than 5500 beds were registered with the Directorate of

Hospitals and Clinics. Of this total, 142 were established in Dhaka alone with a

capacity of 2428 beds (Khan 1996). Additional considerations are seen in the

proportion of GDP allocated to the health care sector: it was more than doubled

between 1985/86 and 1994/95, from 0.6 to 1.3% (Kawnine et al. 1995). A

significant proportion of this allocation was earmarked for primary health care.

While these allocations are encouraging, the perceptions that people have about the

relative quality of health care services in the country may not be so favourable and

remains to be assessed. This assessment is important because even if the problems

of access were to be substantially alleviated, quality factors are likely to strongly

influence patients’ choice of hospitals. In Nepal, for example, the Government

made substantial investments in basic health care; yet utilization remained low

because of clients’ negative perceptions of public health care (Lafond 1995). In

Vietnam, poor service in the public sector led to increased use of private providers

(Guldners and Rifkin 1993). Apparently, quality is important and demands

continuous attention. With the growth of private health care facilities, especially in

Dhaka city, it is important to assess the quality of services delivered by these

establishments. In particular, it is important to determine how the quality of

services provided by private clinics and hospitals compares to that of public

hospitals. If quality issues are being compromised by these establishments, it calls

for the re-evaluation of policy measures to redefine their role, growth and

coverage, and to seek appropriate interventions to ensure that these institutions are

more quality-focused and better able to meet the needs of their patients. A search

of the literature suggests that such a comparative study has not been undertaken.

While anecdotal evidence suggests the existence of serious service-related

problems in both sectors, this study was designed to determine and compare the

quality of services provided by both private and public hospitals. The study also

attempts to determine whether the service quality ratings are reasonable predictors

of the type of hospital chosen by patients. Demographic variables of income and

education were included with service quality ratings to test the model’s predictive

capability. The theoretical basis of this paper is that the quality of services

provided by the hospitals is contingent on market incentives: because private

hospitals are not subsidized and depend on income from clients, they will be more

inclined than public hospitals to provide quality services and to meet patients’

needs better. By doing so, they will not only be able to build satisfied and loyal

clients who will revisit the same facility for future needs; the clients will also serve

as a source of referrals to recommend the private establishments to friends and

family, thereby sustaining the long-term viability of private hospitals. In public

hospitals, on the other hand, there is little or no market incentive to motivate the

staff to take extra initiative or effort to improve the condition of patients and

ameliorate their suffering. This suggests that their service quality will be rated

lower than private hospitals. Quality assessment, however, requires careful

consideration. Two major concerns are: who will assess quality and on what

criteria. While quality care may be defined as the degree of excellence in overall

care, the judgment of quality may depend on whose perspective is sought.

Historically, the establishment of quality standards has been delegated to the

medical profession and has been defined by clinicians in terms of technical

delivery of care. More recently, patients’ assessment of quality care has begun to

play an important role, especially in the advanced industrialized countries, and

their satisfaction or dissatisfaction with services has become an important area of

inquiry. Thus, Donabedian suggests that, ‘patient satisfaction should be considered

to be one of the desired outcomes of care . . . information about patient satisfaction

should be as indispensable to assessments of quality as to the design and

management of health care systems.’ Because customers or clients of hospitals and

clinics have the most direct experiences with the services provided by these

institutions, this study focuses on their perspective. On a complex issue like health

care, while some feel that the customer cannot really be considered a good judge of

quality and dismiss their views as too subjective, Petersen (1988) suggests that, ‘It

really does not matter if the patient is right or wrong. What counts is how the

patients felt even though the caregiver’s perception of reality may be quite

different.’ In Bangladesh, the customer’s viewpoint is neither sought, nor given

any importance (as far as we know) in strategy formulation; thus, very little is

known about how the ‘customers’ assess health-care service quality. Since the

recipients of health care can provide valuable, albeit partial, insights, and since

their opinions should drive meaningful changes in the system, their perspective

was central to this paper.It was also important to establish the criteria for assessing

service quality. Some guidelines were available from research on this topic

conducted in other countries.

Conceptual framework

The important components of hospital services as derived from theoretical

consideration sand the data structure are as follows.

Responsiveness

The literature identifies responsiveness as an important component of service

quality and characterizes it as the willingness of the staff to be helpful and to

provide prompt services. Six items were used to delineate and measure the

construct.

Assurance

Assurance is defined as the knowledge and behaviour of employees that convey a

sense of confidence that service outcomes will match expectations. Six items were

used to measure this construct and reflect the competence, efficiency and

correctness of services provided to patients.

Communication

Communication with patients is vital to delivering service satisfaction because

when hospital staff take the time to answer questions of concern to patients, it can

alleviate many feelings of uncertainty. In addition, when the medical tests and the

nature of the treatment are clearly explained, it can alleviate their sense of

vulnerability. This component of

service is valued highly as reflected in the in-depth interviews and influences

patient satisfaction levels significantly. Four items were used to measure this

construct.

Discipline

Lack of discipline pervades many organizations and institutions and is commonly

manifested in absenteeism and non-performance of prescribed duties. Manipulation

of or non-adherence to written rules are also not uncommon. In the hospital

environment, lack of discipline can be tremendously disruptive, attenuating

perceptions of quality services. Thus, maintenance of the facilities or ensuring that

the staff maintain clean and proper appearances are some indicators of the extent of

discipline in the environment. Adherence to visitation hours and keeping noise

down to acceptable levels in the hospital environment are additional indicators of

discipline or the lack thereof. Six items were used to measure discipline.

Baksheesh

The concept of baksheesh, the extra compensation that is expected in many service

settings in Bangladesh for ‘due’ services, is becoming notoriously common,

especially in the public sector. It represents a payment to service providers to

ensure that expected services are delivered. Baksheesh is distinguished here from

bribes in the sense that bribes can represent solicited or unsolicited demands for

money to render ‘undue’ services. For example, a bribe may be required to obtain

hospital admittance out of turn or to obtain priority access to a particular doctor;

baksheesh will ensure that a scheduled appointment is met.

The above constructs represent the initial set of factors along which hospital

services were compared; they were also used to model the type of hospital that

patients would select. The research method is explained next.

The health care industry is undergoing a rapid transformation to meet the ever-

increasing needs and demands of its patient population. Hospitals are shifting

from viewing patients as uneducated and with little health care choice, to

recognizing that the educated consumer has many service demands and health care

choices available (Howard J.E., 2000). Within all systems there are many highly

skilled, dedicated people working at all levels to improve the health of their

communities. To move towards higher quality care, more and better information is

commonly required on existing provision, on the interventions offered and on

major constraints on service implementation. Consumers need to be better

informed about what is good and bad for their health, why not all of their

expectations can be met, and that they have rights which all providers should

respect (WHO, 2000). The challenge is to develop health systems that equitably

improve health outcomes, respond to people’s legitimate demands and are

financially fair. Recent research indicates that the way health systems are designed,

managed and financed seriously affects people’s lives and equitable health

outcomes are essential for global prosperity and the well-being of societies.

There is growing interest in improving the performance of health systems in many

countries. It is a major preoccupation, reflecting common pressures for cost

containment on the one hand and rising consumer expectations on the other. This

has led to a number of recent initiatives both to measure and to improve

performance against quality, efficiency and equity goals. Many countries are

developing initiatives to measure performance to guide and inform he

improvement process. Indeed, measurement and improvement are increasingly

linked, as is indicated by familiar phrases such as ‘evidence-based medicine’ and

‘evidence-based policy’. Equally important, if action is to be taken to improve

performance,it is the need to understand the roles and motivation of different actors

and available instruments in each health system. “Performance” is defined as the

extent to which the health system is meeting a set of key objectives. The key

objectives for the health system are suggested as being: improving health outcomes

and responsiveness to consumers, economic efficiency and equity of health (or

access to care). The success or failure of any initiative to improve health

performance will depend on the political and institutional context in which it is

placed.

