“IMPACT OF HOSPITAL SERVICES ON OUTPATIENT SATISFACTION”

A CASE STUDY OF MURSHID HOSPITAL

A RESEARCH PROJECT

Submitted to the Board of Advanced Studies and Research

Dow University of Health Sciences
In partial fulfillment of the requirement
For the Degree of
Master of Business Administration
(Health Management)

By

Dr. Ishrat Nazir

Institute of Health Management

Dow University of Health Sciences

Karachi, Pakistan

May, 2017

SUPERVISOR

Mr. Mohammad Rizwan

Assistant Professor
MBA, MS
 CHAPTER 1

INTRODUCTION

1.1 Background of Research

The general procedure for a patient care can be seen in three steps i.e. waiting in OPD, during

consulting in doctor’s room and after taken service from the doctor. It is imperative for the

hospital to understand the whole processes included in the experience of the patient. The

experience of the patient includes various variables, for example, specialist's expertise, his

communication with the doctor, performance and behavior of the paramedical staff, different

medical services offered by the healthcare center, behavior of care staff, cleanliness and structure

of the hospital. Patient satisfaction and loyalty is an important performance measurement tool for

a private health care sector. There are various problems faced by the patients in outpatient

departments, like overcrowding, delay in consultations, lack of proper guidance that leads to

patient dissatisfaction. It is seen that like every other public healthcare sector, the patients have

received more attention and quality care; in private healthcare hospitals. The Hospitals effort to

maintain and establish relationship between patients and Hospital staff, has offered a great deal

of advantages, for example, surviving competitive competition, loyalty in patient, diminishing

the need to contend exclusively on cost premise and expanding new patient base by referrals.

This study will help the patients in enhancing and developing more comfortable and satisfied

association and loyal relationship with hospitals, and creating more trust and confidence towards

private healthcare hospitals.

It is observed that, the mandatory effort should be taken by healthcare organization is to

understand how to develop and nurture a long term patient- hospital relationships. The patients

develop loyalty towards hospitals based on their interpersonal experience with the doctors,
 nurses and the quality of services offered by the hospital. Patients create their own judgment of

their experience about the management system of the hospitals they visit and thus it is important

to diagnose the most practical way of finding patient’s needs so that finding where care for

patients needs to be improved and fine tuned.

It is seen that, today, hospitals are facing tremendous pressure of competition and the attention

towards healthcare has continuously increased particularly wants and needs within the society

and people are becoming more health conscious.

So, now-a-days hospitals are working hard to overcome this competition in a way to, expand

medical facility investment, high quality human resources, new system designs, and latest

medical services in order to develop and enhance competitive power.

1.1.1 Service Process of Hospitals

Hospitals are facing competitive situations due to globalization and the open-door policy for the

health care market. The growth, new medical services and advance technological changes

towards health have continuously increased particular wants and needs of the general public.

Hence, private hospitals are working hard to increase their medical facility investment, good

quality human resources and provide quality services in order to develop competitive power.

1.1.2 Human Resource Management in Hospitals

To improve and provide quality healthcare services, Human Resource Management is being

acknowledged by hospitals today. Selection, high-quality training, empowerment, and

teamwork, are now-a-days important tools in healthcare organizations.

1.1.3 Patient Satisfaction

Patient satisfaction is of prime importance when patients themselves make selection decisions.

Health care service dimensions and factors affecting patient satisfaction, researchers have
 studied on various service quality areas in which patient satisfaction are considered the most

important tool for evaluating the quality aspects of hospitals such as latest equipment, physical

facilities, ease of supplementary services, nature and response of doctors and medical staff.

Today, hospitals are forced to deliver a good quality service to the patient and how it could be

best measured. A key factor in establishing and delivering quality medical services is the need

to understand the patient’s desire and requirements in order to provide quality services which

meet those needs as per the resources available.

1.1.4 Outpatient Services

Out-patient department is located at the ground floor of the clinical division. It is a unit in which

walk-in patients are treated and provided medical services. Its primary objective is to provide

healthcare services at minimal cost. The outpatient services provide the main relationship

between the hospital and the public. Today, the outpatients are very important for every

hospital. The services offered in OPD are as follows.

 Preventive services like immunization and well - baby clinics.

 Curative Services like investigations and procedures.

 Follow up of chronic illnesses and follow-ups.

 Rehabilitative services like physiotherapy.

The OPD department is the first impression of the hospital. The OPD is the entry point for

future prospective patients.

1.1.5 The Service Quality Dimensions and Patient Satisfaction Relationships

The health care sector in recent years has reshaped its medical service delivery system in order

to effectively satisfy the needs and desires of the patients. This patient-centered health care
 service approach shifts the culture of the health care system from decisions of medical

professionals to the views and needs of its users.

The patient satisfaction is a fundamental requirement for health care providers. Satisfaction is

important when patients themselves make selection decisions. Impact on patient retention and

customer loyalty, patient satisfaction influences the rates of patient compliance with physician

advice. Researchers have defined various service quality dimensions, to understand various

factors affecting patient satisfaction.

Recent studies have shown that medical health service quality dimensions significantly

influence patient satisfaction. In order to provide health care resources effectively, health care

providers should identify patient’s priorities among service quality dimensions and to improve

these dimensions for patient satisfaction.

1.2 Purpose of the Research

The purpose of this study is to analyze very carefully the relationship between the qualities of

medical services, satisfaction level and re-visit intention of patients and to advise various

marketing solutions for private hospitals. This study will also help hospitals to offer patients the

best medical services and enhance their position in today’s very competitive environment.

