a case study of travancore medical college hospital kerala, india

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Critically evaluate service quality as a determinant factor

for patient satisfaction in gaining patient loyalty.

A case study of Travancore Medical College Hospital Kerala, India.

BY

ANEESH POOCHAPANDIYIL VELAYUDHAN PRASANNAN

SUPERVISOR : MR. CILLIERS DIEDERICKS

WALES ID : 1092227390326

KCB ID : 15040

Submitted in fulfilment of the requirements of the Taught Masters Dissertation to the

University of Wales, for the degree of Masters in Business Administration (MBA).

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DECLARATION

This research work is purely the author’s own effort where the ideas of other

scholars and authors are referenced using the Harvard Referencing style. It has not

been previously accepted in substance in any degree and in not being concurrently

submitted in candidature in any degree

This dissertation is the result of my own investigation, except where otherwise

state, where correction services have been used, the extent and nature of the

correction is clearly marked in footnote(s). The ethical issues have been kept into

consideration during the preparation of this report and the responses of the

individuals to the research survey are kept confidential.

I hereby give consent for my work, if accepted to be available for

photocopying and for inter-library loan, and for the title and summary to be made

available to outside organizations.

Signed ……………………………………………………….. (Candidate)

Date: 14/02/2012

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Table of contents Page No.

1. Introduction 1

1.1 Research background 2

1.2 Research Aim 4

1.3 Objectives 4

1.4 Rationale for choosing the research topic 5

1.5 Company profile 6

1.6 Conclusion 7

2. Literature review 7

2.1 Introduction 7

2.2 Aims and objectives 7

2.3 Literature Review 8

2.4 Service Quality Conceptualization 8

2.5 Dimensions of service quality 11

2.6 Measuring Service quality 12

2.6.1. Gap Model 13

2.6.2 SERVQUAL Model 15

2.6.2.1 Advantage of SERVQUAL Model 18

2.6.2.2 Criticism of SERVQUAL Model 18

2.6.3 SERVPERF Model 20

2.7 .Patient satisfaction 20

2.8. Patient satisfaction and its dimensions 23

2.9 .Theories of customer satisfaction 24

2.10. Measure of customer satisfaction 24

2.11. Patient Loyalty 25

2.12 Importance of custom loyalty 26

2.13 Measurement of patient loyalty 27

2.14 Service quality and customer satisfaction relationship. 29

2.15 Service quality and customer loyalty relationship 29

2.16 Customer satisfaction and customer loyalty relationship 29

2.18 Conclusion 30

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3. Research Methodology

3.1 Introduction 31

3.2 Aims and objectives 31

3.3 Research Methodology 31

3.4 Research Design 32

3.4.1 Exploratory Research 33

3.4.2 Descriptive research 33

3.4.3 Explanatory research 33

3.4.4 Justification for research design 33

3.5 Research Philosophy 34

3.5.1 Epistemology 34

3.5.2 Positivism 34

3.5.3 Realism 34

3.5.4 Interpretivism 35

3.5.5 Ontology 35

3.5.5.1 Subjectivism 35

3.5.5.2 Objectivism 35

3.5.6 Axiology 35

3.5.7 Justification of research philosophy 36

3.6 Research approach 36

3.6.1 Justification of research approach 37

3.7 Research Strategy 38

3.7.1Quantitative data 38

3.7.2 Qualitative data 38

3.7.3 Justification of research strategy 38

3.8 Source of data 38

3.8.1 Primary data 39

3.8.2 Justification of primary data 40

3.8.3 Secondary data 40

3.8.4 Types of secondary data 41

3.8.5 Justification of secondary data 41

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3.9 Sampling 42

3.9.1 Probability sampling or Representative sampling 42

3.9.2 Non Probability Sampling or judgemental sampling 42

3.9.3 Justification of sampling 42

3.10 Conclusion 42

4. Research findings and Analysis

4.1 Introduction 43

4.2 Aim and Objective 43

4.3 Analysis of primary data 44

4.4 Comparing primary data with secondary data 65

4.5 Conclusion 67

5. Conclusion and Recommendation

5.1 Introduction 69

5.2 Aim and Objective 69

5.2.1 Achievement of objective 1 69


5.2.3Achievement of objective 3 72


5.3Conclusion 73

5.4Research limitation 73

5.5Recommendations 74

5.5.1 Recommendation 1 74







5.5.8 Recommendation8 84

6. Reflective summary 85

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7 Reference 86

8 .LIST OF FIGURES

1. Fig 2.1 Gap Model 14

2. Fig 2.2 Measurement of patient loyalty 27

3. Fig 2.3 Patient loyalty and service quality model 28

4. Fig 2.4 The relationship between service quality,

Customer satisfaction and customer loyalty. 30

5. Fig 3.1 Research onion 32

6. Fig 3.2 Source of Data 39

7.Fig 3.3 Primary data 40

8.Fig 3.4 Secondary data 41

9. List of Tables

1. Table 2.1 22 Items of SERVQUAL instruments 17

2. Table 2.2 Customer Benefits 26

3. Table 3.1 Types of Research Design 33

4. Table 3.2 Research Approach 37

5.Table 4.22 Patient satisfactory 65

6. Table 5.1 Gantt Chart of ERP 76

7. Table 5.2 Gantt Chart of recruitment of HR trainers 79

8. Table 5.3 Gantt chart of CCTV 81

9.Table 5.4 Gantt chart of purchase of medicines 83

9.List of Charts

1. Chart 4.1 Distribution of sample size according to age and sex 44

2. Chart 4.2 The reason for choosing hospital 45

3. Chart 4.3 The receptionist was friendly and courteous 46

4. Chart 4.4 The staff respects the patient with respect ,dignity and were

Courteous in the hospital 47

5. Chart 4.5 There is a lot of paper work for admission 48

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6. Chart 4.6 The service cost for hospital is affordable. 49

7. Chart 4.7 All the staffs were in correct uniform 50

8. Chart 4.8 Hospital is visually attractive 51

9. Chart 4.9 Hospital is a convenient location 52

10 Chart 4.10 Hospital has good directional science 53

11. Chart 4.11 Hospital provides services at allocated time 54

12. Chart 4.12 Hospital department is working effectively 55

13 Chart 4.13 You felt ease during your appointment 56

14 Chart 4.14 Doctors listen carefully and adhered to your needs 57

15 Chart 4.15 Hospital addresses the patient complaint quickly 58

16 Chart 4.16 Do you think staff responded immediately 59

17 Chart 4.17 Hospital employee are sympathetic and re assuring 60

18 Chart 4.18 Hospital doctor prescribes affordable medicine 61

19 Chart 4.19 Average waiting time in the hospital 62

20 Chart 4.20 Charges of TMC hospital is affordable 63

21 Chart 4.21 Recommending hospital to the friends and relatives 64

10. 1 Appendix 1 92

2. appendix 2

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Chapter 1

Introduction 1 Introduction

All business organisations including health care organisation are interested in

achieving long term financial success (Al Hawary et al., 2011). Healthcare is one of

the most important elements of life and people always demand a better quality of

health to have a healthy life. This patient centric approach and consumer satisfaction

became the fundamental requirement for healthcare providers (Desai, 2011).In the

recent years the number of private and public hospitals had been increased

tremendously. In order to gain competitive advantages in the health care industry

and improve the operative efficiency the hospitals have adopted quality improvement

measures (Yasin et al., 2011) . Likewise Bullet (1996) had identified service quality

as a corporate market strategy and financial performance driver and had stated that

the hospitals can achieve competitive advantage and operational efficiency by

adopting service quality as a strategic tool. According to Shaktivel et.al (2005)

customer satisfaction is one of the critical factors that judges the service quality

delivered to the customers (Shaktivel et.al (2005); cited by Ooi et al., 2011).Impact of

patient satisfaction in choosing hospitals are important. Research had shown that

there are links between patient satisfaction and healthcare quality (Kessler & Mylod,

2011). Woodruff in 1997 had pointed out that service providers consider customer

loyalty as a competitive advantage. Many researches had proved that enhanced

customer loyalty increase profitability of the organisation (Woodruff (1997); cited by

Wang & Wu, 2012). On the other hand Strasser et.al in 1995 had stated that

negative word of mouth can cause hospitals a revenue loss of 6000$ to 400,000 $

(Naidu, 2009).With the increasing no of private and public hospitals the completion to

be the top health care provider is intense. The private hospitals compete with each

other to provide the best healthcare. According to Lim and Tag (2000) the public

awareness and rising literacy rate in the population made healthcare providers to

provide high quality treatment to the patient. Every patient have expectations what

their health care centre is going to provide them .Every healthcare centres should

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give attention to reduce the gap between what patients actually expects and the

service that is actually delivered. (Lim and Tag (2000); cited by Suki et al., 2011). In

this research the author will be evaluating service quality as a determinant factor for

patient satisfaction in gaining patient loyalty.

First of all the author begins with the research background then the author had

discussed about research aims and objectives then the author had talked about

about the reason for choosing this research topic, the company’s background and

finally will conclude by summarizing the entire research research.

1.1 Research background

India has been witnessing increasing demand for quality healthcare after

globalization. Urbanization had improved quality of life which in turn had demanded

quality health care. Service quality has been chosen as an important element by

consumers for selecting hospitals (Dr.Vanniarajan & Arun, 2010).India has now

become a medical hub and the patients from the Western countries and other parts

of Asia and Africa use undergo treatment due to due to low cost and high quality

treatment. According to KGMP report of 2011 the healthcare industry in India will

grow from USD 79 Billion in 2012 to 280 Billion in 2020 (KMPG, 2012).Eventhoug

the health care spending in India is significantly low as compared to the developed

countries and other emerging countries. The average CAGR for the healthcare

industry in the next 10 years is 21%. . In India more than 50 percent of healthcare

expenditure comes from the individual against the state level government

contribution of less than 30 percent (Padma et al., 2010) .According to the WHO

health statistics 2010 private sector contributes approximately 75 % of the health

sector. The key factors for the growth of healthcare sector are Increase in

population, rising disposable income of the population, rising literacy rate,

demographic changes by 2026 there will be an increase in geriatric population from

current 96 million to 126 million which means that there will be an increased

dependence on hospitals, increase in lifestyle related diseases like cardiovascular

disease, diabetes. The health care industry in India is also facing many challenges

like lack of manpower and infrastructure. The healthcare infrastructure in India lags

behind the global average .India has only .6 doctors per 1000 population against the

global average of 1.3 it is evident from this finding that there is a gap of man power.

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The no of bed available per the 1000 population is only 1.27 which is less than the

global average of 2.6%.However in the last decade there was an increase

participation of private sector in the healthcare industry. In the coming years the

healthcare sector will be facing stiff competition due to increased no of private

hospitals and because of the government policies allowing 100 % FDI in hospital

sector .In order to have a competitive advantage in this highly competitive

environment the hospitals should improve their quality standards in lieu with their

counterparts. Hospitals should implement healthcare accreditations like JCI (Padma

et al., 2010).

Despite of the growth of the healthcare industry the hospitals and other health

care organisations are struggling to deliver quality healthcare in this competitive

environment (Avgar et al., 2011).The service delivery system in the recent years

have been restructured and is now patient centric (Desai, 2011).Moreover the

studies done by Sahay (2008) shows that there is a need for improvement for

customer service (Padma et al., 2009). In recent years concern for service quality

had gained unprecedented levels. Service quality had now become an important

distinguishing factor between services to gain competitive advantage (Rashid &

Jusoff, 2009). According to Taner and Antony (2006) health care service has a

unique position among other service due to its very nature of highly involved risk.

This makes measuring service quality and patient satisfaction in healthcare setting

more important and more complex (Taner & Antony, 2006; cited by Rashid & Jusoff,

2009)

According to Kotler in 1998 customer loyalty is an indispensable tool for profit and

non profit organisation to sustain competitive advantage and to enhance business or

service measures (Chahal, 2008). The research done by many researchers like

Berry et .al (1989) had emphasised the fact that “good service quality leads to the

retention of customers and attraction of new ones, reduced cost ,enhanced

corporate image, positive word of recommendation increases profitability of an

organisation”. Service quality has become an important element in selecting

hospitals by people (Berry et .al (1989) ;Reichheld and Sasser (1990);Rust and

Zahorik (1993) ;Cronin et.al (2000);Kang and James (2004) ;Yoon and Suh

(2004); cited by Dr.Vanniarajan & Arun, 2010).According to Analeeb (1998) was in

the point of view that hospitals who don’t give importance to customer satisfaction

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may be inviting extinction. Service quality are of great importance for the service

marketers because they are under the direct control of the service providers and its

consequence may improve service satisfaction and it will influence the buyers

behavioural intention which will lead to use the service again .This will ultimately lead

to customer loyalty (Padma et al., 2010).By doing this research the author can find

the gaps in the service provided by the hospital and can recommend the hospital to

reduce the gap between the customers expectation and the actual service delivered

so that they can increase patient satisfaction and gain patient loyalty .

1.2 Research Aim

Critically evaluate service quality as a determinant factor for patient satisfaction in

gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,

India.

1.3 Objectives

1. To review literature on service quality, patient satisfaction and patient loyalty.

2. To investigate the current service quality measures adopted by Travancore

Medical College Hospital

3. To evaluate the service quality offered by Travancore Medical College

Hospital and its effect on patient satisfaction in gaining patient loyalty.

4. To recommend Travancore Medical College Hospital to improve the service

quality so that they can increase patient satisfaction and gain patient loyalty.

1.4 Rationale for choosing the research topic

Service quality is an important determinant to appraise the triumph of any entity as

success in meeting the client’s expectation is the definitive objective of business.

Customer contentment has been considered as significant success factor in today’s

spirited business milieu, as they facilitate in retaining customers and maintaining

market share. It is also not different in case of hospital. It is one of the imperative

benchmark used to measure the patient satisfaction in gaining fidelity towards the

hospital. Because the totality of services rendered by the hospital to its patients is

the input en route for the patients and the contentment derived is the output.

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Escalating customer satisfaction is vital for customer allegiance. Service providers

should always manage to improve customer satisfaction it is one of the factor by

which the patient measures the quality of the medical services offered. Hence an

attempt has been done to articulate to evaluate service quality as a determinant

factor for patient satisfaction in gaining patient loyalty, for which a case study was

done in Travancore Medical College Hospital, one of the leading private sector

hospitals in Kerala, India.

1.5 Company Profile

Travancore Medical College Hospital Kerala, India. The TMCH consists of 800

bedded multi speciality hospital with state of the art facilities. It is a unit of Quilon

medical trust started with the view to promote medical education and health care to

the minorities of the society with the motto “service with love”. The hospital has a

highly qualified doctor, dedicated nursing staff and a technically sound paramedical

staff. The hospital has unique facilities like 15 bedded medical ICU unit, 15 bedded

emergency ICU unit, 6 bedded neuro ICU unit. There are about 10 operation

theatres in the hospital along with other laboratory units such as biochemistry It is

one of the premier medical facility for trauma, emergency, critical care and

ambulatory care. TMCH is one of the reputed medical emergency care centres in the

south Kerala region, and receives most complicated referral cases from many other

hospitals. The administration and medical team are highly qualified based on

education training. The hospital is equipped with the most advanced high technology

instruments to provide the best treatment available. The hospital has a dedicated

highly experienced nursing staff to avoid mal practice. They have a medical college

and a nursing college attached to the hospital .TMCH is the leading medical

education provider in Kerala. They admit nearly 100 students each year. The

hospitals have the best infrastructure available and the best available medical

teachers in India. The hospital has 22 department with the most experienced and

eminent doctor of Kerala. As a part of the social commitment the hospital was

providing free treatment for the patients hospitalised in the ward. The hospital also

has satellite centres in the interior parts of the kerala where there are no hospitals

and the patients around that place fully depend on these hospitals. As a part of the

professional development in career the hospital proves continuing medical education

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programmes on regular basis so that all the doctors in the hospital can participate

and be updated (Travancore medical college, 2012).