Many countries face similar problems in assuring and improving the performance

of their health care system. Some of the main topics that are increasingly being

raised on the health policy agenda in most countries include the following:

Improving health status and outcomes for the entire population; Raising clinical

effectiveness -ensuring that clinical decisions are based on the best current practice

(avoiding over-use and under-use); Improving safety or reducing medical errors -

developing health care organizations that are capable of detecting medical errors or

adverse events to patients, and which are then able to effectively act on them to

avoid future occurrences; Raising responsiveness of the system - providing timely

services (reducing wasteful delays) which are patient-centered and respectful of

individuals' preferences, needs, and values; Improving efficiency/containing costs -

providing the right incentives to providers, funders and consumers to get better

value for money; and, Ensuring the equity - ensuring that the same quality of care

is provided to all, regardless of race, gender, geographic location, or ability to pay,

and reducing the gaps in health outcomes across different regions and socio-

economic or ethnic groups.

In all health systems, regulation plays an important role in determining the

availability, accessibility, and cost and, increasingly, the quality of services

provided. The major values and objectives of each health system are often secured

via regulation. Regulation has been used to serve quite different functions in each

country. It can have an extensive control function by defining and checking on

unacceptable medical practices, or it can encourage good practice by providing

positive principles according to which the medical profession should operate.

Regulation also plays an important role in facilitating the accountability of the

system and protecting patient’s rights.

Health care quality is a global issue. Despite differences in the levels and methods

of health care funding the challenges and solutions in quality are remarkably

similar between countries. There are defined such common national concerns over

quality: unsafe health systems; unequal access to health care services, waiting lists;

dissatisfaction on the part of users and the wider public; unacceptable levels of

variations in performance, practice and outcome; overuse, misuse or under-use of

health care technologies; ineffectual or inefficient delivery; unaffordable waste

from poor quality and unaffordable costs to society (Shaw Ch., 2002).

Technological innovations, particularly in the fields of biotechnology, genetics,

and information and communication technologies, are bringing substantial benefits

in the prevention, diagnosis and treatment of disease, as well as access to care

(Cotis J.P., 2003). Such innovation is costly and is predominantly carried out in the

private sector, although drawing on knowledge created in the public sector science

base. Innovation is also a risky process with many promising leads failing at

successive hurdles before a safe, efficacious and high quality product is brought to

the market. Meanwhile, many countries are seeking to establish health priorities.

Such priorities should take account of, and help guide, the direction of innovation –

so a better match is delivered between innovation and a society’s health needs.

Patient empowerment can cut health care costs and improve quality .There is now

a body of literature showing that better-informed patients have better outcomes,

choose less risky procedures and avoid equivocal treatments. This should increase

confidence that patients can not only make constructive use of performance data

designed for them, but can also be reliable informants for performance assessment.

The role of the health care professionals are of the great importance in order to

assure high quality services which should be provided to the patients with dignity

and respect. The general notion of responsiveness can be decomposed in many

ways. One basic distinction is between elements related to respect for human

beings as persons – which are largely subjective and judged primarily by the

patient – and more objective elements related to how a system meets certain

commonly expressed concerns of patients and their families as clients of health

systems, some of which can be directly observed at health facilities (WHO, 2000).

Respect for persons includes: 1) respect for the dignity of the person; 2)

confidentiality or the right to determine who has access to one’s personal health

information; 3) autonomy to participate in choices about one’s own health. This

includes helping choose what treatment to receive or not to receive.

All people are consumers of health services. What are their expectations with the

health services? Users of health services want safe, appropriate interventions,

treatment and care. They want to be treated with dignity and respect. They want

information that is accurate, timely and relevant. Consumers believe that if this is

to happen then consumers of the health services must be involved and consulted,

not only in relation to their own healthcare, but also about service planning and

delivery, health evaluation and research (Graham J.D., 2001). Many errors could

be avoided because of intervention or questioning by a consumer or career. Errors

increase when the consumers are not heard. The closest most health services come

to measuring consumers’ experiences is the occasional satisfaction survey. But

only targeting a reduction in complaints is not a sign of improvement. What is

needed is an effective evaluation of the accessibility of complaints procedures and

the introduction of incentives, such as feedback and proof of real action, to

encourage and support complaints. To participate as equal partners, health

servicesconsumers need to be able to consult, to develop policy and strategies and

to train for their advocacy role.

Considerable attention has been given to the literature on the value of measuring

patient satisfaction with medical care. Measuring and improving levels of

satisfaction is important for a number of reasons. For one, patient satisfaction can

be viewed as a positive outcome of the medical care provided; patients, as

consumers, deserve to be satisfied with the product. Also, patient satisfaction

measures provide health care managers with useful information about the structure,

process, and outcomes of care. They alert administrators to the positive and

negative aspects of their institutions. Patients increasingly expect choice as well as

quality in healthcare. But in order to make informed choices, they need to know

how well different hospitals or doctors are performing compared with their

colleagues elsewhere. Patient satisfactions assessments help maximize an

organization's quality and the value of the care it provides.

The following dimensions of care that patients’ value was established (Edgman-

Levitan S,Cleary P., 1996): respecting a patient's values, preferences and expressed

needs ;information and education; access to care; emotional support; involvement

of family and friends; continuity and transition; physical comfort; coordination of

care.

Researchers have reported that patients' judgments of quality care rely on the

Responsiveness of healthcare providers to patients' unique needs (Atkins P.M. et

al., 1996). To patients, the "appearance of environment and employees, reliability,

dependability of service delivery, responsiveness, and competence, understanding

the patient, access, courtesy, communication, credibility, and security" indicate

quality care. Patient satisfaction also hinges on whether the "service experience

meets consumer expectations". Consequently, assessing patient satisfaction and

quality care depends on the way in which quality care is defined. Data from patient

satisfaction surveys are used to identify particular

patient needs and develop interventions addressing those needs and priorities, thus

enabling hospital administrators and clinicians to evaluate the services they

provide. Although the literature pertaining to patient satisfaction in the inpatient

setting is extensive, there is a paucity of data on patient satisfaction pertaining to

outpatient clinical services.

The study addresses the issue of quality in health care sector. Patients’ satisfaction

was chosen as the indicator of service quality provided by ambulatory care units.

The study is focused on searching for main sources of satisfaction versus

dissatisfaction with health care services and their relation to socio-demographic

characteristics of ambulatory care units’ patients.

CORE CONCEPTS OF HEALTH CARE QUALITY

QUALITY VALUES IN HEALTH CARE

Openness, confidence, motivation and commitment are the foundations of a quality

culture. But often, traditional practices and attitudes towards authority, mutual

support and individual responsibility actively resist improvement. These create a

culture of low expectations (from public and professions), vertical command

structures, restricted information and a negative view of accountability and

responsibility. This is still a major problem in central and Eastern Europe.

Quality design involves service providers, clients, and managers in a structured

process to explicitly identify client needs and design service processes with key

features to meet those needs. In the context of quality design, features are concrete,

practical expressions of clients’ needs, desires, and expectations. While quality

design is often applied to develop an entirely new process or service where a

comparable one does not exist, it may also be used to substantially redesign an

existing process or service.

DEFINITIONS OF HEALTH CARE QUALITY

The most comprehensive and perhaps the simplest definition of quality is that used

by advocates of total quality management (W. Edwards Deming, 1982): "Doing

the right thing right, right away.”

Almost as universal is the view by Ovretveit J. (1992), who, almost a decade later,

recognized the three "stakeholder" components of quality, namely client,

professional and management quality. Client quality addresses what the clients and

carers want from the service. Professional quality indicates whether the service

meets the needs as defined by professional providers and referrers and whether it

correctly carries out techniques and procedures which are believed to be necessary

to meet the client needs. The management quality aspect is concerned with the

most efficient and productive use of the resources with in limits and directives set

by higher authorities and purchasers.