1.3 Justification of the study

Patient satisfaction and loyalty is an important performance measurement tool for a private

health care sector. This research study is based on the identification of various problems faced by

the patients in outpatient departments, like overcrowding, delay in consultations, lack of proper

guidance that leads to patient dissatisfaction. This research study will also justify the overall

experience for the patients facing in hospital like, doctor’s competence, his interaction with the

patients, behavior of the paramedical staff, various facilities offered by the hospital, behavior of
 support staff and overall hygiene. This study will help the providers in developing stronger and

more loyal relationships with the patients. Researcher has identified several possible variables

that may result in patient’s satisfaction with the hospital’s services like tangibles, reliability,

responsiveness, assurance and empathy

1.4 Scope of Study

The scope of this study would be developing stronger and more comfortable relationship with the

provider, patient’s loyalty towards hospital based on significant interpersonal experience they

have with the doctors and nurses and about the quality of services of the hospital.

1.4.1 Inclusion Criteria

Patients in OPD, emergency, diagnostics and pharmacies. Patients whose age ranges are from

18-50 years old. Patients, who are willing to give consent. Patients, who are able to listen/read

and understand local language. Patients who visit the hospital as outpatient in the hospital.

1.4.2 Exclusion Criteria

Patients who have psychological illness, inpatients, gyne and ops, patients whose age ranges are

less than 18 or greater than 50 years. Patients, who are not willing to give consent.

1.5 Hypothesis or basic assumptions

H01 The hospital facility has significant influence upon patient satisfaction.

H02 Behavioral and personal attention of doctors and paramedical staff has a significant

influence on patient satisfaction.

H03 Patient satisfaction has a significant influence on re-visit intention for medical services.

H04 Patient satisfaction has a significant influence for referring hospital to other patients.

1.6 Definition of key terms

Service Process
Customers of service organization obtain benefits and satisfactions from the services themselves

and from how those services are delivered.

Human Resource Management

Human resource management (HRM) is the governance of an organization’s employees.

Empowerment

A management practice of sharing information, rewards, and power with employees so that they

can take initiative and make decisions to solve problems and improve service and performance.
 CHAPTER 2

Literature Review

2.1 Introduction

A review of the literature reveals many studies that have shown a significant relationship

between patient satisfactions and impact of hospital services on outpatient departments and also

between service quality perceptions and satisfaction. Researchers have identified several possible

variables that may result in patient’s satisfaction with the doctor’s services. Fred David, Garner

C.Alkin (2006) felt that these variables have included perceived doctor’s competence, care and

concern towards patients, cost of treatment and communication between doctor and patient.

In their study Gilmore Audrey, Goodman Bill Reidstead man (2006) state that patients and

consumers perception of quality service in health care is not accurate because of the inability of

patients to analyze and judge the technical competence of medical practitioners with accuracy. It

is further observed that our medical courses focus on imparting technical knowledge to the

students and hence doctors do not receive any soft skill training which will enable them to get

closer to their patients.

Further it is seen that Boonshoof and Gray (2004) have conducted the studies on the

relationships between service quality, customer satisfaction and buying intentions in the private

hospital industry. Their study attempted to assess what dimensions of both customer satisfaction

and service quality drive „Overall Satisfaction and Loyalty‟ in the South African private hospital

industry. The results revealed that the service quality dimensions, empathy of nursing staff and

assurance impact positively on both loyalty and cumulative satisfaction.

The results also revealed that the customer satisfaction dimensions are: satisfaction with food,

satisfaction with the nursing staff and satisfaction with the tariff. All effect positively on both
loyalty and satisfaction. The survey and study conducted, aimed to investigate the relationship

between outpatient satisfaction and service quality dimensions where patients have substantial

freedom in choosing their medical service providers. Results show that the pattern of

relationships between service quality and patient satisfaction was similar across the gender, age

and service type subgroups; it was an exploratory study on service quality. Themes showing

patient satisfaction with healthcare delivery in India were conducted by Sachin Kamble (2007)

who has stated that very little emphasis was given by patients on service quality dimensions. The

aim of the research was to get an idea of patient’s interpretations of satisfaction.

A detailed study was done by Hardeep Chahal (2004) of Ahmedabad Civil Hospital, which

showed that the more satisfied the patients are with the quality of interactions with staff, more

likely they will opt for treatments for similar and different medical problems and would

recommend the hospital to their friends and relatives. Patients basically from pediatric, obstetrics

and gynecology had been selected for the study. Results stated that it is necessary to capture

information on patient‟s needs, expectations and perceptions. Main concerns of patients relate to

being treated with dignity and respect, given clear information and psychological support. Older

patients tended to be more satisfied with medical care services than their younger counterparts.

Further it is seen that the role of government in assuring that our nation’s healthcare system

provides optimal services for its population has been emphasized upon in the World Health

Report, (2000). The meaning of quality on healthcare system has been interpreted differently by

different researchers.

The choice of hospital depends on numerous factors. There is need to understand the service

context and the nature of service offering. Lovelock and Wright, (1999) have given an insight

into the classification process of service which affects the nature of operation chosen.
The required elements are:

1. Degree of tangibility or intangibility.

2. Direct recipient of the service process.

3. Place and time of service delivery.

4. Customization v/s Standardization.

5. Nature of relationship with the customer.

6. Extent to which demand and supply are in balance.

Patient satisfaction according to March S, Swart E, Robra B (2006) is an important indicator in

evaluating the quality of the patient satisfaction (care) in the outpatient department. In a study

conducted at Mageburg, Germany only 3.6% of patients were dissatisfied. Thorne L, Ellamushi

(2002) at the Neuro-surgical care department of National Hospital, London, observed that most

aspects of patient care had 70 to 80% satisfaction.