1.6 Conclusion

The author had divided the dissertation into 5 chapters. In Chapter 1 the author

gives a brief overview of the entire research which includes the research aim and

objective a brief back ground of the health care industry and the hospital selected .

In Chapter 2 the author critically reviews all available literature which are in the forms

of journals, books, website and newspaper which forms the secondary data. In

Chapter 3 the author forms a framework for the primary analysis .The author then

discuss about the various methods adopted in research which include research

strategy, research approach, research philosophy, sample size and the sampling

method used. In Chapter 4 The author will be analysing the primary data,

questionnaire that were distributed to the patients of the TMC hospital and then the

author will be comparing the findings with the secondary research. In Chapter 5 the

author draws a conclusion from the primary and secondary research and the author

put forwards some suggestions that can improve the service quality standards of

TMCH to improve patient satisfaction so gain patient loyalty.

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Chapter 2

Literature Review 2 .1 Introduction

In the present chapter author reviews the literature related to Service Quality,

Patient satisfaction and Patient loyalty get a deep insight and understanding of these

topics and to form the basis of future primary research .All the data’s that we collect

both the primary and the secondary should be compared so that the researcher can

draw conclusions from it and suggest recommendation for improving the present

situation. The author can suggest good recommendation’s only if the author has

done a strong secondary research. So the author had made use of all the available

data to frame a strong foundation for the research.

First of all the author begins the chapter by restating the aim’s and objective

and then begins reviewing the literature by discussing about the conceptualization of

service quality then about the dimensions of service quality. The author had also

discussed the different models of service quality used to measure them.

The author then had focused on patient satisfaction its dimensions and theories.

The discussion then moves on to patient loyalty, importance of patient loyalty and

measurement of patient loyalty. Finally the chapter had concluded by discussing the

relationship between service quality and customer loyalty, relationship between

customer loyalty and customer satisfaction and the relationship between customer

satisfaction and customer loyalty.

2.2 Aim and objective



India.


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quality so that they can increase patient satisfaction and gain patient loyalty

2.3 Literature Review

In the last few decades the hospitals are thriving to provide the highest possible

service quality to its patients at a lowest possible cost. Morris and Bell (1995) had

stated that the issue of defining, measuring and monitoring the quality of healthcare

had been addressed from ancient times (Morris and Bell,1995; cited by Sivakumar &

Srinivasan, 2010).According to Youseff et.al (1996) all hospitals in healthcare sector

provides same type of service but different quality of service (Youseff et.al, 1996

cited by; Suki et al., 2011). According to Berry et al (1988) with the constant increase

in customer and increasing competition service quality is the key factor that major

service companies have (Berry et.al, 1988 ; cited by Sainy, 2010).It is easy to see

that with the rising income of people and literacy rate of people they demand high

quality healthcare.. In a patients view point service quality is ultimately how they

judge the service they had encountered in the hospital which includes the interaction

with the doctors , nurses the staffs of the hospital outcome of the service. There fore

service quality of hospitals can be the key deciding factor for the selection of

hospitals

2.4 Service Quality Conceptualization

First of all there are different concepts for service quality to begin with initially

Takeuchi and Quelch (1983) had assessed the service quality of healthcare by six

dimensions namely reliability, service quality, prestige, durability, punctuality and

ease of use (Takeuchi and Quelch, 1983; cited by Dr.Vanniarajan & Arun, 2010), Gravin (1984) had established 5 categories or approaches to the concept of quality

namely transcendent based on degree of excellence, product based which involves

measurable characteristics of products, User based which involves meeting the

needs of the user, manufacturing based on the conformance with design or

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specification and finally value based which involves how much of something is

related to price (Gravin ,1984; cited byAl Hawary et al., 2011).

Similarly Gonroos (1984) had stated “that the perceived service quality is an

evaluation process where the customer compares his expectation with the service

that he had received ’’. He had proposed that there are two types of service quality

the functional ‘’service quality’’ and ‘’technical service quality’’. The functional service

quality is that the manner in which serve quality is delivered and technical service

quality is what actually the customer received from the service ( Gonroos 1984;cited

by Alrubaiee & Feras, 2011). Later in 1990 Gonoroos had added image of service

providers as a third dimension which acted as a filter in consumers perception of

quality (Padma et al., 2009).However Lehitmere and Jukka (1985) had presented a

holistic view to measure, monitor and operational customer perception of service

quality in health care organisation (Lehitmere and Jukka,1985; cited by

Dr.Vanniarajan & Arun, 2010).

Bopp (1986) had developed a “medical service quality active satisfaction model”.

The mode evaluates the service quality in consumption stage of patients purchase

cycle”. The finding of the study revealed that the factors that that played a role in

patient evaluation include expressive caring, expressive professionalism and

expressive competence of the service interaction. The study results emphasised that

staff’s with expressive caring, professionalism and physicians expressive caring has

a significant effect on patient satisfaction. (Bopp, 1986; cited by Sivakumar &

Srinivasan, 2010)

According to Parasuraman (1988) “service quality is defined as a global

judgement or attitude, relating to overall superiority of the service’’ (Parasuraman

1988; cited by Blery et al., 2011).John (1987) had developed an instrument to

measure the construct the “perceived service quality”. The findings of the study were

encouraging for other researchers by revealing that the measure of perceived

service quality is a multi dimensional construct containing variables namely

competence, credibility, reliability, security, courtesy, communicativeness,

understanding, availability, responsiveness, physical environment. This is in

consistent with generic dimensions of service quality which was later proposed by

Parasuraman et.al (1990).

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Woodside et.al (1989) had defined service quality in healthcare as the gap

between patient expectation and perception (Woodside et.al,1989;cited by Wu,

2011). Similarly Bower et .al in 1994 had studied 5 common attributes of quality

from SERVAQUAL model, of this caring and communication were found to be

important and three of the generic SERVAQUAL dimension were related to patient

satisfaction: empathy, responsiveness and reliability (Bower et .al ,1994; cited by

Dr.Vanniarajan & Arun, 2010)

Zeithmal and Bitner (1996) was in the point of view that service quality lies in

providing excellent or superior service than the customers expectation.(Zeithmal and

Bitner 1996 ;cited by Alrubaiee & Feras, 2011).Other researchers like Lytle and

Mokva (1992) argues that service quality satisfy the need of patient and patient

evaluates the service quality on the basis of service output, service process and

physical environment (Lytle and Mokva ,1992; Wu, 2011).

According to Zeithaml et.al (1990) there are 5 different gaps in service quality.

a) “Word of mouth”

b) “Personal needs”

c) “Previous experience”

d) “Service product content”

e) “External communication of service providers with customers”

The customer expectation is influenced by the first 3 factors and quality

perception is formed by the fourth factor.

According to Maxell (1992) healthcare Service quality has 6 dimensions

namely accessibility, acceptability, appropriateness, equity, effectiveness and

efficiency which the patient considers important. The study done by Bell et.al (1993)

resulted in identifying dimensions similar to Maxell except they added the dimension

Privacy (Bell et.al 1993; cited by Sivakumar & Srinivasan, 2010).

A study conducted by Fitzsimmons and Fitzsimmons (2000) included price as it

is a service winner. They had defined price in terms of monetary and non monetary

and then added the dimension of time. Monetary price is the sum of the expense the

customer had incurred to get the service. The non monetary price includes any

perceived sacrifice like the time spent, the inconvenience and physiological cost like

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perception of risky anxiety (Fitzsimmons and Fitzsimmons, 2000; cited by Al Hawary

et al., 2011).

Walter (2001) had judged the quality of service in health care organisation by

“reliability, availability, credibility, security, competence of staff, understanding of

customer needs, responsiveness to customers, courtesy of staff, comfort of

surroundings, communication with participants and associated goods provided with

the service”. (Walter, 2001; cited by Dr.Vanniarajan & Arun, 2010).

The researchers started evaluating behavioural intentions like word of mouth as

service quality dimensions. Similarly researchers like Yavas .et.al (2004) and

Swanson and Davis (2003) had done research to prove that word of mouth have

effect on service quality. (Yavas .et.al, 2004; Swanson and Davis, 2003; cited by

Urban, 2010). Likewise Sweetney et.al (2008), Dean and Lang (2008) and Murray in

(1991) stated that word of mouth often lead to repurchase behaviour (Sweetney

et.al,2008; Dean and Lang ,2008; Murray,1991;cited by Urban, 2010)

Vasso Eiriz and Jose Antonio Figueirideo (2005) had developed a frame work for

the evaluation of healthcare based on the relationship between customers and

providers. They had considered four quality items namely customer service, cost,

location and competence of the staff. They were in the point of view that service

quality of hospitals should not be judged alone on patient’s evaluation. (Vasso Eiriz,

Jose Antonio Figueirideo (2005); cited by Al Hawary et al., 2011).

2.5 Dimensions of Service Quality

Pollack,B.,L.(2008) had stated that “service quality is an multi dimensional construct

“.Brandy and Cronin (2001) had stated that the advanced “hierarchical

conceptualization model of service quality consist of 3 dimensions namely outcome

quality, physical quality and interaction quality”. “Outcome quality refers to the

patient’s assessment of the main service offered to them”. “The interaction quality

refers to the customer’s assessment of service delivery and physical quality refers to

the customer’s evaluation of the tangible aspects of the service”. Lehtinin and

Lehtinin (1991) had stated that there are “three dimensions for service quality

namely physical quality, interactive quality and corporate quality”. (Alrubaiee &

Feras, 2011).

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The most popular conceptualization of “Service Quality”, “SERVQUAL model is

based on 5 dimensions which are illustrated in the diagram below namely (Markovic

& Raspor, 2010)

1. “Tangibles”

Include physical facility equipment and staffs

2. “Reliability”

Includes ability to provide promised service accurately

3. “Responsiveness”,

Includes willingness to provide prompt services and help customers

4. “Assurance”

Includes knowledge and courtesy of employees to promote trust and

confidence.

5. “Empathy”.

Includes care and attention the organisation provides to the customer

Responsiveness, Empathy and Assurance represents the interactive quality

Sower, V. (2011)

According to Bakar et.al (2008) the dimensions of service quality in healthcare

quality can be studied in a two way approach. It was been divided in to clinical

quality and service quality. Clinical quality involves surgical skills, sufficient drugs

and logistics which help in better outcome. The service quality includes patient

experience namely waiting time, hospital comfort, support from the providers,

physical environment, appointment and visits (Bakar et.al 2008; cited by Atinga et

al., 2011).

2.6 Measuring service quality

Most of the methods developed in the past two decades belong to a user based

paradigm and employ questionnaire to collect the data, some. (Sliwa & O’Kane,

2011).The different methods for collecting service quality data are described below.

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2.6.1 Gap model

Parasuraman et.al (1985) developed a gap model to measure the attributes of

service quality. This initial gap model which included following determinants of

service quality.

However according to Parasuraman et.al (1988) service quality cannot be

conceptualised or evaluated by the traditional method used for evaluating the goods

quality because of its nature of “intangibility, heterogeneity and inseparability”.

Moreover Service quality can be defined as the function difference between

customer expectation and perception of service performance. This results in a gap

between the expectation and perception. Hence the model is also referred to as Gap

model which is illustrated in the fig 2.2 (Parasuraman et.al, 1988; cited by Nassab et

al., 2011). Consumer expectation described as what the consumers want and these

they are formed from marketing, word of mouth, prior experience and personal

needs. Consumer perceptions are formed when they are experienced during the

interactions with the organisation. “Five main Gaps are identified that occur during

the service process”. Four of these gaps occur during service provision and are

influenced by the management and provider (Alin et al., 2009)

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Fig 2.1 Gap Model

(Alin et al., 2009)

a) “Gap 1 Difference between consumer expectation and management

perception of consumer expectation.”

b) “Gap 2 Difference between management perception of consumer expectation

and service quality specification”.

c) “Gap3 Difference between service quality specification and service quality

actually delivered”.

d) “Gap 4. Difference between service delivered and what is communicated

about the service to consumers”.

e) “Gap 5. It is the difference between consumer expectation and consumer

perception of service delivery which is caused by the combined influence of

Gap 1 to 4”.

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Gap 1 which is shown in fig 2.2 will arise when the management lacks to

understand the customers expectation which were formed as a result of marketing,

word of mouth, previous experience. Gap 2 shown in fig 2.2 will arise when the

management fails to achieve the target level of perception of the patient and

transform them to the workable level. Gap 3 as illustrated in fig 2.3 arises when the

actual service delivery standard set by the management will not meet expectation.

Gap 4 as shown in fig 2.2 arises when usually the organisation exaggerates what will

be provided to the customers rather than the real fact it will lead to increase in

customer expectation .Gap 5 as shown in fig 2.2 arises from the difference between

customer expectations and actually the customer receives

2.6.2 SERVQUAL MODEL

The SERVQUAL method developed by Parashuraman et.al (1988) is the most

popular method to access customer satisfaction in service industry. It measures the

quality by comparing the customer’s perception of a quality of a service experienced

and what that customer expected for the service (Parashuraman et. al (1988);cited

by Lonial et al., 2010).

The SERVQUAL method was used in various settings like banks, hotels , dental

clinic, insurance companies, healthcare organisation , telecommunication, hospitals

hotels and fast food chain. Kaul (2005) had said that SERVAQUAL scale was

extensively used in India to measure quality of services provided by retail stores.

Deshpande (2006) had said that SERVQUAL SCALE is used in Hospitals.

Sivakumar and Srinivas (2003) had stated that SERVQUAL was extensively used in

hotels and Jain and Gupta ( 2004) had said that SERVQUAL model was used in fast

food chain (Kaul (2005); Deshpande (2006); Sivakumar and Srinivas (2003); Jain

and Gupta ( 2004); cited by Mengi, 2009).

SERVQUAL Model developed by Parasuraman et.al in 1988 is one of the main

tool for service quality (Parasuraman et.al in 1988; cited by Mengi, 2009). The

SERVQUAL scale has a multi dimensional approach for measuring perception of

service quality. The three dimensions that are relevant for health care are assurance,

empathy and responsiveness (Karl et al., 2010). Assurance refers to customer’s

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perception of trust how they feel with the employee or employees providing care.

According to Lee and Lin (2008) reduced patient trust in care givers can lead to post

discharge non compliance which causes slow or incomplete recovery. Empathy

refers to the level of care and individual attention that is provided to each patient.

(Lee and Lin, 2008; cited by Karl et al., 2010). Likewise Spigelman and Sensor

(2008) had argued that patients are looking for personalised care. According to

Anderson et.al (2004), Anderson et.al (2006), Roszak (2007) had stated that the

responsiveness or waiting time is an additional customer care quality factor that is

critical for the customer perception in healthcare (Anderson et.al (2004), Anderson

et.al (2006), Roszak (2007) ;cited by Karl et al., 2010).