The integrated definition of health care quality combines these three elements: “A

quality health service/system gives patients what they want and need at the lowest

cost” (Ovretveit J., 1992).

The client-focused definitions of quality come from Donabedian A. (1980) and

Morgan and Murgatroyd (1994): "Client satisfaction is of fundamental importance

as a measure of quality of care because it gives information on the providers'

success at meeting those client values and expectations on which the client has

authority”.

Defining quality means developing expectations or standards of quality (Brown L.

et al.). Standards can be developed for inputs, processes, or outcomes; they can be

clinical or administrative. Standards can be applied at the level of an individual,

facility, or a healthcare system. A good standard is explicit, reliable, realistic,

valid, and clear. Standards of quality can be developed according to the dimensions

of quality and should be based on the best scientific evidence available.

Stakeholders (including client and community) expectations of quality should also

be incorporated in the definition of quality standards. Defined standards or

definitions of quality are prerequisites for measuring quality. If standards don’t

exist, they must be designed. Although standards are context-specific, universally

accepted standards are often a good starting point for developing local standards.

Sometimes, even when they exist, standards must be refined to make them usable

by health professionals.

QUALITY DIMENSIONS IN MEDICAL CARE

Diversity arises when examining what is meant by quality in medical care. Medical

quality consists of a mixture of hard technical elements such as correct diagnosis,

appropriate interventions and effective treatments as well as soft elements such as

good communications, patient satisfaction and consideration for patient

preferences (Gill M., 1993). It is not sufficient to consider only the technical

competence of those providing care. Rather, a high quality service is one that

provides effective care and is delivered humanely and efficiently. Good medical

quality consists of technical competence as well - the correct decisions and

appropriateness of interventions, audit and evidence based medicine. Ovretveit J.

(1990) stated that: "Professional quality has two parts: (1) Whether the service

meets the professionally assessed needs of its clients; and (2) Whether the service

correctly selects and carries out the techniques and procedures which professionals

believe meet the needs of clients”.

Brown L. et al. describe nine quality dimensions of health service delivery:

effectiveness, efficiency, technical competence, interpersonal relations, and access

to service, safety, continuity and physical aspects of health care

THE MEANING OF QUALITY

The definitions and dimensions outlined above constitute a broad conceptual

framework that includes almost every aspect of the health system performance. All

these dimensions come into play as clients, health providers, and health care

managers try to define quality of care from their unique perspectives. What does

quality of health care mean for the communities and clients that depend on it, the

clinicians who provide it and the managers and administrators who oversee it?

The Client. For the clients and communities served by health care facilities, quality

care meets their perceived needs, and is delivered courteously and on time (Brown

L. et al.) In sum, the client wants services that effectively relieve symptoms and

prevent illness. Because of satisfied clients often are more likely to comply with

treatment and to continue to use health services, the dimensions of quality that

relate to client satisfaction affect the health and well-being of the community.

Patients and communities often focus on effectiveness, accessibility, interpersonal

relations, continuity, and amenities as the most important dimensions of quality.

However, it is important to note that communities do not always fully understand

their health service needs - especially for preventive services - and cannot

adequately assess technical competence. Health providers must learn about their

community’s health status and health service needs, educate the community about

basic health services, and involve it in defining how care is to be most effectively

delivered. Which decisions should be made by health professionals and which

should be made by the community? Where does the technical domain begin and

end? This is a subjective and value-laden area that requires an ongoing dialogue

between health professionals and the community. Answering these questions

requires a relationship and two way communication between the parties.

The Health Service Provider. From the providers’ perspective, quality care implies

that he or she has the skills, resources, and conditions necessary to improve the

health status of the patient and the community, according to current technical

standards and available resources. The providers’ commitment and motivation

depend on the ability to carry out his or her duties in an ideal or optimal way.

Providers tend to focus on technical competence, effectiveness, and safety. Key

questions for providers may be: How many patients are providers expected to see

per hour? What laboratory services are available to them, and how accurate,

efficient, and reliable are they? What referral systems are in place when specialty

services or higher technologies are needed? Are the physical working conditions

adequate and sanitary, ensuring the privacy of patients and a professional

environment? Does the pharmacy have a reliable supply of all the needed

medicines?

Are there opportunities for continuing medical education? Just as the health care

system must respond to the patients’ perspectives and demands, it must also

respond to the needs and requirements of the health care provider. In this sense,

health care providers can be thought of as the health care systems internal clients.

They need and expect effective and efficient technical, administrative, and support

services in providing high-quality care. The Health Care Manager. Quality care

requires that managers are rarely involved in delivering patient care, although the

quality of patient care is central to everything they do. The varied demands of

supervision and financial and logistic management present many unexpected

challenges and crises. This can leave a manager without a clear sense of priorities

or purpose. Focusing on the various dimensions of quality can help to set

administrative priorities. Health care managers must provide for the needs and

demands of both providers and patients, to be responsible stewards of the resources

entrusted to them by the government, private entities, and the community. Health

care managers must consider the needs of multiple clients in addressing questions

about resource allocation, fee schedules, staffing patterns, and management

practices. The multidimensional concept of health care quality is helpful to

managers who tend to feel that access, effectiveness, technical competence, and

efficiency are the most important dimensions of quality.

Integrated quality development increases the capability of a service to achieve high

quality in quality dimensions (patients, professionals, managers) at the same time.

If quality activities are performed in the right way, then there is no trade-off

between increasing patient satisfaction, improving professional outcomes, and

reducing costs (Ovretveit J., 2001). A definition of quality needs to guide towards

what should be measured. It should be one which resonates with professionals'

values, but also conveys a patient focus, and brings in the idea of reducing waste

and increasing efficiency. According to Donabedian A. (2003), concept of quality

can be rather precisely defined, and that it is amenable to measurements accurate

enough to be used as a basis for the effort to monitor and assure it.

QUALITY EVALUATION METHODS

Common principles of quality evaluation methodology include the following

(Shaw C., 2002): Statutory mechanisms ensure that the safety of public, patients

and staff is established and evaluated. Their regulations, standards, assessment

processes and results are accessible to the public.

Voluntary external quality assessment and improvement programmes are

recognized by and consistent with statutory investigation and inspection. Their

standards, assessment processes and operations comply with international criteria.

There are formal mechanisms to define and protect the rights of patients and their

families in relation to the receipt of health services.

Local quality programmes are systematically planned and coordinated to meet

national priorities and the needs of local stakeholders. They use standards,

measures and improvement techniques which are explicit and known to be

effective.

The capacity to collect meaningful and consistent information on outcomes - in

relation to the means employed and the goals that have been set - is vital for

improving the performance of any system (Shaw C., 2002). The availability or

unavailability of information on specific areas may tell a lot about the strengths

and weaknesses of a system. For example, without information on patients’

experience of the system via satisfaction surveys or on their reoperation, re-

admission rates it may not be possible to evaluate the quality of health care

provided. While there has been an international mobilization for establishing

appropriate performance indicators for health systems, and procedures for

collecting data, system-wide information on the quality of care still remains rare.

What is being measured, and how, is important in a health system, equally relevant

is who is doing the measurement and who has access to the information. The

public dissemination of performance information on individual providers is not an

easy decision in any country. Physicians and hospitals are often skeptical,

underlying difficulties of interpreting data and importance of confidentiality for

medical work. To be able to design new approaches to quality monitoring and

improvement, health policy makers will need to understand the likely origins of

those findings, their magnitude relative to other sectors of the economy and

potential models of improvement (Mattke S., 2002). There is much potential in

sharing the experiences in different countries to understand which factors are

conducive to the design of successful models.