It is observed in the work of Alkess L H Cimiotti J, Sloane DM that in different countries

organizational behavior and the retention of a qualified and committed nurse work force might

be a promising area to improve hospital care safety and quality, both nationally and

internationally. Improvement of the hospital work environment can be a relatively low-cost

strategy to improve the healthcare and improve patient outcomes.

Observed by Yesudian (1994), Bhat (1996) and Kutty (2000) tells us that outpatient care has

been dominated by the private sector for decades and Uplekar, Rangan (1993) and Kamat (2001)

feel that poor quality and lack of public health care are observed and noted, particularly in the

treatment of tuberculosis and malaria. However, despite numerous studies on healthcare systems

in India, direct systematic comparisons of the nature of clinical care offered by public and private
sector practitioners are lacking. Such evidence is badly needed to inform policies that seek and

identify ways in which both sectors might complement each other.

Carlucci D. (2013), Arab M. (2014) and Kleefstra S. (2010) observed that patient satisfaction is

one of the most important and widely used indicators in measuring health care quality and

outcomes. According to Carlucci D. (2013), there has been a growing interest in assessing

patient satisfaction to identify care dimensions requiring improvement.

2.1.1 Word of Mouth

It is observed that the value in Hospitals is complicated because, first of all the high level of

information asymmetry between patient and the Hospital means that the patient must have trust

in the Hospital to ensure its efficacy, tarrifs and product design are well matched to his or her

requirements. Taner & Antony (2006) are of the opinion that a patient must have a lot of trust in

the health provider, which implies the patient must be highly involved in the delivery process,

despite less expertise. Due to the lopsided information received by Hospitals, the health care

administrator determines the services that will suit the patient’s requirements.

Hogg, Laing, & Newholm (2004) are of the view that there is high patient involvement. Taner &

Antony (2006) felt that there is usually a very high quantam of risk associated with the very

nature of the medical service.

A study conducted by Ekrem & Fazil (2007) suggests that for Hospitals it has become extremely

important to analyse and take strategic steps as a result of tremendous competition and medical

reforms in technology. If we have more Private Hospitals then the authorities need to develop

new methods to maintain their existing patients and increase the new patient numbers. Duncan &

Breslin (2009) are of the view that Hospitals have difficulties creating meaningful value through
innovation because of poor Health care financing and lack of vertical and horizontal integration

and the slow change of basic research into practical health outcomes for the patients.

Duncan & Breslin, (2009) further stated that Hospitals that can overcome all these difficulties

stand a better chance to survive competition by offering high-value care. Hospitals need to study

and understand why patients purchase such professional services as this may be the key to a

unique competitive advantage. Because of the requirement of developing patient satisfaction

through value-enhancement strategies Richardson & Gurtner (1999), Beresford & Branfield

(2006), Nordgren (2009), propose that marketing managers today are committed to develop plans

to provide value for patients.

Today many professional firms fail to do so and thus offer inferior value to customers. Ekrem &

Fazil, (2007) are also of the view that Hospital management authorities aiming at incorporating

quality, customer satisfaction and loyalty have evolved, as seen by their attempts to make

patients influence customer perceived value, by getting patients involved in value creation.

However Laing & Hogg (2002), Ham & Alberti (2002) state that in spite of all these changes in

the healthcare industry and a shift towards a more patient-centred enviornment patients still tend

to be regarded as passive recipients of care.

Laing & Hogg, (2002) are of the view that the patients are usually passive because of the belief

that the doctor knows best, which granted power primarily to doctors who became dominant in

their approach, while the patient deferred to the doctors opinion and obeyed instructions that the

doctor knew best for patient’s health. Alternatively, patients themselves may not be willing to

express their expectations and behaviour with respect to health care. The environment according

to Beresford & Branfield, (2006) and Lo (2006), in Hospitals may be changing from a traditional

model of transactional or commercial activities towards a more performance based organization,

 built on a network and partnership approach and involving a shift in responsibility from the

doctor to the patient.

Robinson (2001) are of the opinion that the decline of restrictive forms of managed care and

rapid increases in the availability of health care information via the Internet may produce a

situation in which consumer - provided information is more highly valued by recipients during

their information searches and selection. Word of mouth communications or referrals have

significant importance for the health care system, both traditionally as a means to cut through

information asymmetry and more recently as a tool for health care providers to gain

understanding about what patients actually value.

The provider’s intention to offer positive word of mouth communications correlates positively

with customer perceptions of value and quality; this was stated by Derbaix & Vanhamme (2003)

when considering the range of professionals involved in a mother’s health care.

2.2 History

SERVQUAL is used to measure the quality of services provided by an organization, from a

customer’s perspective in the service industry. Parasuraman et al., (1988) has initiated a lot of

discussions and debates on medical services quality from the perspective of patients. He

suggested measuring the quality of services provided to customers through recognized

performance by users and of expectations based upon the five dimensions of service quality i.e.

tangibles, reliability, responsiveness, assurance and empathy.