SERVQUAL instrument has been designed to be applied on a variety of service

settings. SERVQUAL is used as a diagnostic technique for uncovering quality

strength and weakness. SERVQUAL instrument has a variety of potential application

and is widely used for assessing the consumer expectation and perception of

Service Quality. It also point out problems that require managerial attention

(Yesilada, 2009).

This model contains 22 items illustrated in the table 2.1 for accessing customer

perception and expectation regarding the quality of service. SERVQUAL is a

diagnostic technique used to uncover the quality strength and weakness

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Table 2.1 ,22 item of SERVQUAL Instrument

(Joanna lee, 2011)

The SERVQUAL scale has 22 questions which is used to measure the “5

dimensions” of the “service quality” namely “Reliability”, “Tangibility”, “Security”,

“Empathy” and “Responsibility” .These questions are scored in “LIKERT scale” from

1 to 5 .They are marked from “strongly agree to strongly disagree ” (Nair et al.,

2010).

The results of perception and expectation are compared to each question and the

difference between perception and expectation gives the final score The negative

results reveal that perceptions are below the expectation and there is an

unsatisfactory service experience for the client. The positive result shows that there

is a satisfactory service experience for the client.

According to Parasuraman et al in (1988) SERVQUAL is a concise scale with

good reliability and validity. Zeithaml (1987) SERVQUAL involves perceived quality

which is customer’s judgement about an entity’s overall excellence (Parasuraman et

al ,1988, Zeithaml ,1987; cited by Yesilada, 2009).

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According to researchers like Bahia and Natel (2000), Sachdev and Verma

(2004) and Chiu (2002) SERVAQUAL is the best known leading instrument used by

managers of different industrial, commercial and non profit setting (Bahia and Natel

2000 ,Sachdev and Verma ,2004 ,Chiu,2002 ; cited by Urban, 2010).

Likewise Sureshchandra et.al (2003) had identified 5 factors for service quality

from customers perspective which includes core services or service product, Human

element of service delivery, systemization of service delivery, tangibles of service,

social responsibility (Akbar & Parvez, 2009).According to Taner and Antony (2006)

SERVQUAL and Service quality gap model are the widely accepted tool in health

care setting (Taner and Antony (2006); cited by Jane Li & Ying Huang, 2011).

2.6.2.1 Advantages of SERVQUAL

According to Rohini and Mahadevappa (2006) the advantages of SERVQUAL

include (Rohini and Mahadevappa ,2006;cited by Padma et al., 2009).

1. The SERVQUAL instrument is used as a standard instrument for accessing

different dimension of Service Quality

2. The SERVQUAL instrument has shown its credibility for a number of service

situations

3. The SERVQUAL instrument has been reliable

4. The SERVQUAL instrument has a limited number of items so it can be easily

filled by customers and employers.

2.6.2.2 Criticism of SERVQUAL Model

SERVQUAL model has also drawn many criticisms, Cronin and Taylor (1992) and

Oliver (1993) had criticized SERVQUAL model for using attitudinal model in place of

disconfirmation model(Taylor (1992),Oliver (1993);cited by Padma et al.,

2009).Cronin and Taylor (1992) and Boulding et.al in (1993) had criticized

SERVQUAL model for conceptualization for service quality as gap between

perception and expectation(Cronin and Taylor (1992) , Boulding et.al in

(1993);Padma et al., 2009). Cronin and Taylor (1992) and Richard Allaway (1993)

had criticized for focusing only on functional quality rather than technical quality.

Babakus and Boller (1991) and Carman (1990) had criticises SERVQUAL for

number and structure and dimension, polarity of the scale and variance extracted in

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explaining service quality. Caraman had also criticised SERVQUAL for Item

composition, Ambiguity and usage of expectations battery, Moment of truth (Padma

et al., 2009).Sureshchandra et.al (2001) had criticised SERVQUAL for exclusion of

crucial factors such as core service, image, value, physical ambience, service

encounters. Caruana et,al (2000) had criticised it for the order effect of expectations

and perceptions (Sureshchandra et.al ,2001, Caruana et,al ,2000; cited by Padma

et al., 2009).According to Tan and Pawitra (2001) had argued that there is some

limitation to SERVQUAL method. They said that SERVQUAL assumes a linear

relationship between customer satisfactions and service attributes which can’t be

true at all the situations (Tan and Pawitra, 2001; cited by Yesilada, 2009).

SERVQUAL method was criticized for its applicability in other service industry.

Developing a list of service dimension required for an industry requires determining

factors that are required by the customers in that industry. As a result of criticism,

alternative measures of service quality for specific setting were developed. Knutson

et.al (1991) had developed LODGSERV a model used to measure the quality of

lodging industry. The model contains 5 original SERVQUAL dimensions and 26

items. Getty and Thompson (1994) introduced another specific model for hotel

setting called LODGQUAL model which has 3 dimensions namely tangible, reliability

and contact (Knutson et.al (1991), Getty and Thompson (1994); cited by Markovic &

Raspor, 2010).

In 1999 Wong Ooi Mei et.al developed a HOLSERV model which includes 27

items grouped in 5 original SERVQUAL dimensions. Steven Knutson and Patton

(1995) had developed DINESERV for measuring the service quality in restaurants. In

2000 O’Neil et.al had developed DIVEPERF model to measure the perception of

diving services.

Sower (2001) had developed eight dimension of Hospital service quality. It

includes respect and caring, the way in which the hospital staff interacts with the

patients. Effectiveness and continuity, transition from unit to unit or hospital to home

handling .Appropriateness, include the physical facility and staff professionalism

.Information, keeping patient and family members informed about the procedures.

Efficiency includes billing procedure. Meals include quality and efficiency of the meal

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service. The first impression includes the first contact with the hospital and Staff

diversity, Sower, V. (2011).

In (2003) Kahn had introduced ECOSERV it was used to utilize the service quality

expectation in ecotourism it uses 30 items and dimensions of SERVQUAL

Kahn,2003; cited by Markovic & Raspor, 2010).Kettinger and Lee (1994) had

identified 4 dimension in a study of information system quality and did not have a

tangible dimension. Cronin and Taylor (1992) had developed one factor

measurement instrument instead of 5 factor proposed by Parasuraman et.al (1988)

(Cronin and Taylor (1992), Kettinger and Lee (1994); cited by Akbar & Parvez,

2009). Ramsaran –Fowdar R. ( 2008) had proposed a modified SERVQUAL scale

for private healthcare PRIVHEALTHQUAL two more dimensions were added namely

core medical services and information dissemination (Ramsaran –Fowdar

R,(2008);Alrubaiee & Feras, 2011).

2.6.3 SERVPERF Model

Cronin and Taylor (1992) had argued “that performance is the measure that best

explains the customer’s perception of customer’s expectation so expectation should

not be included in the service quality measurement instrument”. They formed a

performance only scale called SERVPERF model (Cronin and Taylor (1992); cited

by Blery et al., 2011). Beside theoretical argument they provided empirical evidence

that SERVPF model is superior over SERVQUAL across 4 industries namely Bank,

Pest control, Dry clean and Fast food. SERVPERF model uses 22 questions and 5

dimensions of SERVEQUAL model but does not include expectation. Mazis et al,

Cronin and Taylor was on the point of view that because of its unweighted

measurement of performance it is a better method of measuring service quality. A

higher perceived performance implies higher service quality (Blery et al., 2011).

2.7 Patient satisfaction

Anderson and Suvillian (1993) had stated that increasing customer satisfaction is

vital for customer loyalty. According to Bolton (1998) service providers always seeks

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to manage and increase customer satisfaction (Wu & Wang, 2012).Patient

satisfaction is an important factor as it measures the quality of the medical service

offered. Customer satisfaction also gives the information of the provider’s success in

meeting the client’s expectation as they are the ultimate authority (Habbel, 2011).

According to Dimitriades in (2006) stated that satisfied customers tends to be less

influenced by competitors less price sensitive and they stay loyal longer. Customer

satisfaction has been considered as critical success factor in today’s competitive

business environment as they helps in retaining customers and maintaining market

share (Dimitriades, 2006;cited by Ooi et al., 2011)

According to Ware et.al in 1983, Moret et.al (2008) and Donahue et.al (2008)

patient satisfaction in medical care is an multi dimensional concept with dimensions

that corresponds to major characteristics of providers and services (Ware et.al in

1983, Moret et.al, 2008 and Donahue et.al, 2008; cited by Alhashem et al., 2011).

Likewise Donabedian (1980) had stated that informal assessment of satisfaction has

an important role in physician client interaction, since it can be used continuously by

the practitioner to monitor and guide that interaction and in the end how successful

the interaction was (Donabedian 1980; cited by Habbel, 2011).

However client satisfaction has some limitation as a measure of quality. Patients

generally have an incomplete understanding of the medical treatment in hospital.

Moreover the patient sometimes demand and expect thing that would be wrong for

the practitioner because they may be professionally or socially forbidden (Habbel,

2011).

Donabedian (1980) was in the point of view that these limitations will not lower the

validity of patient satisfaction as a measure of quality, but they are the best

representation of certain components of definition of quality, namely, client

expectation and valuation (Habbel, 2011).Mano and Oliver (1993) and Westbrook in

(1987) had stated that satisfaction is both cognitive and an affective evaluation of

service experience.

Armstrong and Kotler (1996) interpreted satisfaction as a feeling which results

from a process of evaluation what has been received against what was expected

including the purchase decision and needs and wants associated with the purchase

(Akbar & Armstrong and Kotler ,1996;cited by Parvez, 2009).Oliver (1997) is

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defined “customer satisfaction” as a “consumer’s fulfilment response”. (Oliver 1997;

cited by Wittmer et al., 2011). Kane et.al (1997) had said that customer satisfaction

is a complex concept that includes cognitive and affective components. He was of

the view that satisfaction is an “attitude response to value judgement that patients

make about their clinical encounter” (Kane et.al, 1997; cited by Alrubaiee & Feras,

2011).

Some researchers like Hogg and Gabbott (1998) had suggested that customer

satisfaction is an antecedent for service quality. Likewise Bitner (1990),Bolton and

Drew (1991), Parasuraman et.al (1988) was in the point of view that accumulation of

a satisfaction and dissatisfaction creates an overall assessment of service quality.

Eventhought satisfaction and service quality are considered to be two different

construct they are related (Sivakumar & Srinivasan, 2010).

In (1998) Gabbott & Hogg had acknowledged the work of Bitner and

Hubbert (1995) which distinguishes the different hierarchical level of satisfaction

which is related to quality judgement (Sivakumar & Srinivasan, 2010).

According to Moordian and Oliver (1997) satisfied customers can increase

the profitability by providing new referral through positive word of mouth. Brahme

2000-2001 was in the point of view that these satisfied customers act as unpaid

ambassadors of the service providers business (Moordian and Oliver,1997;cited by

Sivakumar & Srinivasan, 2010).Johnson et.al (2006) had described the basic

concept of satisfaction into transaction specific and cumulative. Transaction specific

is customer’s transient evaluation of a particular product or service experience and in

the other hand Cumulative satisfaction is the total consumption experience of the

product to the date (Johnson et.al 2006; cited byTuu & Olsen, 2012).

According to Hesselink and Wiele satisfaction is a positive affective state

resulting from the appraisal of all aspects of party’s working relationship with each

other (Akbar & Parvez, 2009).Zeithaml and Bitner (2003) had said that satisfaction is

customer’s evaluation of a product or a service in terms of whether that product or

service had met their needs and expectation. They had also said that “customer

satisfaction is a boarder concept.” (Zeithaml and Bitner ,2003; Akbar & Parvez,

2009).Pakdil and Harwood (2005) had said that “satisfaction is the most important

quality dimension and key success indicator in healthcare”. Zineldin in 2006 had

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defined satisfaction as ‘’an emotional response’’ (Pakdil and Harwood 2005; cited

byAlrubaiee & Feras, 2011). Piporas et.al (2008) had said that patient expectation

and perception are not simply related because medical or health service is not

technically comprehensive. So patient will not have a clear idea of expectation in the

clinical setting (Piporas et.al, 2008; cited by Alrubaiee & Feras, 2011).

Jackson et.al in 2001 (Alrubaiee & Feras, 2011) had stated that after

clinical visit the “patient satisfaction” is strongly influenced by the communication

between patient and doctor. Patient age and functional status also influences

“patient satisfaction”. According to them patient satisfaction can be used for four

purposes

a) “Compare different healthcare programmes”.

b) “To evaluate quality of care”.

c) “To identify the aspect of service needed”.

d) “To assist the organization to identify consumers”.

Parasuraman et al (1994) was in the point of view that greater

customer satisfaction will lead to positive customer behaviour such as repeated

purchases, positive word of mouth communication which will lead to increased

market share and increased profit margin of the company (Parasuraman et al, 1994;

Sainy, 2010).

2.8 Patient satisfaction and its Dimensions

According to Conway and Willcock (1997) cure is the fundamental expectation in

health care service. Linde- Peltz (1982) was in the point of view that patient

satisfaction is an evaluation of health care dimension. Tucker and Adams in (2001)

had stated that patient satisfaction is predicted by factors relating to caring, empathy,

reliability and responsiveness (Naidu, 2009).

Ware et.al (1978) had identified the factors such as physicians conduct, service

availability, continuity, confidence, efficiency and outcome. Fowdar (2005) had

included core service, customization, professional credibility, competence and

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communication. Woodside et .al in (1989) had included admission, discharge,

nursing care, food housing keeping and technical services (Naidu, 2009).

2.9 Theories of customer satisfaction

According to Expectancy-Disconfirmation theory by Oliver (1980)

customer purchases products and services with pre purchase expectation of

anticipated performance. Once the product or service is used the outcome is

compared against the expectation. When outcome matches expectation confirmation

occurs. Disconfirmation occurs when there is a difference between outcome and

expectation .Satisfaction is caused by confirmation or positive disconfirmation of

expectation and dissatisfaction is caused by negative disconfirmation of consumer

expectation (Oliver, 1980; cited byPadma et al., 2010).

According to Personal Control Theory proposed by Rotter (1969) satisfaction

with one’s life experience or job is related to person’s perception of psychological

covariance between their actions and desired outcomes (Rotter, 1969; cited by

Padma et al., 2010).

According to Boulding et.al (1993) and Oliver (1993), in transaction specific model

customer relation has been modelled as function of psychological constructs such as

attitude, expectation and disconfirmation. Whereas Gustaffson and Johnson (2004)

had proposed cumulative satisfaction model in which the benefit is derived from the

product or service attributes form the primary antecedent to satisfaction (Boulding

et.al, 1993, Oliver, 1993 Gustaffson and Johnson, 2004; cited byPadma et al., 2010).

2.10 Measuring customer satisfaction

Measuring customer satisfaction is an extremely difficult challenge given to the

changing healthcare industry. Evenhaim (2000) had said that measuring customer

satisfaction is important for programme planning, identifying patient concern, quality

improvement as well as customer relationship management and strategic planning

initiatives. Ford et.al (1997) had said that healthcare staff should measure patient

satisfaction in order to identify the patient related service problems and come with

solutions to improve patient satisfaction.