In general, three policy options exist to reform existing arrangements for

performance measurement and improvement:

• Strengthening and/or modifying the institutions for professional self-regulation

• Using improved information to strengthen 'external' regulation

• Providing consumers with sufficient information about performance and with

choice of providers so that market forces can lead to better quality

These choices raise technical, economic and political issues. In particular, they

have different implications for whether the benchmarking of performance is open

or closed to public view. There are different types of measurement of health care

institutions performance (WHO, 2002):

Regulatory inspection. Most countries have statutory inspectorates to monitor

compliance of health care insitution with published licensing regulations.

Inspections standards have legal authority and are transparent, but by the same

token are not easily updated. Standards address the minimal legal requirements for

a health care organization to operate and care for patients; they do not usually

address clinical process or hospital performance. Inspection of health care

insitutions induces conformity, and measures performance in terms of minimal

requirements for safety. It does not foster innovation or information for consumers

or providers.

Surveys of consumers’ experiences. Standardized surveys of patients and

relatives can reliably measure health care insitution performance against explicit

standards at a national level. Performance is becoming more focused on health

education, patient empowerment, comfort, complaint mechanisms and continuity

of care.

Third-party assessments. A research project funded by the European Union

(Shaw C., 2000) identified systematic approaches linking national or international

standards to local practices of private or public health care insitutions. These

approaches have been compared in a number of studies of standards and methods

used by industry-based (ISO, Baldrige) and health-care-based (peer review,

accreditation) programmes (Klazinga N., 2000, Australian Quality Council, 1999,

Donahue K.T., van Ostenberg P., 2000, Bohigas L., Heaton C., 2000). The

programmes, which are voluntary and independent to varying degrees, use explicit

standards to combine internal self-assessment with external review by visits,

surveys, assessments or audits (Shaw C., 2001).

ISO Standards. International Organization for Standardization certification

measures health care institution performance in terms of compliance with

international standards for quality systems, rather than in terms of institution

functions and objectives. ISO developed a series of standards (ISO 9000)

originally for the manufacturing industry (medicines, medical devices) that have

been used to assess quality systems in specific aspects of health services and

hospitals and clinics. Health care institutions (or, more commonly, parts of them)

are assessed by independent auditors who are themselves regulated by a national

“accreditation” agency. The theoretical advantage is that ISO certification is

internationally recognized in many other service, but ISO 9000 standards relate

more to administrative procedures rather than to health care performance.

Furthermore, the terminology of the standards is difficult to relate to health care,

and interpretations vary among national agencies (Sweenwy J., Heaton C., 2000).

The audit process tests compliance with standards and is not intended for

organizational development.

Peer review. Peer review is a closed system for professional self-assessment and

development. Peer review schemes could provide a source of standards and

assessments to harmonize professional and human resource management within

and between countries with reciprocal recognition of training.

Accreditation. Accreditation programmes measure health care institution

performance in terms of compliance with published standards of organizational –

and, increasingly, clinical – processes and results. They are mostly independent

and aimed at organizational development more than regulation but could contribute

reliable data to national performance measurement systems.

Statistical indicators. Statistical indicators can suggest issues for performance

management, quality improvement and further scrutiny. They provide relative

rather than absolute messages and need to be interpreted with caution inversely

proportional to the quality of the underlying data and of the definitions used.

The OECD project on Health Care Quality Indicators (HCQI) is developing

measures to help decision-makers formulate evidence-based policies to improve

the performance of health working group (WHO, 2003) began to define

performance measures for hospitals’ voluntary selfassessment and for external

benchmarking in six domains: clinical effectiveness, patient centeredness,

production efficiency, safety, staff development and responsive governance. The

group has considered background information on international, national and

regional or provincial systems that use standardized data to evaluate several

dimensions of health care institution performance for purposes of public reporting,

accountability, accreditation or internal use (Guisset, A.L, Sicotte C, Champagne

F., 2003). Factors such as underlying values, financing and organizational

arrangements plays role in the selection of possible performance measurement

methods (Leatherman Sh., 2001). The choice of method also depends on whose

behaviour is tried to change: providers, professional bodies, citizens or managers.

Identifying a best method may not be realistic, but being aware of the possible

approaches, their strengths and limitations, and the experience of countries that

have tried them, can help in making a choice.

Performance indicators are employed for four basic functions: facilitating

accountability; monitoring healthcare systems and services as a regulatory

responsibility; modifying the behaviour of professionals and organizations at both

a macro (population) and micro (patient) level; and forming policy initiatives.

Professional accountability, dominant in most health systems historically, views

the physician as the key to controlling quality and uses certification, accreditation,

licensing and litigation as instruments for enforcement. But the professional model

of accountability is increasingly regarded as insufficient unless accompanied by

one of the other two. The economic model is based on the idea that the competitive

market can be used to enforce accountability. Health plans can influence

physicians’ choice of treatment by declining to fund some practices or encouraging

others. And accountability through public reporting is believed to have resulted in

improved performance in certain areas. The political model meanwhile views the

citizen as receiving a public good, so the governments role is to act as an agent of

change on behalf of the public. Objective measures of performance are

increasingly used at several levels. Importantly, performance indicators can help to

make policy priorities explicit, for example by defining national priorities and then

identifying specific performance targets within those priorities. Assisting

healthcare professionals in practicing evidence-based medicine is a key objective

for improving quality. Performance indicators, embedded in clinical guidelines and

peer reviews, are among the most common approaches aimed at bridging the

knowledge gap, but have limited effectiveness when used alone to change

physician behaviour.

PATIENTS SATISFACTION AS QUALITY INDICATOR

Consumers of health care services play a variety of roles in health care quality

assessment and monitoring. By expressing their preferences, they supply the

valuations needed to choose among alternative strategies of care (Donabedian A.,

1987). They help define the meaning of quality in the technical sense. Moreover,

their preferences are the paramount consideration in defining the quality of the

interpersonal process and of the amenities of care. Consumers are also valuable

sources of information in judging the quality of care. Some data, mainly, about

non-technical aspects of care are most easily obtained from consumers. Most

importantly, consumers can and do, through expressing satisfaction or

dissatisfaction, pass a judgment about many aspects of the process of care and its

outcomes. Consumers, if properly informed, could help to regulate the quality of

care by means of their choices. Health care is now entering an age of "accountable

consumerism" in which patients demand service excellence. Patients’ expectations

for care have been defined differently in the literature. Some studies view patients'

expectations as probabilities, judgments about the likelihood that a set of events

will occur (Mc Kinley, 2002; Conway T., Willcocks S., 1997). Others view

expectations as values-patients' desires about care are expressed as perceived

needs, wants, importance, standards, or entitlements (Kravitz R. L., 1996). These

expectations may pertain to health care in general or to a specific health care

encounter such as a clinic visit or hospitalization. Whether patient expectations are

considered as probabilities or values, an understanding of patient expectations is

important because meeting these expectations may lead to greater satisfaction with

care.

The measure of patient satisfaction is viewed as important in outcomes research

and quality improvement efforts (Maxwell D., 2001, Kenagy et al., 1999, Pichert et

al., 1998). In addition to increased patient compliance and health outcomes, patient

satisfaction has been linked to greater service utilization and risk management. As

a result, managed care organizations are placing greater emphasis on patient-

perceived outcomes measures, such as satisfaction and functional status. Patient

satisfaction even has been found to moderate individuals' decisions to sue in the

face of adverse outcomes. As the patient is becoming widely recognized as a

reliable and important source of information about quality of medical practice

(Lawthers A.G., Rozanski B. S., Nizankovski R., Rys A., 1999), important steps

towards making performance transparent comes with the publication of concrete

figures on the quality of outcomes relevant to patients. Patient surveys are an

important part of this. Advantages of the patients’ surveying are that it identifies

what is valued by patients and the general public, and standardized surveys can be

tailored to measure specific domains of experience and satisfaction. However, to

reach the valid and reliable results still remain a challenge for the health care

organisations (Sitzia J., 1999). If questionnaires and the process itself are validated

by rigorous scientific scrutiny, then a useful comparison of the data is guaranteed.