Later on these researchers classified the factors of medical services quality into: (i) services that

satisfy needs without any defects, (ii) the ease and convenience of services and the operation

process, and (iii) service provision which satisfies a patient’s expectations and also felt that a
very wide approach is required that is necessary in order to measure the service quality in

Hospitals.

There is another study where Babakus and Mangold (1992) measured expectation level and

performance level of five dimensions of SERVQUAL indices i.e. tangibles, reliability,

responsiveness, assurance and empathy. When it came to research on the quality of patient-

focused Hospital medical services, Choi (1999) focused on outpatients in large-sized hospitals in

Korea and classified medical services quality into (i) treatment, (ii) care (iii) promptness and

convenience of medical procedure. Further, Kim et al. (2003) emphasized on quality of services

for dental outpatients in hospitals and clinics and laid emphasis on four dimensions of medical

services quality i.e. the convenience of doing the procedure, the latest technology available, the

courtesy of the personnel communicating, tangibility and visibility of the care in the department.

A detailed survey was conducted by Lee (2005) to test outpatients in dental clinics which were

available in the greater Daegu area of Korea and he differentiated medical services quality into:

(i) treatment, (ii) professionalism, (iii) courtesy, (iv) convenience, and (v) comfortableness.

Hence, factors involving medical services quality in Hospitals vary considerably depending upon

the various kinds i.e. (dentist department versus general department) and the types i.e. (inpatient

in Hospitals versus outpatient in Hospitals) of medical services provided.

Irfan et al (2012) found that public hospitals are not making any visible efforts to meet patient’s

needs and wants. The studied service quality construct does not have a significant impact on

patient satisfaction except assurance.

Zarei et al. (2012) studied service quality in the private hospitals of Iran from the patients’

perspective. Results indicated that tangible has the highest expectations and perceptions and the

lowest expectation and empathy perception has the lowest expectations.

Punnakitikashem et al. (2012) measured service quality of the hospital implementing lean

management. Study found that the service quality level of the hospital implementing lean is

moderate. In addition, the largest positive gap between patients’ perception and expectation is in

term of tangibility. The largest negative gap is with respect to assurance.

Yousapronpaiboon & Johnson (2013) studied Out-patient service quality perceptions in private

Thai hospitals, results found that assurance was the dimension most strongly associated with

overall PSQ, followed by empathy, responsiveness, tangibles and reliability.

Essiam (2013) examined the quality dimensions and patient satisfaction in a public university

hospital in Ghana. Findings revealed gaps across all the SERVQUAL dimensions with

SERVIQUAL dimensions. Patients’ satisfaction was best explained by perceived responsiveness,

followed by perceived empathy, perceived assurance, perceived tangibility, and perceived

reliability.

Mosadeghrad (2014) conducted an exploratory in-depth individual and focus group interviews

with 222 healthcare stakeholders including healthcare providers, managers, policy-makers, and

payers to identify factors affecting the quality of healthcare services provided in Iranian

healthcare organizations. Results found that personal factors related to the provider and patient,

factors pertaining to the health care organization, health care system and broader environment

affected health care service quality.

Belaid et al (2015) studied the impact of health service quality and its impact on patient’s

satisfaction, case in a public hospital in Bechar. Results indicated that there was a relationship

between overall service quality and patients' satisfaction with the services of specific hospital.
 Özlü and Uzun ( 2015) found that there were differences in patient satisfaction with nursing care

in surgery clinics in different hospitals in turkey related to educational background, profession,

the hospital in which the patients stay and previous hospital experience.

Shan (2016) found that lack of trust was behind patient dissatisfaction with hospital inpatient

care in Heilongjiang in China.

Devi and Muthuswamy (2016) investigated service quality perception in multispecialty hospitals

in India. Result indicated that tangibility, reliability and responsiveness were the three most

important dimensions of hospital service quality perceived by patients.

Zamil et al ((2012) investigated the impact of health service quality on patients’ satisfaction over

private and public hospitals in Jordan. The result indicated that there was an impact of health

service quality on patient's satisfaction. Responsiveness dimension has the lowest mean out of

other service quality diminutions in public and private sectors

2.3 Recent Practice and Policies

2.3.1 Human Resource Management

In the healthcare sector the front-line staff increasingly perceives themselves as an enterprising

self. Meeting the expectations of the frontline staff can lead to a more effective patient care.

According to Boaden et al. (2008), "Professional ideology enables performance that might

otherwise not be achieved". Individual performance was concerned with how an individual does

her or his work, which then leads to outcomes for patients.

It was noticed that organizational performance was perceived as being assessed using 'targets'

that were seen by some to be in conflict with patient care. Many individuals being unable to

describe a link between their own individual performance and that of the organization. The new

service management school of thought as per Korczynski (2002) celebrates a set of new HRM
practices, underpinned by the concept of the satisfaction mirror between customers and front-line

workers. The production line approach to services leads to failure because its narrow, low-skilled

jobs and emphasis on the use of technology leads to workers either having a poor service attitude

or leaving the firm through boredom and dissatisfaction.

Human resource management (HRM or simply HR) is the management of an organization

workforce or human resources. HRM is responsible for adding new employee, new doctor, new

nurse, search particular employee detail from the hospital database. Effective HRM enables

employees to contribute effectively and productively to the overall company direction and the

accomplishment of the organization's goals and objectives.

In a study of six organizations, Hyde et al. (2009), found frequency distribution of employee‟s

expectations to be 22 percent for infrastructure, 45 percent for HR practices and 33 percent for

help and support. Expectations were remarkably consistent across organizations and job roles.