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According to Ford et.al (1997), the commonly used qualitative and

qualitative instruments to measure satisfaction may vary substantially in cost,

accuracy, generalizability and convenience. (York & McCarthy, 2011).

2.11Patient Loyalty

According to Woodruff (1997) customer loyalty is considered as an important

source of competitive advantage (Woodruff, 1997; cited by Wang & Wu,

2012).Patient loyalty is the surrogate of customer satisfaction and service quality

measures as understanding these measures are the first step in improving a patient

provider relationship. Customer loyalty can be described as customer’s willingness to

continue to do business with a firm over long term by purchasing and using its goods

and services repeatedly and recommending the firms product and services to friends

and relatives. It is more expensive to win a new customer than retaining an existing

customer. The net return of investment for company would be higher on retention

strategies than investing in attracting new customers (Blery et al., 2011).

John and Sasser defined “customer loyalty” as the “feeling of attachment

to or affection for the company’s people, product or service” (Blery et al., 2011).

According to Hallowell,R (1996) “customer loyalty” can be defined as “attitude

loyalty” and “behavioural loyalty” . “Attitude loyalty is customer’s affection for the

product or service willingness to recommend the service and behavioural loyalty is

the customer’s intention to repurchase” (Hallowell,R ,1996; Blery et al., 2011).

According to Pearson (1996) “customer loyalty is a mindset of

customers who hold a favourable attitude to the company, shows intention to

repurchase the products and recommend the product service to others”. Oliver

(1981) had argued that customer first becomes loyal in a cognitive sense when the

consumer belief in one brand and is preferred than its alternatives because of the

knowledge or information of the brand attributes. The second stage is affective

loyalty where the consumer develops a liking and good attitude for the brand based

on cumulative satisfying usage occasionally. At the third stage is Conative loyalty

where the customer is committed to rebuying the same product it is due to

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behavioural intention. This leads to action loyalty where the consumer exhibits

consistent repurchase behaviour (Oliver, 1981; cited by Sainy, 2010).

2.12 Importance of Customer Loyalty.

Reichheld (1996) and Soderland M (1998) was on the view that high level of

customer loyalty increases a firms profit through different ways like lower marketing

cost, ability to charge a premium price, increased customer referral and lower

operating cost (Reichheld, 1996,Soderland M,1998;cited by Sainy, 2010).It is more

expensive for the organisations to attract to customers. Research done by Peterson

and Barnes (1995) shows that long term relationship of both customers and the firm

should have mutual benefits (Peterson and Barnes, 1995; cited by Blery et al.,

2011). The customer benefits according to the researchers are presented in the

Table below:

Table 2.2 Customer benefits

Barlow, 1992 Social benefit associated with personal

recognition from employees

Barnes, 1994 Social Benefits include familiarity, personal

recognition, social support

Bitner, 1995 Confidence benefits, faith in the

trustworthiness of the service provider.

Shetha & Parvitar,

1995

reduction of choices by engaging in an ongoing

loyalty programme by the marketers

Berry, 1995 Risk reduction

Kemperer,1987 Economic advantage like treatment benefits

Peterson,1995 Special pricing consideration

Rosenblatt,1977 Freedom from having to make decision.

Zeithmal,1981 Providers gain knowledge of consumers taste

and this ensures better treatment.

Author (2012)

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2.13 Measurement of Patient loyalty

According to Peltier et.al (1999) patient loyalty can be measured by

(Peltier et.al (1999); cited by Chahal, 2008) . The figure below shows the 3

factors lead to patient loyalty

a) “Using provider again for same treatment” (UPAS),

b) “Using same provider for different treatment” (UPAD),

c) “Referring providers for others” (RPO).

Figure 2.2 Measurement of patient Loyalty

(Chahal, 2008)

a) “Using provider again for same treatment (UPAS)

Using the provider again for the same treatment

expresses the willingness of reusing the same healthcare

provider for previously received service. The level of

patient satisfaction and perceived service quality

influenced the patient’s willingness to reuse the same

healthcare facility

b) “Using same provider for different treatment (UPAD)

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Visiting the same unit for different treatment is considered

to be the second long term measure of patient loyalty

c) Referring providers for others (RPO)

This is the strongest measure of patient loyalty as they

are associated with positive referral from existing patients

and it is based on their personal experience .

The patient loyalty concept used above fig 2.2 signify the perception of care

received by patient during their hospital care, the perceived care received by the

staff later on as well as the overall impression and intention to recommend the

facility. In other words the patient develops loyalty towards a hospital is based upon

the interpersonal experience that they had during the interaction with the doctor,

nursing staff and the operation quality of the hospital. According to Ostwald et.al

(1998) the patient uses the associated facility and human factor to gauge the quality

of hospital service and influence of customer satisfaction. The fig 2.3 below reflects

that the physician performance, nursing performance, operational performance and

overall service quality supplement the patient loyalty to measure to have a better

insight of process (Ostwald et.al (1998); cited by Chahal, 2008)

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Figure 2.3 Patient loyalty and service quality model

(Chahal, 2008)

2.14 Service Quality and Customer Satisfaction relationship

Sureshchandra et.al (2003) had identified that a strong relationship

exist between “service quality” and “customer satisfaction” while emphasizing that

“these two are made of different conceptual constructs in customer’s point of view”.

(Sureshchandra et.al, 2003; cited by Akbar & Parvez, 2009)

Spreng and Mckoy (1996) had said that “service quality leads to

customer satisfaction”. Thus the researcher can argue “that perceived service quality

has a positive effect on Customer satisfaction”. (Spreng and Mckoy,1996;cited by

Akbar & Parvez, 2009)

2.15 Service quality and customer loyalty relationship

Boulding et.al (1993) had conducted various “research on the relationship

between service quality and customer loyalty”. Boulding et.al in 1993 had done a

research on “elements of repurchasing as well as willingness to recommend “and his

study was able to establish a “positive relation between service quality and

repurchase intention and willingness to recommend”. Thus the researcher can argue

that there is a positive relation between service quality and customer loyalty since

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repurchase intention and recommendations forms the basis of customer loyalty.

(Akbar & Parvez, 2009)

2.16 Customer satisfaction and Customer loyalty relationship

Numerous studies done by various researchers like Andreson & Suvllivan

in 1993, Bolton& Drew 1991, Fronell in 1992 had found a “positive correlation

between customer satisfaction and customer loyalty”. Similarly studies in service

sector by Anderson & Suvillian 1993,Bansal & Taylor in 1999 ,Cronin & Taylor in

2000 had also “empirically validated the relationship between customer satisfaction

and customer loyalty”. Hart and Johnson in 1999 had stated that “true customer

loyalty is total satisfaction”. Thus the researcher can argue that customer satisfaction

has a positive effect on customer loyalty. (Akbar & Parvez, 2009)

2.17 Relation between service quality and patient satisfaction

Relationship Between Service Quality, Customer Satisfaction & Customer Loyalty

Figure 2.4 (Mengi, 2009)

Thus the researcher can argue that Service quality is a focussed evaluation

of “customer’s perspective of reliability, responsiveness, assurance, empathy and

tangibles”. “Customer satisfaction is influenced by perceived service quality, product

quality, price along with personal and situational factors”. The customer loyalty is

influenced by both service quality and customer satisfaction. The fig 2.4 shows the

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relation between “the customer perception of service quality, customer satisfaction

and customer loyalty” and their interrelationship.

2.18 Conclusion

Service quality is an important determinant factor that is considered in meeting the

client’s expectation. Service quality is of prime importance because it is in the hand

of the service providers. Studies have been shown that service quality plays an

important role in customer satisfaction and there is a relation between customer

satisfaction service quality and patient loyalty each customer has their own

perceived perceptions for service quality. In healthcare sector the perceptions of the

patients will always cannot be taken in to account as they lacks the knowledge of

the technical aspects of the hospital.

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Chapter 3

Research Methodology 3.1Introduction

The author begins the chapter by restating the research aims and

objectives then the author discusses about the research philosophy, then he talks

about research strategy research approach and about data collection and then

moves on to discusses about the sample size of the research the sampling

technique to be adopted and finally concludes the chapter




India.








3.3 Research Methodology

According to Burns (1997) research can be defined as a systematic investigation

to find a solution for a problem (Burn,1997: cited by Kumar, 2011). Saunders et.al

(2007) stated that “research process is a series of linked stages and gives the

appearance of being organized in a linear manner” (Saunders et al., 2007).

Dr.C.Rajendra Kumar (2008) was on the point of view that “research methodology is

a way to systematically solve the research problem” (Kumar, 2008).

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3.4 Research Design

“Research Design” is the general plan how research will be done. Saunders

et.al in 2007 had classified the research in to six stages and labelled them as

research onion in fig 3.1. They had divided research into philosophies, approach,

strategy, choices, time horizon, technique and procedure. Saunders “research onion

is the way of exhibits the issue underlying your choice of data collection method or

methods and peeled away the outer two layers the research philosophy and

research choice.” (Saunders et al., 2009). “Research Philosophies”, “Research” and

“time horizon” guide the researcher to “desired process of Research Design”.

“Research Philosophies” and “Research Design” helps to answer the “research

question”. “Research Strategy” depends upon “research topic”, “data collection”,

“analysis” and “time factors”. “Research design” can be classified as “Exploratory”,

“Descriptive” and “Explanatory”.

Figure 3.1 Research onion

(Saunders et al., 2009)

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3.4.1 Exploratory research

It is an attempt to have an develop an initial understanding of the new

phenomenon (Babbie, 2010).The difference between the different research is given

in table 3.1.

3.4.2Descriptive Research

It is the precise measurement and reporting of characteristics of some

population or phenomenon .It also involves analysing the existing data (Babbie,

2010) .The

3.4.3Explanatory Research

It is a study which involves establishing a cause effect relationship between

different aspects of phenomenon under study (Babbie, 2010).

Types of Research Design

Table 3.1 (Saunders et al., 2009)

3.4.4 Justification for this research design

The researcher had used “explanatory design” to because the researcher is trying to

trying to find the relationship between the different aspects of phenomenon of study.

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3.5 Research Philosophy”

“Research Philosophy contains important assumptions, in which research will be

conducted”. It forms the basics of research strategy and is influenced by practical

consideration.

3.5.1Epistemology

In this the researcher has a role of a scientist and resources are selected objectively.

Epistemology refers to the nature of the knowledge in the way we conceive our

surrounding Epistemology is of three types Positivism, Realism, Interpretism.

3.5.2 Positivism

If we intent to adopt an approach similar to natural scientist then our approach is

positivist. In positivism theory is explored to develop a hypothesis. It’s a value free

research observations which are quantifiable and statistical analysis can be carried

out (Wilson, 2010). If we are following a positive approach for our study then we

believe that we are independent of our research and is truly objective. Positivists are

in the point of view that the research should be done in a scientific manner. It is an

empirical research which is done under strict guidelines of polices by trained

scientist. The research is usually carried out in a deductive approach moving from

theory to observation. In general positivist wants their findings to be applicable to the

whole of the population (Wilson, 2010).

3.5.3 Realism

It is a scientific approach to the development of knowledge which is similar to

positivism

Realism is truth and is divided in to

1. Direct realism In direct realism researcher does just observations and

recording of what we experience through our senses.

2. Critical realism the researcher sees the entire research as a part of bigger

picture..

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Critical realism the researcher can experience the world in two

ways. First one is the thing by itself and the sensation it conveys and the second

is the mental processing that goes on sometimes after sensation meets our

senses. On the other hand Direct realism says that only first step is enough

(Saunders et al., 2009).

3.5.4 Interpretivism

In this research the researcher take an active role in carrying out research. This type

of research the emphasises the need for conducting research on people rather than

on objects. The researcher looks in to a particular subject in depth. The purpose of

the research is not to generalise but to actively engage in high level of participation

and interactions (Wilson, 2010).

Interpretivism comes from two intellectual traditions

1. Phenomenology: - We can make sense about the world around us.

2. Symbolic Interactions: - We are continuously Interpreting other actions and

making new meaning by combining our views and their action (Saunders et

al., 2009).

3.5.5 Ontology

It deals with that which is at least in principle that can be categorised. Ontology is

that which can be rationally understood or at least partially (Poli, 2010).Ontology is

concerned with the nature of reality (Saunders et al., 2009).

It is divided into subjectivism and objectivism

3.5.5.1 Subjectivism

In subjectivism here is a continuous interaction with constantly changing world

3.5.5.2 Objectivism

In objectivism everything has its own identity

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3.5.6 Axiology

Axiology is that which studies the judgement of the value. It is a more credible form

of research. Philosophy is based on the value of researches with respect to data

collected. if we want our research to be credible we have to uphold our values in

each stage of research process. (Saunders et al., 2009).

3.5.7Justification of research philosophy

The researcher had adopted positivist approach because it does not emphasise on

human interest and aims to analyse quantitative data in a statistical analysis.

3.6 Research Approach

According to Saunders in 2007 there are “two approaches deductive and

inductive”.

In deductive approach a hypothesis are developed and research strategy is

designed to test the hypothesis. Table 3.2 shows that deductive approach is a highly

structured approach. In this the researcher is independent of what is being

researched. In deductive approach it explains the relationship between different

variables. There is a collection of quantitative data.

While in “inductive approach” “data are collected and theory is developed as a result

of data analysis” (Saunders et al., 2009). Table 3.2 shows that inductive approach

involves understanding the human attach to the event. There is a collection of

qualitative data. The researcher is the part of the research process.

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Research Approach

Table 3.2 (Saunders et al., 2009)

3.6.1 Justification Of research approach

The researcher will be adopting a deductive approach because of the

Positivist research philosophy. It also relies on prior conceptual and theoretical

framework covered by a large number of quantitative data. It also tests the existing

theory where the findings can be generalised.

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3.7 Research strategy.

Is study method used to gather the data which can be divided in to:-

3.7.1Quantitative data

It emphasizes the production of generalized and precise statistical finding.

Qualitative Data is used when we want to verify whether a cause produces an effect

(Rubin & Babbie, 2011).

3.7.2 Qualitative data

The first challenge faced by the researchers is to select the best qualitative

method to answer the research question. The qualitative method had developed

from a philosophical perspective each of which had developed the influence of

associated methodology (Issel, 2009). In qualitative data we are we get the inner

meanings of humans through observation which are intended to gen theoretical

observation and are not easily reduced to numbers. (Rubin & Babbie, 2011).

3.7.3 Justification of Research Strategy

The researcher had chosen quantitative research strategy. The researcher will

be using questionnaires .The researcher will be testing the hypothesis and the theory

with data. Qualitative researchers consider prime importance to state hypothesis and

test the hypothesis with the data to see if they are supported.

3.8 Source of Data

We can divide the data as archival data or secondary data which already exist

in some forms e.g. pay rolls and Primary data which have to be collected in the due

course of the research (Burt et al., 2009)

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Fig 3.2 Source of data

(Burt et al., 2009).

3.8.1 Primary Data

“Primary Data” are those data fig 3.3 which have do be collected in the due

course of research. They can be collected by different ways by observation,

questionnaire, personal interview, telephonic interview. Primary data can be

collected either by quantitative research or qualitative research.

Quantitative technique includes survey, observation and experiments

and Qualitative technique includes in depth interview, Projective technique and focus

group. (Wiid & Diggines, 2009).It is illustrated in the diagram below.