Health care institutions using performance indicators to differentiate themselves

and demonstrate customer focus reap considerable advantages, especially if they

have a quality management system to underpin the development of performance.

That is thebenefit of bothpatients and staff (Kolking H., 2003, Dolan T.C., 1998).

The Commission for health improvement has embraced patient centeredness as a

core organizational value (CHI, 2004). It states: “Patients, careers and service users

matter to CHI. Our inspections help improve the quality of care people receive on

the NHS. We work with patients and patient organizations to do this”. One of these

principles is that CHI will be patient centered. Placing the patient at the center of

the provision of care is yet another new and important approach to improving the

quality of medical care (Grol R., 2001, Elaine Y. et al., 2002). From an ethical

perspective, patient autonomy is seen as a basic value and underlying premise for

the provision of health care in itself. From a psychological perspective, greater

patient involvement and greater patient control are assumed to lead to better

adherence to treatment recommendations and thus to better health. From an

epidemiologic perspective, patients are seen as rational beings who, after being

informed of the relevant benefits and risks of treatment alternatives, can share in

decision making. Satisfaction of health care consumers can refer to two things: first

to “revealed preferences”, that is to real consumption, assumed to be the

expression of what consumers want, and second to what consumers say they want

(“stated preferences”) (Dussault G., 1999). In health, there are so many economic,

social, cultural, organizational potential obstacles to the expression of consumers’

real preferences that revealed preferences say little about what consumers really

want. Also, consumers have only imperfect information about their needs and

about the options of services available, and most of their utilization of services is

on the recommendation of providers. Indeed, the utilization of services probably

reflects more the preferences of providers, than of users. There are now many

validated indicators which measure the stated satisfaction of consumers, and it is

possible to rely on these to assess satisfaction. According to Jenkinson C. et al.

(2002), patients’ experiences of health and medical care are at the very core of the

purpose of clinical medicine. If medical treatment succeed only in a limited

technical sence, but without any benefit to those receiving them, then interventions

have failed. Health care providers must consider whether and how patient

expectations of their services can be managed (McKinley et al., 2002).

Dissatisfaction with the health care services provided could be reduced if

consumers know what they can expect

and then receive it.

LEGISLATION ON QUALITY IN HEALTH CARE

Quality in health care is strongly linked with quality assurance (QA) and patients’

rights. Quality assurance - is a planned and systematic approach to monitoring,

assessing and improving the quality of health services on a continuous basis within

the existing resources. QA should encompass three perspectives on quality:

• Clinical standards

• Performance management

• Client satisfaction

In March 1996 the UEMS (European Union of Medical Specialist) launched the

Charter for quality assurance in European Union. The charter contents 6 articles

about QA for individual specialist group practice, for hospital, professional

scientific organizations, EU Member State or region and financing of QA (Charter

on quality assurance in medical specialist practice in the European Union, 1996).

QA is a professional concept initiated and controlled by professional itself.

Professional and scientific organizations are required to develop quality criteria in

their specialty. QA is moral and ethical obligation for individual specialist, but

basically it should be a voluntary responsibility. The policy of UEMS is the

encouragement of the implementation of the process of QA projects at all practice

whether for individual specialist, group practice, department hospital, professional

scientific organizations, EU Member State or region.

CUSTOMER SATISFACTION

The modern age can be called as the “Age of Consumers”. In today’s cut-throat

competition the consumer is considered as the king. Many policies of various

organizations are aimed at keeping the consumer happy and satisfied. It is very

important for each and every organization to keep its consumers satisfied in order

to maintain its competitiveness in the market. Not only does this help the

organization to maintain the size of its share in the market, it might even help it to

increase the size of its share. It might also be instrumental in increasing the overall

market size. This helps in increasing the overall profitability of the organization. It

also helps the long-term survival prospects of the organization. Consumers when

viewed on the macro level exhibit similar traits. However when we take a closer

look and come down to the micro level, we find that the consumers vary as

compared to one another on one aspect or the other based on a variety of attributes

(Kotler, 2003). In the present business scenario of cutthroat competition, customer

satisfaction has become the prime concern of each and every kind of industry.

Companies are increasingly becoming customer focused. Companies can win 2

customers and surge ahead of competitors by meeting and satisfying the needs of

the customers. World over businesses have realized that marketing is not the only

factor in attracting and retaining customers. Other major factors responsible for the

same are satisfaction through service quality and value. Even the best marketing

companies in the world fail to sell products and services that fail to satisfy the

customers’ needs. So customer satisfaction is the keyword in today’s fiercely

competitive business environment.

Whether the buyer is satisfied after purchase depends on the product’s performance

in relation to the buyer’s expectations. In general, satisfaction is a person’s feelings

of pleasure or disappointment resulting from comparing a product’s perceived

performance in relation to his or her expectations. If the performance falls short of

expectations, the customer is dissatisfied. If the performance matches the

expectations, the customer is satisfied. If the performance exceeds expectations,

the customer is highly satisfied or delighted. The link between customer

satisfaction and customer loyalty is not proportional. Suppose customer

satisfaction is rated on a scale from one to five. At a very low level of customer

satisfaction (level one), customers are likely to abandon the company and even bad

mouth it. At levels two to four customers are fairly satisfied but still find it easy to

switch when a better offer comes along. At level five, the customer is very likely to

repurchase and even spread good word 3 out of mouth about the company. High

satisfaction creates an emotional bond with the brand or company, not just a

rational preference.

CUSTOMER EXPECTATIONS

How do buyers form their expectations? From past buying experiences, friends’

and associates’ advice, and marketers’ and competitors’ information and promises.

If marketers raise expectations too high, the buyer is likely to be disappointed.

However, if the company sets expectations too low, it won’t attract enough

customers. Some of today’s most successful companies are raising expectations

and delivering performances to match. These companies are aiming for TCS- total

customer satisfaction. A customers’ decision to be loyal or to defect is the sum of

many small encounters with the company. The key to generating high customer

loyalty is to deliver high customer value. So a company must design a

competitively superior value proposition aimed at a specific market segment,

backed by a superior valuedelivery system.

The value proposition consists of the whole cluster of benefits the company

promises to deliver; it is more than the core positioning of the offering. Whether

the promise is kept depends on the company’s ability to manage its value delivery

system. The value delivery system includes all the experiences the customer will

have on the way to obtaining and using the offering. Customer satisfaction is a

feeling of pleasure or disappointment on the offers perceived performance in

relation to buyers’ expectations. Expectation is defined as what the customer

wants/requires from the product/service and 4 perceived performance is the

perception of the customer about the product/service i.e. evaluation of the

product/service after using it. So perception is what the customer actually

receives/gets from the product/service. The evaluation is done by comparing the

expectations with the perceived performance of the product/service. Therefore

customer satisfaction is a function of perceived performance and customer

expectations. Customers who are just satisfied find it easy to switch over when a

better offer comes than those who are highly satisfied. For customer focused

companies satisfaction is both a goal as well as a marketing tool. What a consumer

thinks about the product or services offered by a firm can have a marked effect on

the purchase of its products or services. So one of the tasks before the management

is to know what the consumer expect and what they are getting in return.

Satisfaction is a judgment that a product or service feature, or the product or

service itself, provided (or is providing) a pleasurable level of consumption related

fulfillment, including levels of under- or over fulfillment. The expectations-

disconfirmation paradigm provides the most popular explanation of consumer

satisfaction. However, and as is occasionally noted, if a customer experiences

disconfirmation after consuming a product, future expectations regarding the

product should be revised toward the performance perceived by the customer. If

expectations do not change in the face of disconfirmation, the implication would be

that the customer did not learn from their consumption experience (Oliver, 1997).