McKee, Eerlie & Hyde (2008) are of the opinion that many expectations concern HR practices

and other aspects of HRM so HR function has an important role to play in developing,

negotiating and aligning expectations, especially as healthcare organisations and consequent

expectations of staff are changing.

It is a known fact that the primary front-line staff (customer-facing employees) in the healthcare

industry is doctors and nurses. According to Korczynski (2002) the doctors have a more

impersonal relationship with the patients while the nurses provide tender loving care. The

interaction of the doctors is limited to the diagnosis and discussions related to the treatment and

during the treatment. However, the nurses interact with patients throughout their stay as in-

patients. They pay regular visits to the patient and help them with their needs.
Korczynski (2002) states that this form of authority is in line with bureaucratic authority and is

termed as 'medical rational authority'. 'Patient advocacy', where nurses act as the voice for the

often voiceless patients is a concept exclusive to the healthcare organizations and something that

contradicts the concept of medical rational authority. In the current scenario of healthcare sector,

especially for the profit-maximizing hospitals, another distinct challenge to medical rational

authority is the importance given to hospitality of the patients.

2.3.2 Patient Centered Care

Although the direct assessment of work practices and performance in healthcare trails similar

inquiries in other industries, researchers have examined the relationship between a variety of

work arrangements and patient care indicators. For example, researchers have studied the

relationship between human resource management (HRM) practices, teamwork and relational

coordination, and quality of patient care. Gittell et al. (2010), West et al. (2006), Preuss (2003),

Borrill et al. (2000) and Aiken et al. (1994) all provided one of the first comprehensive analyses

of the link between work practices and healthcare related performance outcomes.

According to Ash and Seago (2004) the effects of workplace practices on organizational

outcomes in healthcare is also available from studies of the relationship between unionization

and organizational performance. Taken together, this evidence suggests that other work-related

systems and practices that promote communication and collaboration, such as Patient centered

care, are likely to increase the quality of patient care as well. A number of areas remain relatively

under explored in this growing body of literature. First, much of the research on work practices

in healthcare has focused on those that provide employees with a greater level of input and

coordination.
Gittell et al. (2008) surveyed that patient centered care, provides a unique opportunity to examine

a workplace innovation that is intended to affect both patients and the workforce that cares for

them i.e. for a similar analysis regarding the effects of relational coordination on employee and

patient outcomes. Gittell et al. (2010) felt that studies regarding work organization in the

healthcare setting have tended to focus either on innovations regarding the delivery of care, such

as patient rounding and clinical pathways, or on work practice innovation, such as the use of

High involvement work practices (HIWP) and other HRM practices. There is apparently little

research that examines the complementarities between how patients are cared for and how

frontline staff performs their work.

2.3.3 The Effects of Patient-Centered Care on Quality of Care and Patient Satisfaction

Robinson et al. (2008), Wolf et al. (2008) and Daviset al. (2005) stated that the Patient centered

care (PCC) approach to the over arching goal of the Patient centered care (PCC) model is to

provide care that is most conducive to patients preferences, needs and desires. The Patient

centered care (PCC) approach to healthcare departs from the physician or institution centered

model, which places almost all the power and authority regarding patient care in the hands of the

treating professionals, primarily the physicians and the organizations in which treatment is

provided.

Wolf et al (2008), Lemieux Charles and McGuire (2006) observed that the primary mechanism

used to deliver patient-centered care is the organization of work around inter disciplinary teams.

The Institute of Medicine claims that this newer model of patient care necessitates a particular

work design aimed at increasing coordination and opportunities for patient and staff input, and

this was even stated by Corrigan et al. (2001). In fact, this dimension of Patient centered care
resembles other well established work arrangements that have received significant attention in

the literature.

Researchers found that the focus on quality through specific “production” processes, staff

engagement, involvement and coordination on productivity and performance outcomes are

similar to the innovations currently pervading healthcare. Unlike the HIWP model however,

Patient centered care entails the facilitation of input and participation from both frontline staff

and the patients for whom they care. According to Audet et al. (2006), Bergeson and Dean

(2006), Davis et al. (2004) and Fiach et al. (2004) the existing Patient centered care literature has

identified five dimensions of the delivery care model i.e. (1) access to care (2) patient

engagement in care or patient preferences (3) patient education or information systems (4)

coordination of care across hospital staff and (5) patient emotional support.

Charmel and Frampton (2008) and Wolf et al. (2008) feel that despite the increased use of

patient centered care-based methods for delivering care, empirical research has not kept pace

with them, and the evidence regarding their effectiveness is limited. What evidence there is

supports a positive relationship between the adoption of Patient centered care and improved

quality of care outcomes.

2.3.4 Patient Satisfaction

Hospitals have always been a place of care that provides the population with complete

healthcare, both curative and preventive. In the hospitals, quality of care is measured with two

metrics: patient outcomes and patient satisfaction. Satisfaction is a person’s feelings of pleasure

or disappointment resulting from comparing a product’s or service’s perceived performance (or

outcome) in relation to his or her expectations. (Kotler, 2000). Patient satisfaction is defined as

the appraisal, by an individual, of the extent to which the care provided has met that individual’s
expectations and preferences (Brennan 1995). It is the degree to which the individual regards the

healthcare service, product or the manner in which it is delivered by the provider as useful,

effective, or beneficial (Online Medical Dictionary, 2012). Patient satisfaction mostly appears to

represent attitudes towards care or aspects of care (Jenkinson et al.. 2002).It is referred to patient

satisfaction as patients’ emotions, feelings and their perception of delivered healthcare services