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Fig 3.3 Primary Data

(Wiid & Diggines, 2009)

3.8.2 Justification of “Primary Data”

The research will be carried out by distributing questionnaire. They will be

formulated in a semi structured method so that the respondent can give more

information.

3.8.3 Secondary Data

Secondary Data are those which already exists that had been gathered for a

previous studies (Churchill Jr & Iacobucci, 2010).

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3.8.4 Types of Secondary Data.

“Secondary data” can be classified in to several types most important one

is internal data those found within an organisation .External data can be again

divided into that are regularly published and we get the information for free for

example, census report, statics and that are published by different commercial

organisations and sells the information eg AC Neilson (Churchill Jr & Iacobucci,

2010).

Figure 3.4 Secondary Data

(Churchill Jr & Iacobucci, 2010)

3.8.5 Justification for secondary Data

Secondary data will be collected from the

Hospitals website since the website will be biased the researcher will also collect

data from government statistics, newspaper articles, journals and books.

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3.9 Sampling

“Sample is a subset of a population” (Lohr, 2010). “Sampling techniques” are of two

types :-

3.9.1Probability Sampling or Representative sampling

With “probability sample the chance, or probability, of each case being

selected from the population is known and is usually equal for all cases”. (Saunders

et al., 2009).

3.9.2 Non Probability Sampling or Judgemental Sampling

For a “non Probability sampling the probability of each case

being selected for total population is not known and it is impossible to answer the

research question or address the research objectives that require statistical

interference about the characters of the population” (Saunders et al., 2009).

3.9.3 Justification of sampling

The researcher will be using probability sampling. The researcher had used simple

random sampling the research. The researcher will be distributing 500

questionnaires to the patient of the hospital.

3.10 Conclusion

This chapter discusses about the primary research of the research method. The

author had adopted explanatory research as research design in the light of this he

had adopted deductive approach and positivism as research philosophy. Books

journals and the hospital website will be used for secondary research and primary

data will be collected by distributing questionnaires to 500 patients. Simple random

sampling of Probability sampling will be uses as sampling technique.

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Chapter 4

Research Findings and Analysis

4.1Introduction

In this chapter the author had stated by restating the aims and objectives .Next the

author will be analysing the questionnaires that he had distributed in the hospital.

The author had distributed 500 questionnaires in the TMC hospital and had a total

respondent of 291. The respondents were selected using simple random probability

sampling and the data were analyses quantitatively using Chi square test .Rho test

was done to analyse the factors for patient satisfaction.




India.








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4.3 Analysis of questionnaire

The author had distributed 500 questionnaires and had only found 291

questionnaires useful for the research of this sample size 52% were males

and 48% respondents were female

Q1. About you and age

Chart 4.1:- Distribution of sample size according to age and sex.

Author (2012)

From the Table 4.1 (appendix 1) it is clear that the total distribution of sample

population of the family is 291; among this the male representation is 152 (52%) and

female representation is 139 (49%). The Chart 4.1 illustrates that the highest

representation is included in the range 50-65 age group where male’s form 27.63%

and 20.86 % of females were considered.

The obtained chi-square value shows that there is no significant association in the

distribution of sample for age and sex group of patients in the hospital . It means that

the difference in the distribution of sample age and sex from the hospital is not

significant, independent and not associated to each other.

14.47 13.15

23.8

27.63

21.05

10.79

23.02

19.42 20.86

25.89

0

5

10

15

20

25

30

<25 Age 25-‐40 Age 40-‐50 Age 50-‐65 Age >65 Age

Males % Females %

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Q.2. Are you employed.

The ratio of earners to non-earning dependents indicates to the work participation

ratio and the division of the society into productive and unproductive members. The

work participation rate at younger age is comparatively low in the sample.

The Table 4.2 (appendix 1) shows that there are 133 earners in a total of

291 members and thus, the ratio of earners to non-earning dependents is 0.841:1.

The proportion of earners to total members is only 45.70%, which leads to a higher

dependency ratio. The lower work participation rate of the younger age groups and

that of women and the higher proportion of people above 65 probably explain the

higher dependency ratio. In the three areas, not much of difference is noted in these

ratios. A very high ratio shows that the number of earning members and dependents

are related.

Q3. Why did you choose the hospital?

Chart 4.2 :- The reason for choosing the hospital

Author(2012)

As per Table 4.3 (appendix), affordable cost was the key reason for choosing

the hospital raised by patients, whereas for meeting consultants was the next reason

opined by the patients for their reason for selecting this hospital. The chart 4.2

30.26

18.42

25

16.44

9.86

36.69

19.42 23.74

15.1

5.03

0

5

10

15

20

25

30

35

40

Cost Gp Consultant Refferals Previous visit

Males Females

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illustrates that 30.26% of males and 36.69% of females of the total 91 respondents

had selected the hospital due to affordable cost. Followed to this, GP was the

reason cited by the patients for their interest shown to this hospital for the treatment.

From the Table 4.3 (appendix 1), it can also be seen that the chi-square value

(3.31) obtained is not significant at 0.05 level. For the various factors of selecting the

hospital. i.e., there is an independent association among the reasons and gender

wise classifications.

Q4.The receptionist was friendly and courteous?

Chart 4.3:- The receptionist was friendly and courteous

Author (2012)

The Table 4.4 (appendix) & chart 4.3 shows that 80 patients (24.34% males &

30.93% females) as the status “strongly agree”, for the question receptionist was

friendly and courteous.

From the Table 4.4(Appendix), it can also be seen that the chi-square value

(28.37) shows that there is significant association in the distribution of sample and

gender wise group of patients in the hospital. i.e. It means that the difference in the

24.34

27.63

15.13 17.6

15.13

30.93

26.61

18.7

15.1

8.63

0

5

10

15

20

25

30

35

Strongly Agree Agree Neutral Strongly Disagree Disagree

Males % Females %

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opinion about the receptionist for the attitude of friendly and courteous and gender

wise group of patients in the hospital significant and associated to each other.

Q5. The staff treated you with respect, dignity and was courteous in the hospital?

Chart 4.4:- The staffs treated you with respect, dignity and were courteous in the

hospital?

Author(2012)

From the Table 4.5 (appendix 1) and Chart 4.4 it is It is interesting to

note that 70 patients 22.36% males and 25.89% females) have observed that the

status “strongly disagree” about the discipline of the staff in the hospital.

From the table 4.5(appendix1) , chart 4.4 it can also be seen that the chi-square

value (4.47) obtained is not significant at 0.05 level shows that there is no significant

association in the distribution of sample for the opinion about the discipline of the

staff in the hospital and gender wise group of patients in the hospital. It means that

the difference in the opinion about the discipline of the staff in the hospital and

gender wise group of patients in the hospital is not significant and not associated to

each other. This shows that the staffs are not treating the patients with care and

respect.

19.07

22.36

15.13

21.05 22.36

10.79

23.02

19.42 20.86

25.89

0

5

10

15

20

25

30

Strongly Agree Agree Neutral Strongly Dis agree Disagree

Males % Females %

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Q6. There is a lot of paper work for admission?

Chart 4.5 There is a lot of paper work for admission.

Author (2012)

From the Table 4.6 (appendix) and Chart 4.5 it is clear that the opinion about the 57

patients (18.42% males and 20.86% females) have observed it as the status “no

opinion”. It is interesting to note that 65 patients (20.39% males and 24.46%

females) have observed that the status “disagree” about the paper work for

administration in the hospital.

From the Table 4.6, it can also be seen that the chi-square value (2.79)

obtained is not significant association in the distribution of sample for the opinion

about the paper work for administration in the hospital and gender wise group of

patients in the hospital. It means that the difference in the opinion about the paper

work for administration in the hospital and gender wise group of patients in the

hospital is not significant and not associated to each other. This shows that paper

work for the admission to the hospital consumes much time, what others can

tolerate.

23.68

15.13

18.42 20.39

22.36 20.14

17.98

20.86

24.46

16.54

0

5

10

15

20

25

30

Strongly Agree Agree Neutral Disagree Strongly Disagree

Males % Females %

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Q7 The service cost of hospital is affordable?

Chart 4.6 :- The service cost of hospital is affordable

Author (2012)

From the Table 4.7 (appendix1) and Chart 4.6 it is clear that the opinion about the

paper work for administration in the hospital is supported by 83 patients (30.92%

males and 25.89% females) as the status “strongly agree”, where as the status

“agree’ is supported by 73 respondents (25% males and 25.17% females) out of the

total respondents of 291 patients. 50 patients (17.76% males and 16.54% females)

have observed it as the status “no opinion”.

From the table4.7 (appendix1), it can also be seen that the chi-square value

(3.20) shows that there is no significant association in the distribution of sample for

the opinion about the affordability of service cost and gender wise group of patients

in the hospital. It means that the difference in the opinion about the affordability of

service cost in the hospital and gender wise group of patients in the hospital is not

significant and not associated to each other.

30.92

25

17.76 16.44

9.86

25.89 25.17

16.54 15.82 16.54

0

5

10

15

20

25

30

35

Strongly Agree Agree Neutal Disagree Strongly Disagree

Males % Females %

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Q8. All Staff were in correct uniform?

Chart 4.7 All Staff were in correct uniform

Author (2012)

From the Table 4.8 (appendix) and Chart 4.7 it is clear that the opinion

about the employees towards neatness in the hospital is supported by 82 patients

(28.89% males and 28.09% females) as the status “strongly agree”, where as the

status “agree’ is supported by 69 respondents (15.13% males and 17.98% females)

out of the total respondents of 291 patients. 43 patients (18.42%males and 20.86%

females) have observed it as the status “no opinion”.

From the Table4.8 (appendix 1), it can also be seen that the chi-square value


the opinion about the employees towards neatness and gender wise group of

patients in the hospital. It means that the difference in the opinion about the staff

wearing the correct uniform and gender wise group of patients in the hospital is not

significant and not associated to each other. Most of the patients were not satisfied

with the staff because they were not wearing proper uniform

23.68

15.13

18.42 20.39

22.36 20.14

17.98

20.86

24.46

16.54

0

5

10

15

20

25

30

Strongly Agree Agree No OpLon Disagree Strongly Disagree

Males % Females %

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Q9 The hospital is visually attractive?

Chart 4.8 The hospital is visually attractive

Author (2012)

From the Table 4.9 (appendix 1) and Chart 4.8 it is clear that the opinion about the

hospital towards attractiveness and comfortable physical facilities is supported by 81

patients (27.63 % males and 28.05% females) as the status “strongly agree”, where

as the status “agree’ is supported by 68 respondents (23.68% males and 23.02%

females) out of the total respondents of 291 patients. 50 patients have observed it

as the status “no opinion”(13.78% males and 18.07% females)

From the Table 4.9 (appendix 1), it can also be seen that the chi-square value


the opinion about the hospital towards attractiveness and comfortable physical

facilities and gender wise group of patients in the hospital. It means that the

difference in the opinion about the hospital towards attractiveness and comfortable

physical facilities and gender wise group of patients is not significant and not

associated to each other. This shows that the patients have a general complaint

towards the attractiveness of the hospital

27.63

23.68

13.78

17.76

15.13

28.05

23.02

18.07 16.54

13.66

0

5

10

15

20

25

30

Strongly Agree Agree Neutral Strongly Disagree Disagree

Males % Females %

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Q10. Is the hospital in a convenient location?

Chart 4.9 Is the hospital in a convenient location

Author (2012)

From the Table 4.10 (appendix1) and Chart 4.9 it is clear that the opinion about the

location of the hospital is supported only by 51 patients (19.07% males & 15.82%

females) as the status “strongly agree”, where as the status “agree’ is supported by

53 respondents(17.10% males & 19.42% females) out of the total respondents of

291 patients. 48 patients (15.13% males & 19.98% females) have observed it as the

status “no opinion”. It is interesting to note that 72 patients (25% males & 17.98%

females) have observed that the status “strongly disagree “about the fact that

hospital is not in a convenient location.

From the Table 4.10 (appendix1), it can also be seen that the chi-square value

(37.86) shows that there is significant association in the distribution of sample for the

opinion about the location of the hospital and gender wise group of patients in the

hospital. It means that the difference in the opinion about the location of the hospital

and gender wise group of patients in the hospital is significant and associated to

19.07 17.1

15.13

23.68 25

15.82

19.42 17.98

22.3 24.46

0

5

10

15

20

25

30

Strongly Agree Agree No opinion Disagree Strongly Disagree

Males %

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each other. The analysis of the findings shows that the hospital is in a convenient

location and it is a favourable factor in attracting patients.

11. Does the hospital have good directional signs?

Chart 4.10 Does the hospital have good directional signs

Author (2012)

From the Table 4.11 (appendix1) and Chart 4.10 it is clear that the

opinion about the directional signs in the hospital is supported by 60 patients as the

status “strongly agree” (20.39 %males and 20.86% females), where as the status

“agree’ is supported by 53 respondents(17.1 % males and 19.42% females) out of

the total respondents of 291 patients. 61 patients (19.07% males and 23.02%

females) have observed it as the status “no opinion”.



the opinion about the directional signs in the hospital and gender wise group of

patients in the hospital. It means that the difference in the opinion about the

directional signs in the hospital and gender wise group of patients is not significant

and not associated to each other. The analysis of the findings shows that the

expectations of the management for the well being of the patients are not strictly

adhere in the hospital

20.39

17.1 19.07

21.05 22.36

20.86 19.42

23.02

17.26 19.42

0

5

10

15

20

25


Males % Female %

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Q 12. Does the hospital provide services at the allocated time?

Chart 4.11 Does the hospital provide services at the allocated time

Author (2012)

From the Table 14.12 (appendix1) and Chart 14.11 .It is interesting to note that 78

patients (27.63% males and 25.89% females) have observed that the status

“strongly disagree” about the timely service at the time of appointment.

From the Table 14.12 (appendix1) it can also be seen that the chi-square

value (0.19) there is no significant association in the distribution of sample for the

opinion about the timely service at the time of appointment and gender wise group of

patients in the hospital. It means that the difference in the opinion about the timely

service at the time of appointment in the hospital and gender wise group of patients

is not significant and not associated. The analysis of the findings shows that the patients cannot expect a timely service from the hospital at the time of appointment.

15.13

17.76 15.78

23.68

27.63

14.38

18.7 16.54

24.46 25.89

0

5

10

15

20

25

30


Males % Females %

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Q13 The department is working effectively?

Chart 4.12 The department is working effectively

Author (2012)

From the Table 4.13(appendix1) and chart 4.12 it is clear that the opinion about the

sufficient staff in the hospital is supported by 82 patients (28.28% males and 28.05%


65 respondents (22.36%males and 22.3% females) out of the total respondents of

291 patients. 52 patients (16.44% males and 19.42% females) have observed it as

the status “no opinion”.

From the Table 4.13 (appendix1), it can also be seen that the chi-square

value (0.53) shows that there is no significant association in the distribution of

sample for the opinion about the sufficient staff in the hospital and gender wise group

of patients in the hospital. It means that the difference in the opinion about the

28.28

22.36

16.44 17.76

15.13

28.05

22.3

19.42

16.54

13.66

0

5

10

15

20

25

30


Males % Females %

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sufficient staff in the hospital and gender wise group of patients is not significant and

not associated. The analysis of the data points out that the department in the

hospital is not running effectively.

Q14You felt ease during your appointment?