MEASURING SATISFACTION

Although the customer oriented companies seek to create high customer

satisfaction that is not is main goal. If the company increases customer satisfaction

by lowering its price or increasing its services, the result may be lower profits. The

company might be able to increase its profitability by means other than increased

satisfaction. Also, company has many stakeholders, including employees, dealers,

suppliers, and stockholders. Spending more to increase customer satisfaction might

diverts funds from increasing the satisfaction of other partners. Ultimately, the

company must operate on the philosophy that it is trying to deliver a high level of

customer satisfaction subject to delivering acceptable levels of satisfaction to the

other stakeholders, given its total resources.

Complaint and suggestion system

A customer-centered organization makes it easy for customers to register

suggestion and complaints.

Customer Satisfaction Surveys

Responsive companies measure customer satisfaction directly by conducting

periodic surveys. While collecting customer satisfaction data, it is also useful to

ask additional questions to measures repurchase intention and to measure the

likelihood or willingness to recommend the brand to others. Ghost Shopping

Companies can hire people to pose as potential buyers to report on strong and

weak points experienced in buying company’s and competitors’ products. Lost

Customer Analysis Companies should contact customers who have stopped

buying or who have switched to another supplier to learn why this happened.

The measurement of customer satisfaction has become very important for the

health care sector also. The concept of customer satisfaction has encouraged

the adoption of a marketing culture in the health care sector in both developed and

developing countries. As large numbers of hospitals are opening up and the people

are becoming more aware and conscious of health, great competition has emerged

in this industry. So to retain their patients hospitals have to provide better

facilities/services to its customers. Various factors that can affect the patients’

satisfaction include behaviour of doctors, availability of specialised doctors,

behaviour of medical assistants, quality of administration, quality of atmosphere,

availability of modern facilities etc. As grew the competition, so grew the trend of

providing better facilities to the customers by the hospitals. In last few years, a

plethora of hospitals have mushroomed in and around the city. These hospitals are

advertising heavily about the specialized treatments provided by tthese hospitals.

There are various hospitals that provide specialized treatments for various diseases.

Because of neck to neck competition between hospitals customers run to these

hospitals for specialized treatments. Interestiongly all hospitals claim to have a

high success rate. They claim to provide the best treatment and other essential

facilities at reasonable cost and in easy way to their customers. But how much of

this is true and how many of their claims are myths are not known to vast majority

of customers. As competition is increasing, the hospitals are making their best

efforts to provide quality health care services to its customers. They have begun

practicing a patient satisfaction strategy comprising consumer-oriented plans,

policies and practices to genuinely meet the needs of customers. Also, with

increased awareness and high expectations of the customers’ hospitals have to

provide them better facilities. Patients have begun to demand high quality of

services i.e. a consumer oriented approach. These days patients have become more

aware about their rights so they want they should be better facilities like

responding to their queries promptly, friendly environment, understanding their

problems, availability of specialized doctors, maintaining cleanliness, regular

repots etc. i.e. providing them every type of essential facilities. So, if the hospitals

want that their customers must be satisfied, they have to provide not only better

treatment but other facilities also.

The current study is focused on examining the various factors related to patient

Satisfaction with the following specific objectives:

1. To study the customer expectations from hospital services.

2. To study the customer perception of hospital services.

3. To study the degree of satisfaction of customers from hospital services.

REVIEW OF LITERATURE

Many studies have been conducted on the customer satisfaction. An attempt

has been made to present in brief, a review of literature on customer satisfaction in

general as well as on the customer satisfaction from hospital services. Priscilla et al

(1983) proposed a cognitive model to assess the dynamic aspect of consumer

satisfaction/ dissatisfaction in consecutive purchase behavior. They found that

satisfaction have a significant role in mediating intentions and actual behavior for

five product classes that were analyzed in the context of a three- stage longitudinal

field study. They found that repurchases of a given brand is affected by lagged

intention whereas switching behavior is more sensitive to dissatisfaction with

brand consumption. David and Wilton(1988) have extended consumer satisfaction

literature by theoretically and empirically examining the effect of perceived

performance using a model first proposed by Churchill and Surprenant,

investigating how attractive conceptualizations of comparison standards and

disconfirmation capture the satisfaction formation process and exploring possible

multiple comparison processes in satisfaction formation. They suggest that

perceived performance exerts direct significant influence on satisfaction in addition

to those influences from expected performance and subjective disconfirmation.

Saha (1988) made an attempt to investigate the interrelationships between job-

satisfaction, life satisfaction, life satisfaction-over-time and health. The

relationship among these four variables and biographical variables were also

examined. The study was conducted over the nurses in Nigeria. The data was

collected from the full time employees only because statements about job

satisfaction and other variables are different when supplied by retirees, part-time

nurses. Bolton and Drew (1991) proposed a model of how customers with prior

experiences and expectations assessed service levels, overall service quality and

service value. They applied the model to residential customers of local telephone

services. Their study explored how customers integrate their perceptions of a

service to form an overall evaluation of that service. They developed a multistage

model of determinants of perceived service quality and service value. The model

described how customers expectations, perceptions of current performance and

disconfirmation experiences affected their satisfaction or dissatisfaction with a

service, which in turn affected their assessment of service quality and value.

Boulding et al (1993) stated that the service quality relates to the retention of

customers at aggregate level. The author has offered a conceptual model of the

impact of service quality on particular behavior that signal whether customers

remain with of defect from a company. The results of the study show stron

evidence of their being influenced by service quality. The findings also reveal

difference in the nature of the service quality. Aurora and Malhotra (1997) had

done a comparative analysis of the satisfaction level of customer of public and

private sector banks, in order to help the bank management to formulate marketing

strategies to lure customers towards them and hence increase customer base.

Grewal et al had expanded and integrated prior price perceived value models

within the context of price comparison advertising. More specifically, the

conceptual model explicates the effects of advertised selling and reference prices

on buyers’ internet reference prices, perceptions of quality, acquisition value,

transaction value, and purchase and search intentions. Two experimental studies

test the conceptual model. The results across these two studies, both individually

and combined, support the hypothesis that buyers’ internal reference prices are

influenced by both advertised selling and reference price as well as buyers’

perception of product quality. The authors also find that effect of advertised selling

price on buyers’ acquisition value was mediated by their perceptions of transaction

value. In addition, effects of perceived transaction value on buyers, behavioral

intentions were mediated by their acquisition value perceptions. Voss (1998) had

examined the rule of price, performance and expectations to determine satisfaction

in service exchange. When price and performance are consistent, expectations have

an assimilation effect on performance and satisfaction judgments; when price and

performance are inconsistent, expectations have no effect on performance and

satisfaction judgments. To examine these issues authors develop a contingency

model that they estimate using data from a multimedia experimental design. The

results generally support contingency framework and provide empirical support for

normative guidelines that call for creating realistic performance expectations and

offering money-back service guarantees.

Garbarino and Johnson (1999) analyze that the relationships of satisfaction,

trust and commitment to component satisfaction attitudes and future intentions for

the customers of a New York off-Broadway repertory theater company. For the

relational customers ( individual ticket buyers and occasional subscribers), overall

satisfaction is the primary mediating construct between the component attitudes

and future intentions and for the high relational customers (consistent subscribers),

trust and commitment, rather than satisfaction, are the mediators between

component attitudes and future intentions.