(Mohan & Saikumar, 2011). The concept of patient satisfaction is multidimensional, and reflects

patient perceptions and expectations compared to the actual care they receive (Edlund MJ,et al,

2003) . Speight (2005) saw that the implicit in patient satisfaction definitions is the assumption

that the patient attaches values to specific attributes of the treatment or service, and that these are

unique to each individual’s experience. It is found that patient satisfaction increases patient

retention, willingness to recommend, improve the rate of patient compliance with physician

advice and requests. It improves trust, loyalty and decreases the number of lawsuits. Service

quality is often regarded as the antecedent of patient satisfaction Irfan (2012), Speight (2005),

Zarei et al. (2012), Shan et al. (2016). For these reasons patient satisfaction survey is an effective

tool that provides information and insight on patients’ views of the services they receive. For the

purpose of this research overall patient satisfaction was defined as “the extent to which

outpatient is content with the healthcare services which they received from al-Bashir Hospital”.

A number of studies report that Patient’s satisfaction is influenced by a number of factors and

according to Peprah (2014), the following factors play a critical role in the satisfaction of

patients; the attitudes of nurses toward patients, the capacity to deliver prompt service without

wasting time, ability to disseminate information to patients and the availability of up-to-date

equipment. Others include the hospital’s ability to render 24 hour service, the patience of the

doctor to clearly explain what was wrong with patients before giving treatment, providing
patients with detail information about their medication, and attractiveness and cleanliness of the

hospital.

2.3.5 Patient Satisfaction and Service Quality Dimensions

A review of the literature reveals numerous studies that have reported a positive relationship

between satisfactions and measures of purchase intentions and between service quality

perceptions and satisfaction. Researchers have identified several possible variables that may

result in patient's satisfaction with physician's services. These variables have generally included

perceived physician's competence, care and concern towards patients, cost of treatment and

communication between the physician and patient.

Bonshoff and Gray have conducted the studies on the relationships between service quality,

customer satisfaction and buying intentions in the private hospital industry. The studies

conducted aim to investigate the structural relationship between out patient satisfaction and

service quality dimensions where patients have substantial freedom in choosing their medical

service providers and to further study the causal relationship between service quality and

satisfaction.

An Exploratory Study on Service Quality Themes determining patient satisfaction with Health

Care delivery in India was conducted by Sachin Kamble who has stated that very little emphasis

was given by patients on service quality dimensions. Aim of the research was to acquire an

understanding of patient's interpretations of satisfaction. Understanding and measurement of

service quality as seen by the patient is equally important to nursing because it is a concept

integral to the provision of a better and more focused service for patients. Results stated that it is

necessary to capture information on patient's needs, expectations and perceptions. Main concerns

of patients relate to being treated with dignity and respect, given clear information and
psychological support. Older patients tended to be more satisfied with medical care services than

their younger counter parts. Results also revealed no consistent satisfaction pattern between male

and female patients.

The quality of services plays a primary role in achieving patient satisfaction (Margaritis E,

2012). Traditionally, service quality is assessed by certain measures, such as morbidity or

mortality.

However, in recent decades, the patients’ perception of their care has also been taken into

consideration (Shirley ED, 2013). Thus, the patients’ perception of the service quality

contributes critically to achieving satisfaction (Choi KS, 2004). In some studies, the positive

assessment of service quality is considered as satisfaction, and these terms are used

interchangeably; however, patient satisfaction is only one of several measures of care quality.

According to Carlucci D (2013) and Jen W (2011), quality judgments are fairly specific, whereas

satisfaction judgments are more general. Patient satisfaction is a positive or negative attitude

reflecting the patient’s feelings in relation to the received services. To obtain satisfaction, the

patient must experience a service; in contrast, the perceived quality of services is not necessarily

the result of experiencing those services (De Man S, 2002). The quality of services is associated

with cognitive judgments, whereas patient satisfaction is associated with affective judgments

(Choi KS, 2004 and Lai WT, 2011). The distinction between service quality as a cognitive

construct and patient satisfaction as an emotional construct suggests a causal relationship in

which the quality of services is a predictor of patient satisfaction (Choi KS, 2004). Several

studies have been done on the relationship between service quality and customer satisfaction.

Not surprisingly, the results show that the quality of services leads to higher satisfaction (Lai

WT, 2011 and Cronin JJ, 2000).

2.3.6 Patient Satisfaction and Behavioral Intention

Lovelock, Writz, and Chatterjee (2006) observed that a natural tendency in such situations is for

patients to use process factors and tangible cues as proxies to evaluate quality. In the competitive

service industries, if core service outcome is the same, the customer may evaluate the service

performance in terms of process quality. In the health care settings, the medical treatment and

medical outcome may be the same but the process quality framework may vary between the

hospitals. Researchers have tried to integrate the effects of clinical quality and process quality on

customer satisfaction and behavioral intentions. The majority of the patients with no or less

medical knowledge may not evaluate the clinical quality but may evaluate the process quality.

There is limited empirical research which has investigated the relationship between process

quality, patient satisfaction and behavioral intentions in the health care sector. However, certain

sub dimensions of process quality have been tested in different service industries. According to

Marley, Collier, and Goldstein, process quality is a result of the service (non-technical) delivery

process engaged in during and outside of the medical procedure. Process quality includes making

the patient’s experience in the hospital proceed efficiently and effectively. Examples of process

quality include the level of personalization and patient service provider interaction, delivery of

medication and food to the patient, the efficiency of admission and checkout, and the timeliness

and accuracy of hospital bills.