Chart 4.13: You felt ease during your appointment

Author 2012

From the findings of Table4.14 (appendix1) and Chart 4.13 that the that you felt ease

during the appointment only by 54 patients (20.15% males and 15.82 % females) as

the status “strongly agree”, where as the status “agree’’ is supported by 60

respondents(20.39% males and 20.86% Females) out of the total respondents of

291 patients. 61 patients (23.68% Males and 17.98% Females) have observed it as

the status “no opinion”.

From the Table4.14 (appendix1), it can also be seen that the chi-square value


the opinion about feeling ease and gender wise group of patients in the hospital. It

means that the difference in the opinion about the nursing staff with regard the

21.05 20.39

23.68

17.76 17.1 15.82

20.86

17.98

20.83

24.46

0

5

10

15

20

25

30

Strongly Agree Agree Neutral Agree Strongly Agree

Males % Females %

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capacity to inspire trust and confidence among the patient and gender wise group

of patients is not significant and not associated.

Q15 Doctors listen carefully and adhered to your needs?

Chart 4.14 Doctors listen carefully and adhered to your needs

Author (2012)

From the Table 4.15 (appendix1) and chart 4.14. It is interesting to note that 72

patients (24.34%males and 24.46%females) have observed that the status “strongly

disagree” about the attitude of doctors as to willingness to listen carefully and help

patients.

From the Table 4.15 (appendix1), it can also be seen that the chi-square

value (0.06) shows that there is no significant association in the distribution of

sample for the opinion about the timely service at the time of appointment and

gender wise group of patients in the hospital. This shows that the relationship of

doctors and patients are not cordial to each other and doctors simply treat patients

just for the reward namely “fees”.

14.47 16.44

21.05 23.68 24.34

13.66

16.54

20.86

23.74 24.46

0

5

10

15

20

25

30


Males % Females %

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Q 16 Do you think the hospital address the patient complaint quickly?

Chart 4.15 Hospital address the patient complaint quickly

Author(2012)

From the Table 4.16 (appendix) & chart 4.15 it is clear that the hospital in addressing

the patient’s complaint quickly is supported only by 45 patients (17.1% Males and

13.66 % Females) as the status “strongly agree”, where as the status “agree’ is

supported by 51 respondents (16.44% male and 18.7% females) out of the total

respondents of 291 patients. 61 patients (22.36% males and 19.42 % females) have

observed it as the status “no opinion”. It is interesting to note that 73 patients(25.65

% males and 24.46% females) have observed that the status “strongly disagree”

about the procedure in addressing the patient complaint quickly.

17.1 16.44

22.36

18.42

25.65

13.66

18.7 19.42

23.74 24.46

0

5

10

15

20

25

30


Males % Females %

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From the Table 4.16 (appendix) , it can also be seen that the chi-square value

(2.08) value shows that there is no significant association in the distribution of

sample for the opinion about the hospital in addressing the patient’s complaint

quickly and gender wise group of patients in the hospital. It means that the difference

in the opinion about the hospital in addressing the patient’s complaint quickly and

gender wise group of patients is not significant and not associated.

Q.17 Do you think the staff responded immediately when called?

Chart 4.16 Do you think the staff responded immediately on call

Author (2012)

From the Table 4.17 (Appendix), Chart 4.16 it is clear that the response of the

staff when called is supported only by 63 patients (21.05% males and 22.3%


65 respondents (21.71% males and 23.02% females) out of the total respondents of

291 patients. 55 patients (18.42% males and 19.42% females) have observed it as

the status “no opinion”. It is interesting to note that 63 patients (20.39% males and

23.02% females) have observed that the status “disagree” about the swift response

of the staff when called and help patients.

21.05 21.71

18.42 20.39

18.42

22.3 23.02

19.42

23.02

12.23

0

5

10

15

20

25


Males % Females %

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From the Table 4.17 (Appendix), it can also be seen that the chi-square value


sample for the opinion about the swift response of the staff when called and gender

wise group of patients in the hospital. i.e., there is an independent association

among the distribution of opinion about the swift response of the staff when called

and gender wise group of patients in the hospital they belong. This shows that

attitude of the staff for swift response when called is not supported by the patients.

Q 18 Do you think that the hospital employees are sympathetic and reassuring?

Chart 4.17 Hospital employees are sympathetic and reassuring

Author(2012)

From the Table 4.18 (appendix) and Chart 4.17 it is clear that the sympathetic

and reassuring attitude of the employees is supported only by 47 patients(15.78%

males and 16.54% females) as the status “strongly agree”, where as the status

“agree’ is supported by 58 respondents(20.39% males and 19.42%females) out of

the total respondents of 291 patients. 54 patients(19.07% males and

17.98%females) have observed it as the status “no opinion”. It is interesting to note

15.78

20.39 19.07

21.71 23.02

16.54

19.42 17.98

22.3 23.74

0

5

10

15

20

25


Males % Females %

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that 68 patients (23.02% males and 23.74% females) have observed that the status

“strongly disagree” about the sympathetic and reassuring attitude of the employees.

From the Table 4.18 (appendix), it can also be seen that the chi-square value


sample for the opinion about the sympathetic and reassuring attitude of the

employees and gender wise group of patients in the hospital. . It means that the

difference in the opinion about the sympathetic and reassuring attitude of the

employees and gender wise group of patients is not significant and not associated.

Q 4.19 Do you think in the hospital doctor prescribes affordable medicines?

Chart 4.18 The hospital doctor prescribes affordable medicines

Author(2012)

From the Table 14.19 (appendix) and chart 14.18 it is clear that the attitude of

doctors in prescribing affordable medicines to patients is supported only by 70

patients as the status “strongly agree”, where as the status “agree’ is supported by

63 respondents out of the total respondents of 291 patients. 53 patients have

observed it as the status “no opinion”.

From the Table 14.19 (appendix1) , it can also be seen that the chi-square

value (0.14) value shows that there is no significant association in the distribution of

23.68 22.36

18.24 18.24 17.1

24.46

20.86

17.98 19.42

17.26

0

5

10

15

20

25

30

Strongly Agree Agree Neutral Disagree Strongly disagree

Males females

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sample for the opinion about the attitude of doctors in prescribing affordable

medicines to patients and gender wise group of patients in the hospital. . It means

that the difference in the opinion about the attitude of doctors in prescribing

affordable medicines to patients and gender wise group of patients is not significant

and not associated. This shows that it is difficult for the patients to purchase life

saving drugs prescribed by the doctors according to their money. That means the

prescribed medicines for treatment are not affordable for patients.

Q 20 Cross tabular questions from 22 to 25.

Chart 4.19 Opinion about the average waiting time in hospital.

Author (2012)

From the Table 4.20 (appendix 1), chart 4.19 it is clear that 180 respondents

(68.96%) opined that the average time taken for completing the procedure at

reception counters comes to 20-30 minutes. Similarly 93 patients (31.95%) opined

that they have to wait an average time for 20-30 minutes for the consultation with the

doctors even after having the appointment time. Whereas 119 respondents

(40.89%) are of the opinion that they have to patiently wait at least 30-45 minutes at

the pharmacy counters for getting the prescribed medicines. At the same time it is

16.49 13.4

9.7

21.64

38.84

16.49

68.96

31.95 33.95

17.52 15.46

40.89

29.55

20.96

52.92

0

10

20

30

40

50

60

70

80

RecepLon ConsultaLon Pharmacy lab InvesLgaLon

<10 min 10-‐20 min 20-‐30 min 30-‐45 min >45 min

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noted that 154 patients (52.92%) were as common in their opinion as to the waiting

time for the lab investigation report, which is more than 45 minute.

The average waiting time taken for various junctures are different and hence it is a

defective decision by the management for not concerned about the precious time of

the patients.

Q 21.Are the charges of TMC hospital affordable when compared charges of

different services rendered by other private hospitals

Chart 4.20 The charges of TMC hospital affordable when compared charges of

different services rendered by other private hospitals

Author (2012)

From the Table 4.20 (appendix1) and Chart.19 it is clear that the opinion of patients

regarding fee charged by the hospital towards various services rendered when

compared to other private hospitals shows unique opinion among the patients.

32.64

18.21

25.08

29.55 30.58

26.11 28.17

26.8

14.43

20.96 19.24

16.49

9.9

25.08

11.68 12.37 12.37 9.6

15.8 14.77

0

5

10

15

20

25

30

35

ConsultaLon fees Sugery Fees Pharmacy fees lab InvesLgaLon

Strongly agree % Agree % Neutral % Disagree % Strongly Disagree %

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(12.63) shows that there is significant association in the distribution of sample for the

opinion of patients regarding fee charged by the hospital towards various services

rendered when compared to other private hospitals and gender wise group of

patients in the hospital. It means that the difference in the opinion regarding fee

charged by the hospital towards various services rendered when compared to other

private hospitals and gender wise group of patients in the hospital significant and

associated to each other. This shows that fee charged by the hospital towards

various services rendered when compared to other private hospitals is almost

similar, and there is no difference in the charges favourable to patients

Will you recommend this hospital to relatives and friends?

From the Table 4.22 (appendix), chart 4.21 it can also be seen that the chi-

square value (4.47) shows that there is no significant association in the distribution of

sample for the opinion about recommending this hospital to relatives and friends and

gender wise group of patients in the hospital. It means that the difference in the

opinion about recommending this hospital to relatives and friends and gender wise

group of patients is not significant and not associated. This shows that patients are

unique in supporting the fact that they will not recommend this hospital to their

friends and relative for treatments.

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Chart 4.21 Will you recommend this hospital to relatives and friends

Author (2012)

Patient satisfaction factors

Table 4.22 Patient satisfaction factor

1 Affordable charges for services rendered 3 6 2 Lower Service cost 2 8 3 Sense of wellbeing you felt in the hospital 4 3 4 Prompt services( no waiting time) 9 2 5 Services provided as expected 5 7 6 Location easily accessible 1 10 7 Efficiency of admitting procedure 7 5 8 Friendly and courteous staff/doctors 10 9 9 Healthy, neat and clean environment 8 4 10 Prompt diagnosis of diseases 6 1 Author(2012)

From the Table 4.22 it is clear that the ranks assigned by the male and

female respondents were separated and analysed. It is clear that “Location easily

21.05 20.39

23.68

17.76 17.1 15.82

20.86

17.98

20.83

24.46

0

5

10

15

20

25

30

Strongly agree Agree No opinion Disagree Strongly Disagree Males Females

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accessible” is the first rank assigned by male respondents; where as female

respondents are giving preference for prompt diagnosis of diseases at right time.

The second rank is for Lower Service cost opined by male respondents, where as it

is the prompt services by the hospital as opined by the female respondents. It is

also note that male respondents gave third rank to Affordable charges for services

rendered and that of female it is sense of wellbeing felt in the hospital.

Based on the findings “Rho test” was done. The value obtained is -0.07. This

shows that there is low negative relationship among the ranks assigned by the male

and female regarding various factors relating to satisfaction towards the hospital

which shows that there is independent opinion regarding gender wise respondents of

the hospital.

4.4 Comparing Primary research with Secondary research

In the second chapter the author had explained the relationship between Service

quality, patient satisfaction and patient loyalty with the help secondary data like

journals and books. So the final findings from the primary data should be compared

with the secondary data to give the final conclusion to the research.

In the chapter 2 (2.3) the author had discussed price of a service is one of the key

factor which acts as a service winner for an organisation which is coherent with the

findings of table 4. This shows that the main reason for the selection of the hospital

is the cost. In the chapter 2 (2.1) the author had discussed the interaction quality of

the staff of an organisation evaluates the service quality of the hospital .The findings

of the chapter 4 supports the fact that the receptionist are very cordial to the patient.

The patients usually have the first interaction with the receptionist they are the face

of the organisation. In the chapter 2 (2.4) the author had discussed that location of

the hospital is an important dimensions of service quality and it is proved by the

findings of chapter 4 that patient considers it as an important factor.

In the chapter 2 (2.4) the author had discussed that the patient measures

the service quality of the hospital on the interaction quality i.e. It refers to the

interaction they encounter with the different staff of the hospital even though they

had warm welcome from the receptionist the interactions with the other staff was

disappointing. The finding of this chapter points out that the patient were not

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satisfied in the way they were treated by the staff, they were in the that the staff were

not in proper uniform and the staff had a swift response when asked for help and

they were feeling uneasiness during their appointment.

In chapter 2 (2.3 and 2.5.2) the author had discussed time as a dimension

of service quality and had stated that waiting time is an important customer care

quality factor that is critical for health care facility. The patient considers the time

spent for the service as a factor which measures the service quality of the hospital

.The findings of this chapter shows that the patient has disappointed with the paper

work in the hospital and it has caused an increased waiting time in all the

departments of the hospital.

In the chapter 2 (2.4) the author had discussed patients evaluation of tangible

assets of the organisation which includes the physical facility and staff. It is evident

from the finding of this chapter that the patients are not satisfied with the visual

appearance of the hospital and the directional’s signs of the hospital.

In the chapter 2(2.7) the author had discussed that patient satisfaction is an

antecedent of service quality and patient satisfaction enhanced by the interaction of

patients and doctor but the findings of this study points out that patients are not

satisfied with the attitude of the doctors not listening to them and prescribing

expensive medicines.

In the chapter 2 (2.13) the author had discussed about that the strongest

measure of customer loyalty is referring the service providers to others is the

strongest form of patient loyalty. But the findings of the research done on TMCH

shows that they will not be recommend the hospital to their friends and hospital.

Based on the findings “Rho test” was done. The value obtained is -0.07. This

shows that there is low negative relationship among the ranks assigned by the male

and female regarding various factors relating to satisfaction towards the hospital

which shows that there is independent opinion regarding gender wise respondents of

the hospital

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4.5 Conclusion

The analysis of the findings shows that there is an independent association among

the distribution of sample age and sex group of patients and the hospital they

belong. It means that the difference in the distribution of sample age and sex from

the hospital is not significant and not associated to each other

The analysis of primary data and comparing it with secondary data aided the author

to achieve the research objective. The conclusions the author made from the

research is as follows. Even though the management of hospital had managed to

reduce the gap between the patient expectation and the actual service delivered in

some areas. There are certain gaps in the service which the management of the

TMCH hospital must give attention in order to improve patient satisfaction to gain

patient loyalty.

The findings of this chapter support the fact that the receptionists are very cordial to

the patient. The patients usually have the first interaction with the receptionist they

are the face of the organisation which is coherent with the secondary data.

The finding of this study shows that the main reason for the selection of the hospital

is the cost which is coherent with the secondary data

The findings of the study shows that location of the hospital which is an important

dimensions of service quality is the factor for the selection of the hospital which is

coherent with the secondary data

The finding of this study shows that even though they had warm welcome from the

receptionist the interactions with the other staff was disappointing. The finding of this

chapter points out that the patient were not satisfied in the way they were treated by

the staff, they were in the opinion that the staff were not in proper uniform and the

staff had a swift response when asked for help and they were feeling uneasiness

during their appointment. The patients measures the service quality on interaction

quality the management of the hospital should attention to reduce this service gap .

The patient considers the time spent for the service as a factor which measures the

service quality of the hospital .The findings of this chapter shows that the patient

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were disappointed with the paper work in the hospital and it has caused an

increased waiting time in all the departments of the hospital. The management of the

hospital should pay attention to reduce the this gap in the service,

The patient satisfaction is an antecedent of service quality and patient satisfaction is

enhanced by the interaction of patients and doctor but the findings of this study

points out that patients are not satisfied with the attitude of the doctors not listening

to them and prescribing expensive medicines. The management should pay

attention to this service gap.