Sharma and Chahal (1999) had done a study of patient satisfaction in outdoor

services of private health care facilities. They had done a survey to understand the

extent of patient satisfaction with diagnostic services. They have constructed a

special instrument for measuring patient satisfaction. The instrument captures the

behaviour of doctors and medical assistants, quality of administration, and

atmospherics. The role of graphic characters like gender, occupation, education,

and income is also considered. Based on their findings, they also suggested

strategic actions for meeting the needs of the patients of private health care sector

more effectively. In their study provided suggestions like becoming more friendly

and understanding to the problems of patients, maintaining cleanliness in the units,

both internally and externally, providing regular report regarding the patients’

progress without waiting for them to demand, conducting surveys to know about

the attitude of the patients with regard to the employees and adopting patient-

oriented policies and procedures. Simester et al (2000) have studied that

multinational firm uses sophisticated, state-of-the-art methods to design and

implement customer satisfaction improvement programs in the United States and

Spain. Their experiments reveals a complex and surprising picture that highlights

implementation issues, a construct of residual satisfaction not captured by

customer needs and the managerial need for combining nonequivalent controls and

nonequivalent dependent variables. Ofir and Simonson (2001) in their study found

that customer evaluations of quality and satisfaction are critical inputs in

development of marketing strategies. Given the increasingly common practice of

asking such evaluations, buyers of products and services often know in advance

that they subsequently will be asked to provide their evaluations. In a series of field

and laboratory studies, the authors demonstrate that expecting to evaluate leads to

less favorable quality and satisfaction evaluations and reduces customer’s

willingness to purchase and recommend the evaluated services. The negative bias

of expected evaluations is observed when actual quality is either low or high, and it

persist even when buyers are told explicitly to consider both the positive and

negative aspects. Dholakia and Morwitz (2002) have examined the scope and

persistence of the effect of measuring satisfaction on consumer behavior over time.

In an experiment conducted in a financial services setting, they found that

measuring satisfaction changes one-time purchase behavior, changes relational

customer behaviors and results in effects that increase for months afterward and

persist even a year later. Their results raised questions concerning the design,

interpretation and ethics in the conduct of applied marketing research studies.

Sharma and Chahal (2003) stated that due to increased awareness among the

people patient satisfaction had become very important for the hospitals. The

authors examined the factors related to patient satisfaction in government

outpatient services in India. They said that there are four basic components which

had impact on the patient satisfaction namely, behaviour of doctors, behaviour of

medical assistants, quality of atmosphere, and quality of administration. They also

provided strategic actions necessary for meeting the needs of the patients of the

government health care sector in developing countries. Folkes and Patrick (2003)

in their study showed converging evidence of a postivity effect in customers’

perceptions about service providers. When the customer has little experience with

the service, positive information about a single employee leads to perception that

the firm’s other service providers are positive to a greater extent than negative

information leads to perception that the firm’s other service providers are similarly

negative. Four studies were conducted that varied in the amount of information

about the service provider, the firm, and the service. The positivity effect was

supported despite differences across studies in methods as well as measures.

Vernoer (2003) had investigated the different effects of customer relationship

perceptions and relationship marketing instruments on customer retention and

customer share development over time. Customer relationship perceptions are

considered evaluations of relationship strength and a supplier’s offerings, and

customer share development is the change in customer share between two periods.

The results show that affective commitment and loyalty programs that provide

economic incentives positively affect both customer retention and customer share

development, whereas direct mailings influence customer share development.

However, the effect of these variables is rather small. The results also indicate that

firms can use the same strategies to affect customer satisfaction that can have

impact on both customer retention and customer share development.

Research Objective

Proposed study aims at accomplishing the following objectives:

To study the impact of monitoring mechanism on customer

satisfaction in a hospital.

To study the impact of attitude of medical & paramedical staff on

customer satisfaction.

To study about the customer awareness for new equipments in

hospital.

To study the impact of “Information sharing on customer

satisfaction”.

RESEARCH METHODOLOGY

IMPORTANCE OF RESEARCH METHODOLOGY

Without using research methodology to find new facts and knowledge is not

possible.

What is research?

“Research is a scientific and systematic search for pertinent information on a

specific topic. In fact research is an art of scientific investigation”.

Defining research problem:

There are two types of research problem, viz., those that relate to states of nature

and those that relate to relationship between variables. At the very outset the

researcher must single out the problem he want to study, i.e. he must decide the

general area of interest or aspect of a subject matter that he would like to inquire

into, initially the problem may be stated in a broad general way and then the

ambiguities, if any, relating to the problem be resolved. Then, the feasibility of a

particular solution has to be considered before a working formulation of the

problem can be set up.

The best way of understanding the problem is to discuss it with one’s

own colleagues or with those having some expertise in the manner. In an academic

institution the researcher can seek the help from a guide who is usually an

experienced man and has several research problems in mind.

Preparation of Research Design:

A research design is the overall plan or program of research. It includes an outline

of what the investigator will do from writing the hypothesis and there operational

implication to the final analysis of data.

Various uses of having a research design are as follows:

It provides answer to various questions.

It acts as a standard guidepost.

It helps in carrying out research validity, objectively, accurately and

economically.

The research problem having been formulated in clear cut terms, the research will

be required to prepare a research design, i.e. he will have to state the conceptual

structure with in which the should be conducted. The preparation of such a design

facilitates research to be as efficient as possible yielding maximal information.

Specifying data requirement:

The first job is to ask certain questions and find suitable answer for them. They

asked ourselves: what specific data will be necessary to test the hypothesis or

establish relationship in which they are interested? What variables are to be

measured?

Determining type of question:

After specifying the required data, they have decided the type of question required

to be asked from the respondent to the illicit data. They have understood various

existing types of questions and decided which of these suited the most to our

project situation.

I have to visit different type of listener having variations in the mindsets towards

the same type question being asked i.e. why I have to admit various categories of

question, which are as follows.

Open Ended Question:

Also termed as free-answer questions. These questions have no fixed alternative

(choice) to which the answer must conform. The respondent answers in his/her

own words and at any length he/she chooses. As such, this form of question

provides the opportunity for greater ambiguity in interpreting answer.

Closed Ended Questions:

Also termed as fixed alternatives questions. They refers to those questions in

which, the respondent is given a limited number of alternative responses from

which he/she selects the one that most closely matches his/her opinion or attitude.

1. The means of obtaining the information.

2. The time available for research, and

3. The cost factor relating to research, i.e. the finance available for the

purpose.

Types of Research

Research purposes may be grouped in four categories, viz

1) Exploratory:

Exploratory research studies are used to formulate a problem for more precise

investigation or of developing the working hypothesis from an operational

point of view. The main emphasis in such study is on the discovery of ideas

and insights.

2) Descriptive and Diagnostic research:

Descriptive research studies are those studies which concerned with

describing the characteristics of a particular individual, or of a group, whereas

diagnostic research studies determine the frequency with which something

occurs or its association with something else.

3) Experimental research:

Experimental research design refers to the framework or structures of an

experiment and as such there are several experimental designs. They can

classify experimental design into two broad categories, informal experimental

design and formal experimental design. Informal experimental designs are

those designs that normally use a less sophisticated form of analysis based on

differences in magnitudes.

“As my objective is to go for a survey hence it can be regarded as a

Exploratory research.”

Determining sample design:

I. Type of universe:

The first step in developing any sample design is to clearly define the set of

objects, technically called the universe, to be studied. The universe can be

finite or infinite. In finite universe the number of items is certain, but in case

of an infinite universe the number of items is infinite, i.e. one cannot have

any idea about the total number of items.

II. Sampling unit:

A decision has to be taken concerning a sampling unit before selecting

sample. Sampling units may be a geographical one such as state, district,

village, etc., or a construction unit such as house, flat, etc., or it may be a

social unit such as family, club, school, etc., or it may be an individual.

III. Source list:

It is also knows as ‘sampling frame’ from which sample is to be drawn. It

contains the name of all items of universe (in case of finite universe only). If

source list is not available, researcher has to prepare it.

IV. Size of sample:

This refers to the number of items to be selected from the universe to

constitute a sample. This is a major problem before a researcher. The size of

sample should neither be excessively large, nor too small. It should be

optimum.

“In case of my research project the sample size was 50”

Collecting the data:

After identification of the research program, the next step is to gather the

requisite data. Field survey is necessary for collecting the data.For the purpose

of collecting the data, a questionnaire was prepared. The respondents were

approached & the responses were obtained with the help of questionnaire.

Sources of secondary data

The secondary data are those, which have already been collected by someone

else & have already been passed through the statistical process. Basically

secondary data provides a starting point for research or market survey. The

information about the mindsets of various people especially students can be

retrieved & it will help us in defining our objectives. By the help of this they

can give our approach a right direction.