Kotler, Bowen, and Makens (2004) surveyed and found that the fundamental aim of today‟s total

quality movements has become total customer satisfaction.

Carrillat, Jaramillo, and Mulki (2009) in their survey noticed that studies demonstrate that

service quality has both a direct and indirect effect on attitudinal loyalty and purchase intentions.

The empathy of nursing staff and their assurance as per Boshoff and Gray (2004) enhance the
loyalty of patients in the case of private hospitals. Patients are more likely to return to a hospital

if they perceive the fees that they are charged as fair, reasonable and good value for the money

paid. The research findings based on developed countries may or may not be applicable to

developing and underdeveloped economies.

Improving the quality of medical care services has become a primary concern for patients, and,

in order to provide better service to patients, service quality has become increasingly important

for hospitals in respect of satisfying and retaining patients (Alhashem et al., 2011; Arasli et al.,

2008). Patients who value the relationships are more likely to stay loyal to their hospital (Kessler

and Mylod, 2011).

According to Carlucci D. (2013), Arab M. (2014), Sherly ED (2010) and Gasquet I (2004)

satisfaction is important from several aspects for healthcare organizations. Satisfied patients are

more likely to comply with treatment regimens, maintain a continuing relationship with a

physician, and thus enjoy better treatment. Therefore, through the continuity of care and

adherence, patient satisfaction has the potential to improve health care outcomes (Sherly ED,

2010).

2.3.7 IT- Assisted Communication in Patient Care

It is seen that the business value of IT literature is replete with exam plus describing relationships

between IT and various types of value and suggestions as to what to control, how to measure,

and when to measure. What seems apparent from this stream of research is that “context”

matters. It is observed that researchers do not often delve into key contextual questions such as

“Why does a hospital adopt information technology?” Is it out of competitive necessity, or the

belief that there is value associated with the use of IT? Or is it simply the government

requirement that makes it necessary to adopt it? These and other explanations have been used to
explain why firms, in general adopt IT, but as it are noted earlier; the intent of the adopter or

context under which the IT was adopted determines what “success” really is.

2.3.8 Performance measurement approach in an outpatient department

Schantin (2004) states that a business process is a sequence of steps which transform inputs into

outputs. It is customer focused, i.e. is activated by market and external or internal customer

needs, value adding, i.e. creates value which is appreciated by the customer, and has a process

owner who has the end-to-end responsibility for the whole process. Furthermore it has access to

all necessary resources and information. As per Reijers (2006) process orientation means

focusing on business processes ranging from customer to customer instead of placing emphasis

on functional structures. Davenport (1993) too feels that process orientation does not only work

for process industry, but can be applied to service industries as well. There is empirical proof that

hospitals with a high degree of process orientation are moderately but significantly more

efficient as per Vera & Kuntz (2007).

2.3.9 Business Process Management

Management approach according to Gulledge & Sommer (2002) has gained much advertence in

industrial engineering and management literature, but less in public sector management

literature. Smith & Fingar (2003) too found that Business process management does not only

incorporate the discovery, design, deployment and execution of business processes, but also

interaction, control, analysis and optimization of processes.

By focusing measurement on processes rather than functions, Hammer (2007) concluded that

alignment and common focus across separate organizational units can be achieved.

Implementing measures and taking corrective actions are operating precepts of process
 management. With the help of measurement, a process can be controlled. Process control is an

important part of business process management.

2.4 Effective Concept

It is noticed that patient’s perception about health care systems seems to have been largely

ignored by healthcare managers in developing countries. Patient satisfaction depends upon many

factors such as: quality of clinical services provided, availability of medicine, attitude, behavior

of doctors and staff, cost of services, hospital infrastructure, physical comfort, emotional support

and respect for patient preferences. Mismatch between patient expectation and the service

received is related to decreased satisfaction. Therefore, assessing patient’s perspectives

according to World Health Organization, Report (2000), gives them a voice which can make

private and public health services more responsive to people’s needs and expectations.

There are very few studies in India that measure patient satisfaction with the services provided

by the healthcare organizations. Patient satisfaction surveys are useful in gaining an

understanding of user’s needs and their perception of the services received. Patients attending

each hospital are responsible for spreading the good image of the hospital and hence the

satisfaction of the patients attending the hospitals is equally important for the hospital

management. Surveys of (OPD) outpatient’s services have elicited problems like overcrowding,

delay in consultation, proper behavior of staff, logistic arrangements, support services, nursing

care, doctor’s consultation, etc. If there are delays in consultation it has to be explored to elicit

the lacunae.

There is tremendous scope to improve the OPD services of a public or private hospital. More

than a decade ago, two landmark reports: The World Health Organization’s- The World Health

Report (2005) and the Institute of Medicine’s crossing the Quality Chasm (2001) called for the
realignment of incentives to balance the competing goals of cost containment and quality

improvement. Both reports concluded that responsiveness to citizen’s expectations was a valued

and desired outcome of health care performance.

Efforts to measure patient satisfaction have thus increased and in some countries, incentives have

been adopted to increase patient satisfaction and care. Till today few studies in the developing

settings were conducted to understand the types of relationships that exist between patient-

loyalty and service quality. The hardworking competitive scenario and mushrooming growth of

service organization have invigorated the need to look beyond customer satisfaction towards

customer retention and loyalty.