The patient evaluates the tangible assets of the organisation which includes the

physical facility and staff. It is evident from the finding of this chapter that the patients

are not satisfied with the visual appearance of the hospital and the directional’s signs

of the hospital. The management of the hospital should reduce this service gap,

The strongest measure of customer loyalty is referring the service providers to others

is the strongest form of patient loyalty. But the findings of the research done on

TMCH shows that they will not be recommend the hospital to their friends and

hospital

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Chapter 5

Conclusion and Recommendation

5.1 Introduction

In this chapter the author had presented a general conclusion for the entire research

and had put forward recommendation to improve the service quality of TMCH so that

they can increase patient satisfaction and gain patient loyalty.

The Author begins the chapter by restating the aims and objectives of the research

which is followed by the discussion how objectives were achieved. The author then




India.








5.2.1 Achievement of objective 1.

The author had critically reviewed the literature available on service quality, patient

satisfaction and patient loyalty. In the beginning of the chapter 2 the author had first

discussed about the service quality then moved on to the how to measure service

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quality. Then discussed about different models of service quality. Then the author

had talked about patient satisfaction ,patient satisfaction and its dimensions, theories

of customer satisfaction and measuring customer satisfaction. Then the author had

discussed about patient loyalty then its importance and measurement of patient

loyalty. Then the author had discussed about service quality and its relationship

between customer satisfaction, then about service quality and its relationship

between customer loyalty, and finally the relation between customer satisfaction and

customer loyalty.

5.2.2 Achievement of objective 2

The author had coined the objective of analysing the current service quality

measures adopted by TMCH was made to find the present service quality standards

offered by the hospital. Without knowing the present status the author cannot put

forward recommendation for the improvement of the organisation. For understanding

the service quality of the TMCH parameters of the service quality were considered

like cost, interaction quality of the staff, responsiveness of staff, the infrastructure,

the atmospherics of the hospital, patient satisfaction.

The analysis of the findings shows that there is an independent association among

the distribution of sample age and sex group of patients and the hospital they

belong. It means that the difference in the distribution of sample age and sex from

the hospital is not significant and not associated to each other.

After the analysis of the primary data and by comparing it with secondary data

helped the author to achieve the second objective by having the data of current

service quality mesaures .Even though the management of hospital had managed to

reduce the gap between the patient expectation and the actual service delivered in

some areas. There are certain gaps in the service which the management of the

TMCH hospital must give attention in order to improve patient satisfaction to gain

patient loyalty.

The findings of this chapter support the fact that the receptionists are very cordial to

the patient. The patients usually have the first interaction with the receptionist they

are the face of the organisation which is coherent with the secondary data.

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The finding of this study shows that the main reason for the selection of the hospital

is the cost which is coherent with the secondary data

The findings of the study shows that location of the hospital which is an important

dimensions of service quality is the factor for the selection of the hospital which is

coherent with the secondary data

The finding of this study shows that even though they had warm welcome from the

receptionist the interactions with the other staff was disappointing. The finding of this

chapter points out that the patient were not satisfied in the way they were treated by

the staff, they were in the opinion that the staff were not in proper uniform and the

staff had a swift response when asked for help and they were feeling uneasiness

during their appointment. The patients measures the service quality on interaction

quality the management of the hospital should attention to reduce this service gap by

giving more customer relation training.

The patient considers the time spent for the service as a factor which measures the

service quality of the hospital .The findings of this chapter shows that the patient

were disappointed with the paper work in the hospital and it has caused an

increased waiting time in all the departments of the hospital. The management of the

hospital should pay attention to reduce the this gap by investing in the IT

infrastructure of the hospital.

The patient satisfaction is an antecedent of service quality and patient satisfaction is

enhanced by the interaction of patients and doctor but the findings of this study

points out that patients are not satisfied with the attitude of the doctors not listening

to them and prescribing expensive medicines. The management should pay

attention to this service gap and enhance patient centred consultation.

The patient evaluates the tangible assets of the organisation which includes the

physical facility and staff. It is evident from the finding of this chapter that the patients

are not satisfied with the visual appearance of the hospital and the directional’s signs

of the hospital. The management of the hospital should reduce this service gap by

investing in the interior of the reception in the first phase and alteron continuing after

evaluation.

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Even though the management of hospital had managed to reduce the

gap between the patient expectation and the actual service delivered in some areas.

There are certain gaps in other areas service where the management of the TMCH

hospital must give attention in order to improve patient satisfaction to gain patient

loyalty.

From the findings it is clear that “Location easily accessible” is the first rank

assigned by male respondents, where as female respondents are giving preference

for prompt diagnosis of diseases at right time. The second rank is for Lower Service

cost opined by male respondents, where as it is the prompt services by the hospital

as opined by the female respondents. It is also note that male respondents gave

third rank to Affordable charges for services rendered and that of female it is sense

of wellbeing felt in the hospital. “Rho test” value obtained is -0.07 and there is low

negative relationship among the ranks assigned by the male and female which

shows that there is independent opinion regarding gender wise respondents of the

hospital.

However the strongest measure of customer loyalty, referring the service

providers to others is the strongest form of patient loyalty. But the findings of the

research done on TMCH shows that they are unique in the opinion that will not be

recommend the hospital to their friends and hospital. This pinpoints a fact that there

is a serious lapse of customer quality measures adopted by TMCH and the

management of TMCH should immediately take steps to reduce the gaps in the

service. As Analeeb (1998) had said that hospitals that fail to understand the

importance of customer satisfaction are inviting a possible extinction. (Analeeb

,1998; cited by Padma et al., 2010)


Steps to take to improve the service quality measures of TMCH have been

discussed by the author under the topic ‘Recommendation’ later in this chapter there

achieving the fourth objective.

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5.3 Conclusion

In the conclusion part the author will be summarizing from Chapter 1 to Chapter 4.

The author begins the chapter 1 by giving a brief overview of the entire research

.Then the author starts the second chapter by restating the aims and objectives of

the research then the author had talked about the service quality, the dimensions of

service quality, measuring of service quality, the gap model of service quality the

SERVQUAL model and the author had criticised SERVQUAL model. Then author

had discussed about the patient satisfaction, then its dimension and theories and

how to measure it. Later the author had discussed about the Patient loyalty, how to

measure the service quality, and discussion had further moved on to service quality

its relationship between customer satisfaction and patient loyalty and customer

satisfaction and patient loyalty.

The author had started the chapter 3 by restating the aims and objectives discusses

about the primary research of the research method. The author had adopted

explanatory research as research design. The research approach was deductive

approach and positivism as research philosophy. Books journals and the hospital

website will be used for secondary research and primary data will be collected by

distributing questionnaires to 500 patients. Simple random sampling of Probability

sampling will be uses as sampling technique.

In the chapter 4 the author had started by stating the aims and objectives .It is the

most important part as it deals with the analysis of primary data and later own the

author had done a discussion by comparing the primary data with the secondary.

5.4 Research limitations

Time was the main constrain for my research. The author could have done a better

analysis by using of SPSS.

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5.5 Recommendation

5.5.1 Recommendation 1

Implementation of Enterprise Resource Planning (ERP)

The findings of table highlight that there is predicament in the admission procedure

in the hospital due to bungling paper work at the time of admission. The author

feels that Implementation of ERPin the hospital will improve the overall efficiency of

the hospital. ERP helps in streamlining and integrating the day to day activity of the

hospital and information flow in the hospital to synergize the resources like the

Staffs, the equipment, operational activities, administration, discipline and the cash

flow. By the implementation of EPR, it is possible to integrate information system of

the hospital covering all departments of the hospital.

By the execution ofERP, it is possible to trim down the admission process,

the billing procedure of both inpatient and outpatient, retrieving old patient file quickly

by entering the registration no. with the help of Electronic medical record, the

receptionist can dispatch the patient file directly to the doctor’s computer.ERP can

connect to the Radiology department and pathological labs. If the doctor needs a

further examination, he/she can send the report directly to the laboratory or the

radiology department and the doctor can access the results as soon as it enters in

the respective departments. It will help in tumbling the waiting time of the results.

The patient will also have a print out of prescription or the discharge summary.

Introduction of all these procedures will standardize the procedures of the hospital

and improve the hospital brand image. With the help of this system the receptionist

or the front desk staff can give flexible appointment to the patients of the visiting

doctors. In his way it is possible to reduce the waiting time significantly and will ease

the pressure on doctors and staff.

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With the help ERP it is possible to improve inventory stock

management of the pharmacy more easily and thereby it helps the management in

reducing operational cost.

In order to implement, a detailed project report on the HIS must be submitted to the

top management of the company. After the approval of the management,

advertisement for bid for ERP should be given on news paper and the company site.

From the bidders we should choose the most credible bidder with good track records

of implementing healthcare ERP. The training for the ERP can be finished in 10-15

days . The ERP can be implemented in 5 weeks time and it is shown in Table 5.1.In

this hospital we can opt for a phased approach so that it will not disturb the normal

business of the hospital. Implementation of ERP in the hospital is a costly procedure

and the project should be implemented with the given time. Many hospitals had

acknowledged that after the implementation of ERP there was a increase in

operation efficiency.

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Table 5.1: Gantt chart for implementation of Enterprise resource planning

Work

Time Frame

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Approval from the officials

Bidding Procedure

Selection of Bidder

Awarding Contract

Implementation

Training

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Recruitment of HR trainers for motivating the doctors and the staffs of the hospital to

implement a patient cantered approach

It is evident that the present approach adopted by the hospital is directive approach

in which the doctor and the management have an upper hand over the patients. The

hospital should change its approach to patient centred approach.

The healthcare managers and executives must ensure that there should be a

proper system in hospital for regular collection and reporting of patient care. The

manager should ensure that while executing health service action plan the

organisation should consider the quality improvement feed backs of the patients

experience in the hospital along with the clinical and operational data. The managers

should adopt evidence based patient centred care by recording and publishing

changes in the patient outcome in regular intervals. l. The managers should develop

and implement policies and procedure to involve patient families and care in service

level quality improvement and patient safety initiatives and healthcare design can be

improved. The managers should implement customised training strategies to build

capacity for all staff to support patient centred approach. The top management

should also focus on working environment, work culture and satisfaction of staff as

they play a vital role for improving patient centred care. Monitoring of the work

environment can be done at regular intervals through survey of workforce, reviewing

the recruitment policies of the staff and monitoring the retention rates of the staff.

The managers can integrate the care experience of patients they had in the hospital

in tune with staff performance appraisal and will foster patient culture. There are

different methods to promote patient cultured approach.

By implementing patient centred consultation the interaction time between the

doctors and patients are increased and this will lead to patient satisfaction which in

turn will lead to patient loyalty

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The hospital should change the tradition way of delivering health care. New

methods should be adopted by the management which includes more interaction

with the patients and employees. The managers should foster a culture to go around

each department and have a chat with the employees so that they will have first an

experience about what happening around each unit. Also the managers should have

chat with the patients who are using the service of the hospital. The direct interaction

will help the organisation to reduce the service gaps. The managers should also

invite employees to have a chair side chat so that they can have an in depth

knowledge of what is happening in each unit. The managent should develop a

patient centred advisory council in which the staffs and clinicians of the hospital are

includes all these fosters patient centred culture in the hospital.

In patient centred approach the importance should be also give to the staff and

clinicians of the hospital as they are the care givers and any factors that affect them

will also affect the end users. So the hospital should motivate the employees by

implementing employee of the month programme, public acknowledgement of staff

member in the news letter which is published by the hospital for their impact on

patient experience. The more informal approach includes thanking the staff during

routine manager staff rounding. The staff satisfaction can be monitored by close

monitoring of the managers of the employees and addressing their issues with the

work place. An open door policy should be adopted by the management to address

the problems. They can be also monitored by surveys as we have mentioned earlier.

Value training is another factor that helps in achieving patient centred approach is

employee’s behaviour. Only when the employee’s personal value stimulates, the

core value of the organisation the cultural transformation takes place..

We should implement these training programmes in a phased manner in each

department within 7 weeks so that there will be smooth transition from the existing

directive work culture to the patient centred work culture. We can implement all these

strategies by recruiting an induction team of experienced HR trainers in the human

resource department. new trainers will be enough for the existing team. The salary

for the HR trainer will be around 240,000 Rs to 300,000 Rs per annum. The first

evaluation of the training can be done after 2 weeks of implementation department

wise

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The return of the investment can be seen in within 6 months and the progress

can be evaluated by the feedback of patient experience in the hospital

Table 5.2: Gantt chart for Recruitment of HR Trainers

Work

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Approval

Advertisement

Interview

Recruitment

Framing of policies

Implementation

Department wise training

Evaluation

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Implementation of surveillance camera to close monitors the overall functions of the

hospital.

As it is evident from the findings that the patients are not satisfied with

the support staff. It shows that there is a lapse of close monitoring of staff by the

management. Since it is large hospital with 800 beds employing more and more mid

level manager will be a financial burden for the hospital. The available option will be

implementation of CCTv camera in and around the hospital and appoint an CCtv

operator. In a long run it will be feasible than appointing more people.

First of all a project report should be submitted to the top officials

then we should seek their approval and then it should be send to the finance

department of the hospital for approval. After that a tender for the implementation of

tender should be published in a leading news paper. As soon as the bidding

procedure is completed the tender should be awarded to a company which has good

track record and credible. The CCTv can be implemented in 2 weeks Soon after the

implementation of the CCTv The HR department have to recruit the CCTv operator.

The average salary for a CCTv operator in India will be nearly 70,000 per year. The

return of investment can be appreciated earlier as it is more cost effective than

implementing more staffs for closes monitoring of staffs. The evaluation of the CCTv

implementation can be done on the 9th week.

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Table 5.3: Implementation of CCTV

Work

Time Frame

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Approval

Bidding procedure

Selection of bidder

Awarding contract

Implementation of CCTv

Recruitment of CCTv operator

Training

Evaluation of progress

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It is evident from the findings that the patients are not satisfied with the

atmospherics of the hospital and the uniform of the staff as they were not in proper

uniform. The management should invest in the interior of the waiting area and

reception. They should provide a television and magazines to the waiting area, so

that it can make feel of comfort to the patients. The management should also invest

in buying hospital furniture’s like chairs and tables in the reception. The management

should implement a dress code for each section of staff. All the front desk staff

should be given same uniform likewise administrative department should have a

different uniform each section of the department should be given different uniform.

There should be a uniformity in uniform in each department The management should

provide identity card to all the staff. The management should emphasise that they

should greet the patients with a smile.

It can be implemented within a time frame of 3 months. we

can give a advertisement in the leading newspaper inviting bids for hospital furniture

,dress for staff and identity card. From the potential bidders we can choose credible

bidder with good track record. By opting this method the hospital can save lot of

money.


It is evident from the finding that the medicines prescribed by the doctors are not

affordable for the patients. The first step in this regard is to ask the doctors to

prescribe generic medicines .But it is the sole decision of doctor to choose which

company’s medicine. Steps may also taken to negotiate directly with company of

reputed in nature to supply bulk quantity at reduced/concessional price, so that the

benefit received can further extend to the patients.