Primary data

In dealing with any real life problem it is often found that data at hand are

inadequate, and hence, it becomes necessary to collect data that are

appropriate. There are several ways of collecting the appropriate data, which

differ considerably in context of money costs, time and other resources at the

disposal of the researcher.

Primary data can be collected through following techniques:-

1. By observation:

This method implies the collection of information by way of observation,

without interviewing the respondents. The information obtained relates to

what is currently happening and is not complicated by either the past

behavior or future intentions or attitude of respondents.

2. Through personal interview:

A rigid procedure has been followed and answers to a set of preconceived

questions have been sought through personal interview. This method of

collecting data is usually carried out in a structured way where output

depends upon the ability of the interview to a large extent.

3. Through telephonic interviews:

This method of collection information involves contacting the respondents

on telephone itself.

4. By mailing of questionnaires:

The researcher and the respondents do come in contact with each other if

this method of survey is adopted. Questionnaires are mailed to the

respondents with a request to return after completing the same.

Data analysis & interpretation

1-Have you visited any hospital/nursing home in the last 1 year?

a. Yes ( ) b. No ( )

|

Yes98%

No2%

2-Which type of hospital have you visited in the last 1 year?

( a) Govt. hospital

(b) Private hospital

(c) Nursing home

(d) Rural primary health care center

Govt. hospital 38%

(b) Private hospital20%

(c) Nursing home16%

(d) Rural primary health care center

27%

3-How would you rate the behavior of medical staff?

(a) Highly satisfactory

(b) Satisfactory

(c) Dissatisfactory

Highly satisfactory27%

Satisfactory56%

Dissatisfactory17%

4- How would you rate the behavior of para medical staff?

(a) Highly satisfactory

(b) Satisfactory

(c) Dissatisfactory

Highly satisfactory53%

Satisfactory29%

Dissatisfactory18%

5- Do you fell that you were over charged for medicines?

(a) Yes ( ) (b) No ( )

Yes 22%

No 78%

6-Does the hospital use the latest equipments?

(a) Yes ( ) (b) No ( )

Yes 85%

No 15%

7- Do you feel that the charges for room/bad were reasonable?

(a) Yes ( ) (b) No ( )

Yes74%

No 26%

8- Were the room comfortable?

(a) Yes ( ) (b) No ( )

Yes 88%

No 12%

9-Did the room have all the amenities like TV, A/C, HEATER etc.?

(a) Yes ( ) (b) No ( )

Yes35%

No 65%

10- How would rate the quality of food ?

(a) Very good

(b) Good

(c) Average

(d) Bad

(e) Very bad

Very good8%

Good 16%

Average35%

Bad 30%

Very bad11%

Conclusion

A hospital is an institution for health care providing patient treatment by

specialized staff and equipment, and often, but not always providing for longer-

term patient stays.

In a country where the population growth rate will place additional demands on the

health sector, its preparedness to serve its constituencies effectively is particularly

troubling as the future begins to catch up. To address the impending problems,

consideration has been given to the privatization alternative.

Quality assessment, however, requires careful consideration. Two major concerns

are: who will assess quality and on what criteria. Quality assessment, however,

requires careful consideration. Two major concerns are: who will assess quality

and on what criteria.

Customer satisfaction is the keyword in today’s fiercely competitive business

environment. The measurement of customer satisfaction has become very

important for the health care sector also. The concept of customer satisfaction has

encouraged the adoption of a marketing culture in the health care sector in both

developed and developing countries. As large numbers of hospitals are opening up

and the people are becoming more aware and conscious of health, great

competition has emerged in this industry. So to retain their patients hospitals have

to provide better facilities/services to its customers. Various factors that can affect

the patients’ satisfaction include behaviour of doctors, availability of specialized

doctors, behaviour of medical assistants, quality of administration, quality of

atmosphere, availability of modern facilities etc. So, if the hospitals want that their

customers must be satisfied, they have to provide not only better treatment but

other facilities also. The current study is focused on examining the various factors

related to patient satisfaction with the following specific objectives:

1. To study the customer expectations from hospital services.

2. To study the customer perception of hospital services.

3. To study the degree of satisfaction of customers from hospital services.

In order to accomplish the objectives of the study, the primary data was collected.

The population of this study comprised of the BAREILLY patients only. Three

major private hospitals in BAREILLY were selected namely:

1. Shri Siddhi Vinayak Hospital

2. Shri Ram Murti Smarak Hospital,

3. Ganga Charan Hospital,

From these hospitals primary data was collected from the respondents. The

respondents were either the patients themselves or their relatives. For sample

selection, a multistage sampling procedure was followed. At the first stage, sample

units consisted of total number of general wards and private wards in the hospital.

10% of the general wards and 10% private, wards were selected randomly. Then

from each selected general ward 3 to 5 patients were chosen and from each

selected private ward one patient was chosen. The information was collected

through a pre-designed, structured questionnaire. A sample of 50 respondents

selected from these hospitals on the basis of their convenience for the first

objective and the second objective. To suggest solutions to the problems observed

during the survey is done through secondary data.

Limitations of the Study

1. First limitation is with the regard to response tendency, as much time the

respondents were very careless in filling the details contained in the

questionnaire.

2. Many time respondents fill ambiguous response by the lack of their time.

3. The research contains the study on limited causes and reasons of patient

dissatisfaction but their can be many more factors on which the study can be

elaborated.

4. Respondent some time not given the proper data because they want it to

keep confidential.

5. Result taken from the analysis comprises the data from Bareilly only which

doesn’t show the responses from the other cities or areas which could have

been more accurate in the study results.

RECOMMENDATIONS

We would like to make following recommendations for improving quality in health

care:

• To facilitate communication between healthcare providers and patients, specially

at immunology department. The aspects of the patient-doctor interaction , the

extent to which patients perceive that their doctors seek to involve them in decision

making show significant level of satisfaction among patients.

• To decrease waiting time and make waiting time more productive by providing

leafletsand medical journals etc., in the waiting rooms. Improve appointment

system, including telephone communication.

• To provide the access to needed information for the patients as well as

information related to legal issues and their rights.

• To motivate health care personal on devoting more time for patients; increasing

the perception on patients-centered approach.

• To enlarge and developed special accessibility to health care service for

employed patients.

Bibliography

Book Preferred

Marketing Management by Philip Kotler Millenium Edition

Research Methodology C...R.Kothari

Marketing Research – Green & Hill

Service Marketing – C. H. Lovelock

Magazine

International Journal For Quality in Health Care , 2000 vol 3

Websites Preferred

www.healthorg.com

Questionnaire

Person name-

Address-

Phone no-

1-Have you visited any hospital/nursing home in the last 1 year?

a. Yes ( ) b. No ( )

2-If yes then indicate the reason

(a) Treatment of self

(b) Treatment of family member

3-Which type of hospital have you visited in the last 1 year?

( a) Govt. hospital

(b) Private super specialize hospital

(c) Private specialize hospital

(d) poly clinic

(e) Nursing home

(f) Rural primary health care center

4-How would you rate the behavior of medical staff?

(d) Highly satisfactory

(e) Satisfactory

(f) Dissatisfactory

5- How would you rate the behavior of para medical staff?

(d) Highly satisfactory

(e) Satisfactory

(f) Dissatisfactory

6- Do you fell that you were over charged for medicines?

(b) Yes ( ) (b) No ( )

7-Does the hospital use the latest equipments?

(b) Yes ( ) (b) No ( )

8- Do you feel that the charges for room/bad were reasonable?

(b) Yes ( ) (b) No ( )

9-Were the room comfortable?

(b) Yes ( ) (b) No ( )

10-Did the room have all the amenities like TV, A/C, HEATER etc.?

(b) Yes ( ) (b) No ( )

11- How would rate the quality of food?

(f) Very good

(g) Good

(h) Average

(i) Bad

(j) Very bad