Thus, it is important to determine the exact way of tracking patient perception over the time as

well as diagnosing where healthcare services need to be improved. Hence, the researcher sees a

definite gap, i.e. a need for a comparative study of patient satisfaction in private and public

hospitals so as to get an insight as to why a patient uses the same hospital for same treatment,

same hospital for other ailments and why he refers the same hospital to other patients.

To be the leaders in today’s challenging scenario of cut throat competition among hospitals, all

private and public hospitals need to take a fresh competitive look at their objectives and

incorporate patient relationship management philosophies to improve their image. Though

patient relationships have found to be part of reputed hospitals like Apollo and Fortis, more

codified patient relationship management is still to be incorporated. This stands to be followed in

the western countries as well. There are no studies available that analyze the Impact of

Healthcare services on outpatient satisfaction in Public and Private Hospitals; hence the need to

conduct a study in these areas is very important.

Customer satisfaction as an important determinant of success and long-term survival in the

health care industry has caught the providers’ attention in the present competitive conditions

(Laohasirichaikul, Chaipoopirutana, & Combs, 2010). For the hospitals, satisfied patients are

important because the patients’ greater satisfaction with the care would entail the patients’ more

adherence of the doctor’s orders, more loyalty, positive word of mouth by the patient, reducing

the number of the patient’s complaints, higher profitability, higher rates of the patient return and

more patient referrals (Choi, Cho, S. Lee, H. Lee, & Kim, 2004; Dawn & Lee, 2004; Wu, 2011).

For these reasons, the patient’s satisfaction evaluation has become a part of the strategic process

of health care organizations. Measuring the patient satisfaction and recognition of its effective

factors is important to the health care managers due to the impacts they make on the health and

financial results of the health care organizations (Raposo, Alves, & Duarte, 2009).

Customer satisfaction is a general attitude that is formed based on the customer experience after

the purchase of a product or consuming of a service that is manifested through an affective

reaction in relation with the difference between what the customer expects and what he/she

receives (Lai & Chen, 2011; Liu, Guo, & Lee, 2011). If the received services by the patient be

weak and inconsistent with his/her expectations, he will then be dissatisfied. However if the

received services conform to or beyond the patient’s expectations, this will result in his/her

satisfaction (Laohasirichaikul et al., 2010). In other words, satisfaction reflects the degree to

which a customer believes the usage of a service has caused positive feelings in him (Cronin,

Brady, & Hult, 2000).

2.4.1 Service Quality Concept

The interest in health care service quality is increasing. With increasing pressure to measure

quality, patient based assessments of medical care are becoming increasingly important. Patients
offer a unique perspective for evaluating the nontechnical aspects of medical care. In literature,

there are various definitions of healthcare service quality. The Institute of Medicine defines

healthcare quality as "the degree to which healthcare services for individuals and populations

increase the likelihood of desired health outcomes and are consistent with current professional

knowledge (U.S.National library of medicine, 2017). According to Donabedian (1988),

healthcare quality is “the application of medical science and technology in a manner that

maximizes its benefit to health without correspondingly increasing the risk”. Ovretveit &

Twonsend (1992) looked to healthcare service quality care as “the provision of care that exceeds

patient expectations and achieves the highest possible clinical outcomes with the resources

available”.

Mosadeghrad (2011) defined Quality healthcare as “consistently delighting the patient by

providing efficacious, effective and efficient healthcare services according to the latest clinical

guidelines and standards, which meet the patient’s needs and satisfies providers”. For the

purpose of this research healthcare service quality is defined as “healthcare services provided in

Murshid hospital whose characteristics and features meet or exceed patient’s needs and

expectations”.

The patient’s perception of the service quality plays an important role in achieving customer

satisfaction and the causal relationship between the service quality and satisfaction has been an

important topic of discussion in many relevant studies (Choi et al., 2004; Karatepe, 2011).

Zeithaml, Berry and Parasuraman (1996) in their study of service quality consequences have

pointed out that customer perception of the service quality is the most important predictor of the

customer satisfaction. In practice, satisfaction and quality are often used interchangeably, but the

consensus of researchers is that these are two distinct constructs, although highly correlated with
each other (Padma et al., 2010). The quality judgments are relatively specific, while the

satisfaction judgments are mainly general (Jen, Tu, & Lu, 2011). To achieve satisfaction, the

patient should experience a service while the perceived service quality is not necessarily the

result of an experience of a particular service (De Man, Gemmel, Vlerick, Van Rijk, & Dierckx,

2002). Also the quality of services is related to the cognitive judgments, while the customers’

satisfaction relates to the affective judgments (Choi et al., 2004; Lai & Chen, 2011). The

differentiation between the service quality as a cognitive construct and the customers’

satisfaction as an affective construct suggests a causal relationship in which the service quality is

a predictor for the patient satisfaction (Choi et al., 2004). H. Lee, Y. Lee and Yoo (2000)

conclude that the customers are (dis) satisfied only when they have perceived and experienced

the services; this shows that the service quality evaluation has priority over the customers’

satisfaction. Therefore the service quality is often seen as the customers’ satisfaction antecedent

(Dabholkar, Shepherd, & Thorpe, 2000; Lei & Jolibert, 2012; Amin, Yahya,

Ismayatim, Nasharuddin, & Kassim, 2013) and the notion that the service quality has a direct

effect on satisfaction, has been widely accepted (Cronin & Taylor, 1992; C. M. Chen, S. H.

Chen, & Lee, 2013).