After getting the list of stock needed for the pharmacy an advertisement can be

placed in the local newspaper so that the potential bidders can bid for the contract of

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the medicines. After the contract process we can purchase the medicine from the

bidders who have a good track record. Before placing the order for the medicines a

meeting with the clinical staff to ensure the quality of the medicine that we will be

purchasing. The entire process can be done within 9 weeks, Table 5.4. Evaluation of

the progress of the sales of medicines can be done after 4 weeks

Table 5.4 Gantt chart for the purchase of medicines at competitive price

Work

Time Frame

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Approval

Bidding procedure

Discussion with doctors

Selection of bidder

Awarding contract

Arrival of stock

Available in pharmacy

Evaluation of progress

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The TMC hospital should start their own health care insurance programmes by

having tie up with leading insurance agents. This will prove a competitive advantage

for the hospital as the hospital can provide cashless treatment for the patients who

come there for service. By having this insurance system the patients will come again

and again to avail treatment and this will ultimately lead to patient loyalty. There is

an increased penetration of health care insurance sector. Indian govt is also taking

steps to cover the poor people under insurance schemes.


The TMC hospital should implement a quality cell in the hospital where all the issues

of the quality will be dealt with. Since there are service gaps in the hospital a

dedicated wing quality assessors should be recruited. The Hr department of the

hospital should place an advertisement on newspaper and all other medium. An

interview date should be placed in the advertisement .Soon after the interview

eligible experienced guys should be recruited. Soon after their placement they

should implement new policies to improve the quality of the hospital. Performance

appraisal of the newly recruited should be conducted on a regular internal.


TMC hospital should work toward the implementation accreditation of JCI (Joint

Commission International) in the hospital which will help in maintaining the service

quality standards of the hospital as they often conduct standard checks. By having

JCI standards it opens a new horizon of business. The hospital can attract more and

more foreign patients. As the hospital is located in one of the famous tourism

destination .The hospital can attract more foreign patient and this will enhance the

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profitability of the hospital. By having the accreditation it will improve the brand

image of the hospital.

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Chapter 6

Reflective summary

In this chapter the author will discuss his experience throughout this course and

completing this dissertation. They have also developed skill after completing MBA

and my dissertation within the time frame was one of the greatest challenge the

author have faced in his life. By completing this dissertation the author have also

developed some skill which will be useful for future the author learned how to work

under pressure and meet deadlines. The multicultural experience that the author had

in UK will also help him to shape his career.

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Appendix 1

Tabular column for the questionnaires for the research

1. About you

Table 4.1:- Distribution of sample size according to age and sex

Status

Male

Female

Total

No % No % No %

<25 Age 22 14.47 15 10.79 37 12.71

25-40 Age 20 13.15 32 23.02 52 17.86

41-50 Age 36 23.68 27 19.42 63 21.64

51-64 Age 42 27.63 29 20.86 71 24.39

>65 Age 32 21.05 36 25.89 68 23.36

Total 152 52 139 48 291 100

χ2test 7.43

Table value for df 4at 0.05 level 9.49

Source: Author(2012)

Cross tabular column for age and sex

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3. Are you employed?

Table 4.2:- Earners and Non-earning dependents in the sample

Status

(No.)

Total members 291

Earners 133

Non-earning members 158

Proportion of earners to total members 45.83

Ratio of Earners to non-earning

members

84:1

Average number of earners in the

household

2.18

Average number of non earners in the

household

1.85


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4. Why did you choose this hospital?

Table54.3:- The reason for choosing the hospital

Category Males Females Total

No % No % No %

Cost 46 30.26 51 36.69 97 33.33

GP 28 18.42 27 19.42 55 18.90

Consultant 38 25 33 23.74 71 24.39

Referrals 25 16.44 21 15.10 46 15.80

Previous visit 15 9.86 7 5.03 22 7.56

152 52 139 48 291 100

χ2test 3.31

Table value for df 4 at 0.05 level 9.49


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5 The receptionist was friendly and courteous?

Table 4.4:- The receptionist was friendly and courteous?

Males Females Total

No % No % No %

Strongly Agree 37 24.34 43 30.39 80 27.49

Agree 42 27.63 37 26.61 79 27.14

Neutral 23 15.13 26 18.70 49 16.83

Disagree 27 17.76 21 15.10 48 16.49

Strongly Disagree 23 15.13 12 8.63 35 12.02

Total 152 100 139 100 291 100

χ2test 28.37


Source: Author (2012)

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6. The staff treated you with respect, dignity and was courteous in the hospital?

The staffs treated you with respect, dignity and were courteous in the hospital

Table 4.5

Males Females Total

No % No % No %

Strongly Agree 29 19.07 15 10.79 44 15.15

Agree 34 22.36 32 23.02 66 22.6

Neutral 23 15.13 27 19.42 50 17.18

Disagree 32 21.05 29 20.86 61 20.96


152 100 139 100 291 100

χ2test 4.47


Source : Author (2012)

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7. There is a lot of paper work for admission?

Table 4.6 :Opinion about the paper work for admission

Males Females Total

No % No % No %

Strongly Agree 36 23.68 28 20.14 64 21.99

Agree 23 15.13 25 17.98 48 16.49

Neutral 28 18.42 29 20.86 57 19.58

Disagree 31 20.39 34 24.46 65 22.33


152 48 139 52 291 100

χ2test 2.79



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8. The service cost of hospital is affordable?

Table 4.7: The service cost of hospital is affordable

Status

Males Females Total

No % No % No %

Strongly Agree 47 30.92 36 25.89 83 28.52

Agree 38 25 35 25.17 73 25.08

Neutral 27 17.76 23 16.54 50 17.18

Disagree 25 16.44 22 15.82 47 16.15


152 100 139 100 291 100

χ2test 3.20


Source :Author( 2012)

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9. All Staff were in correct uniform

Table 4.8:- All Staff were in correct uniform

Males Females Total

No % No % No %

Strongly Agree 43 28.28 39 28.05 82 28.17

Agree 34 22.36 35 25.17 69 23.71

Neutral 22 14.47 21 15.10 43 14.77

Disagree 26 17.10 24 17.26 50 17.18


152 100 139 100 291 100

χ2test 0.78


Source : Author (2012)

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10. The hospital is visually attractive?

Table 4.9: The hospital is visually attractive?

Status Males Females Total

No % No % No %

Strongly Agree 42 27.63 39 28.05 81 27.83

Agree 36 23.68 32 23.02 68 23.36

Neutral 24 13.78 26 18.70 50 17.18

Disagree 27 17.16 23 16.54 50 17.18


152 100 139 100 291 100

χ2test 2.44


Author (2012)

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11. Is the hospital in a convenient location?

Table 4.10 Is the hospital in a convenient location?


No % No % No %

Strongly Agree 29 19.07 22 15.82 51 17.52

Agree 26 17.10 27 19.42 53 18.21

Neutral 23 15.13 25 17.98 48 16.49

Disagree 36 23.68 31 22.30 67 23.02

Strongly Disagree 38 25 34 24.46 72 24.74

152 100 139 100 291 100

χ2test 37.86



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12 Does the hospital have good directional signs?

Table 4.11 Does the hospital have good directional signs

Status Males Females

Total

No % No % No %

Strongly Agree 31 20.39 29 20.86 60 20.61

Agree 26 17.10 27 19.42 53 18.21

Neutral 29 19.07 32 23.02 61 20.96

Disagree 32 21.05 24 17.26 56 19.24


152 139 291

χ2test 1.61


Source Author (2012)

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13 Does the hospital provide services at the allocated time?

Table 4.12 Does the hospital provide services at the allocated time

Status Male Female Total

No % No % No %

Strongly Agree 23 15.13 20 14.38 43 14.77

Agree 27 17.76 26 18.70 53 18.21

Neutral 24 15.78 23 16.54 47 16.15

Disagree 36 23.68 34 24.46 70 24.05


152 100 139 100 291 100

χ2test 0.19


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14 The department is running effectively?

Table 4.13 The departments are running effectively

Status

Males Females Total

No % No % No %

Strongly Agree 43 28.28 39 28.05 82 28.17

Agree 34 22.36 31 22.30 65 22.33

Neutral 25 16.44 27 19.42 52 17.86

Disagree 27 17.76 23 16.54 50 17.18

Strongly

Disagree 23 15.13 19 13.66 42 14.43

152 100 139 100 291 100

χ2test 0.53



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15 You felt ease during your appointment?

Table 4.14 You felt ease during your appointment

Status

Male

Female

Total

(No) % (No.) % (No) %

Strongly Agree 32 21.05 22 15.82 54 18.55

Agree 31 20.39 29 20.86 60 20.61

Neutral 36 23.68 25 17.98 61 20.96

Disagree 27 17.76 29 20.83 56 19.24


Total 152 100 139 100 291 100

χ2test 4.47



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16 Doctors listen carefully and adhered to your needs?

Table 4.15 Doctors listen carefully and adhered to your needs?

Status

Males

Females

Total

(No) % (No) % (No) %

Strongly Agree 22 14.47 19 13.66 41 14.08

Agree 25 16.44 23 16.54 48 16.49

Neutral 32 21.05 29 20.86 61 20.96

Disagree 36 23.68 33 23.74 69 23.711


152 100 139 100 291 100

χ2test 0.06


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17 Do you think the hospital address the patient complaint quickly?

Table 4.16 Do you think the hospital address the patient complaint quickly?

Males Females Total

(No) % (No) % (No)

%

Strongly Agree 26 17.10 19 13.66 45 15.46

Agree 25 16.44 26 18.70 51 17.52

Neutral 34 22.36 27 19.42 61 20.96

Disagree 28 18.42 33 23.74 61 20.96


152 139 291

χ2test 2.08


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18 Do you think the staff responded immediately when called?

Table 4.17 the staff responded immediately when called?

Status

Male Female Total

(No) (%) (No) (%) (No) (%)

Strongly Agree 32 21.05 31 22.30 63 21.64

Agree 33 21.71 32 23.02 65 22.33

Neutral 28 18.42 27 19.42 55 18.90

Disagree 31 20.39 32 23.02 63 21.64


152 100 139 100 291 100

χ2test 2.18

Table value for df 4at 0.05 level 9.459

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20 Do you think that the hospital employees are sympathetic and reassuring?

Table 4.18 Hospital employees are sympathetic and reassuring

Status

Males

Females Total

No (%) No (%) No (%)

Strongly Agree 24 15.78 23 16.54 47 16.151

Agree 31 20.39 27 19.42 58 22.22

Neutral 29 19.07 25 17.98 54 20.68

Disagree 33 21.71 31 22.30 64 21.99


152 139 291 100

χ2test 0.13


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21 Do you think in the hospital doctor prescribes affordable medicines?

Table 4.19

Opinion about the attitude of doctors in prescribing affordable medicines to patients.


No % No % No %

Strongly Agree 36 23.68 34 24.46 70 24.05

Agree 34 22.36 29 20.86 63 21.64

Neutral 28 18.24 25 17.98 53 18.21

Disagree 28 18.24 27 19.42 55 18.90


152 100 139 100 291 100

χ2test 0.14


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22 Average waiting time in the different a cross tabular questions from 22 to 25

Table 4.20

Status

Reception Consultation Pharmacy Lab

investigation

Total

No % No % No % No % No %

Less than

10 minutes 48 16.49 39 13.40 27 9.7

--

--

291

100

10-20

minutes 63 21.64 54 38.84 48 16.49

--

--

291

100

20-30

minutes 180 68.96 93 31.95 97 33.33

51

17.52

291

100

30-45

minutes -- -- 45 15.46 119 40.89

86

29.55

291

100

More than

45 minutes -- -- 60 20.96 -- --

154

52.92

291

100

Author (2012)

Cross tabular column for Question 22 to 25

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Are the charges of TMC hospital affordable when compared charges of different

services rendered by other private hospitals

Table 21

Status

Consultation fee

Surgery

fee

Pharmacy

Fee

Lab investigation

Fee

Total

No % No % No % No % No %

Strongly agree 95 32.64 53 18.21 73 25.08

86

29.55

291

100

Agree 89 30.58 76 26.11 82 28.17

78

26.80

291

100

Neutral 42 14.43 61 20.96 56 19.24

48

16.49

291

100

Disagree 29 9.9 73 25.08 34 11.68 36 12.37 291 100


43

14.77

291

100

χ2test 12.63


Author (2012)

Cross tabular column for question 26 to 29

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Q30 Will you recommend this hospital to relatives and friends?

Table 4.22 :- Will you recommend this hospital to relatives and friends?

Status Male Female Total

No % No % No %

Strongly Agree 32 21.05 22 15.82 54 18.55

Agree 31 20.39 29 20.86 60 20.61

Neutral 36 23.68 25 17.98 61 20.92

Disagree 27 17.76 29 20.83 56 19.24


Total 152 100 139 100 291 100

χ2test 4.47


Source :Author( 2012)

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Appendix 2 Questionnaires for the patients

I Aneesh .Prasannan is doing a survey questionnaire and collecting the data from the most valuable patients of the TMC hospital. Your opinion is very critical in my dissertation research. My analysis and recommendations are based on the response you give to the questioner. All the information submitted by you will be utilized for the academic purpose. Thanks for your co-operation.

Title: Critically evaluate service quality as a determinant factor for patient satisfaction in gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala, India.

For the following question please tick one of the following. 1. About you

Male Female 2. Age group

Under 18 19-34 35-5 55-74 75 and above 3. Are you employed? Yes No 4. Why did you choose this hospital?

Cost GP Consultant Referral Previous visit

5 The receptionist was friendly and courteous?

Strongly agree Agree Neutral Disagree Strongly

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disagree

6. The staff treated you with respect, dignity and was courteous in the hospital?


disagree 7. There is a lot of paper work for admission?


disagree

8. The service cost of hospital is affordable?


disagree

9. All Staff were in correct uniform?


disagree

10. The hospital is visually attractive?


disagree

11. Is the hospital in a convenient location?


disagree

12 Does the hospital have good directional signs?

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128

Strongly Agree Agree Neutral Disagree Strongly

Disagree

13 Does the hospital provide services at the allocated time?

Strongly Agree Agree Neutral Disagree Strongly

Disagree

14 The department is running effectively?


disagree

15 You felt ease during your appointment?


disagree 16 Doctors listen carefully and adhered to your needs?


disagree

17 Do you think the hospital address the patient complaint quickly?


disagree

18 Do you think the staff responded immediately when called?


disagree

20 Do you think that the hospital employees are sympathetic and reassuring?


disagree

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129

21 Do you think in the hospital doctor prescribes affordable medicines?


disagree

22 The average waiting time in reception

Less than 10 min

10 -20 min 20-30 min 30-45 min More than 45 min

23 The average waiting time in Consultation

Less than 10 min


24 The average waiting time in pharmacy

Less than 10 min


25 The average waiting time in laboratory.

Less than 10 min


26 While comparing with other hospitals the consultation fee is affordable?


disagree

27 While comparing with other hospitals the surgery fee is affordable?

USN: 1092227390326 2012

130


disagree

28 While comparing with other hospitals the pharmacy fee is affordable?


disagree

29 While comparing with other hospitals the lab investigation is affordable?


disagree

30 Will you recommend this hospital to relatives and friends?


disagree

a case study of travancore medical college hospital kerala, india

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