Impact of Healthcare Services On Outpatient Satisfaction in Public and Private Hospitals A Study of Hospitals in Mumbai Navi Mumbai Thane Pune and Surat Satvinder Singh Bedi PDF

Impact of Healthcare services on Outpatient Satisfaction in
Public and Private Hospitals: A study of Hospitals in Mumbai,

Navi Mumbai, Thane, Pune and Surat.
Thesis Submitted to D.Y.Patil University, Navi Mumbai

Department of Business Management,
In partial fulfillment of the requirements for the award of the
Degree of
DOCTOR OF PHILOSOPHY
In
BUSINESS MANAGEMENT
Submitted by
Satvinder Singh Bedi.
(Enrolment No.DYP-PhD-116100009)
Research Guide
Prof. Dr. R. GOPAL
Director, Dean & Head of Department
D.Y. Patil University, Navi Mumbai

Department Of Business Management,
Sector 4, Plot No. 10,
CBD Belapur, Navi Mumbai – 400 614
August, 2014
Impact of Healthcare services on Outpatient Satisfaction in
Public and Private Hospitals: A study of Hospitals in
Mumbai, Navi Mumbai, Thane, Pune and Surat.
DECLARATION
I hereby declare that the thesis titled “Impact of Healthcare services on Outpatient
Satisfaction in Public and Private Hospitals: A study of Hospitals in Mumbai, Navi
Mumbai, Thane, Pune, and Surat”,submitted for the Award of Doctor of Philosophy
(Ph.D) in Business Management at D.Y. Patil University, Navi Mumbai, Department
of Business Management, is my original work and the Dissertation has not formed the
basis for the award of any degree, associateship, fellowship or any other similar titles.
The materials borrowed from other sources and incorporated in the thesis have been
duly acknowledged.
I understand that, I myself could be held responsible and accountable for plagiarism,
if any, detected later on.
The research papers published are based on the research conducted in the course of
the study and are also based on the study and not borrowed from other sources.
Date: Signature of the student
Enrolment No: DYP-PhD-116100009
i
CERTIFICATE
This is to certify that the thesis titled “Impact of Healthcare services on Outpatient
Satisfaction in Public and Private Hospitals: A study of Hospitals in Mumbai, Navi
Mumbai, Thane, Pune, and Surat”, submitted by Satvinder Singh Bedi is a bona fide
research work for the award of the Doctor of Philosophy in Business Management at
D.Y Patil University, Navi Mumbai, Department of Business Management, in partial
fulfilment of the requirements for the award of the Degree of Doctor of Philosophy in
Business Management and that the thesis has not formed the basis for the Award
previously of any degree, diploma, associate ship, fellowship or any other similar title
of any University or Institution. Also certified that the thesis represents an
independent work on the part of the candidate.
Place:
Date:
Signature of the Signature of the Guide

Head of the Department
ii
ACKNOWLEDGEMENT
I am greatly indebted to D. Y. Patil University, Department of Business Management

which has accepted me for the Doctoral program and provided me with an excellent
opportunity to carry out my research work.
I am extremely grateful to Prof Dr R. Gopal my guide, for his professional

competence, encouragement and patience. A person of great vision and intelligence
without whose advice and proper guidance, it would not have been possible to
complete my research.
I dedicate this work to the loving memory of my mother, who has been the guiding
light in my life.
For the development of this work itself I feel a deep sense of gratitude to my wife
Gursharan for believing in me and who has always been my pillar of support.
I am deeply thankful to my children Kabir and Aanchal for their love and patience.
I express special thanks:
To my Father and the rest of my family for their constant interest and support.
To the Trustees and management of Padmabhushan Vasant Dada Patil
Pratishthan‟s College of Engineering, for their cooperation.
To Dr Ramanj Balram, Dr Ruchika Sood, Mr. Ajay Saraf, Ms Rachel Rego
and all my other management students for helping me in my research work.
To Ms Nilam Nindrojiya for her invaluable effort to compile my work.
To Dr Aruna Deshpande, Dr Rajendra Sawant, Dr Nayana Mody, Dr Alka
Bhedi, Dr Manjeet Singh, Dr Ashok Rathod and Dr Shashank Dhond for their
keen interest and well wishes.
Place:
Date:
Signature of student:
iii
I dedicate this work to the loving memory of my
mother, who has been the guiding light in my life.
iv
TABLE OF CONTENTS
Chapter No Title Page

. No.
DECLARATION
i
CERTIFICATE
ii
ACKNOWLEDGEMENT iii &
iv
LIST OF TABLES
x
LIST OF DIAGRAMS
xiv
LIST OF ABBREVIATIONS
xviii
EXECUTIVE SUMMARY xx
1 INTRODUCTION 1
1.1 Service Process of Hospitals in India 3
1.2 Human Resource Management in Indian Hospitals 3
1.3 Emerging Healthcare in India 5
1.4 Understanding Indian Healthcare 6
1.5 Surveys of inpatients and outpatients widely used 8
1.6 Patient care Innovation 11
1.7 Patient Satisfaction 12
1.8 Service Encounter 14
1.9 Healthcare Business Process 16
1.10 ERP Systems in Healthcare Institutions 19
1.11 Gaining Patients Trust 21
1.12 Human Performance Improvement in the Health Care 25

Organizations.
1.13 Retaining Customers 27
v
1.14 Customer orientation for delivering service quality to 30
patients
Factors affecting patient satisfaction and healthcare 30

1.15
quality
1.16 The service quality dimensions and patient satisfaction 31

relationships
LITERATURE REVIEW 34
2
Studies done on medical services quality in Hospitals. 38
2.1
Value in the word-of-mouth 43
2.2
Role of HRM in Healthcare Organizations 46
2.3
Patient centered care 51
2.4
The Effects of Patient-Centered Care on Quality of 52
2.5
Care and Patient Satisfaction
Patient Satisfaction and Service Quality Dimensions 54
2.6
Patient Satisfaction and Behavioural Intention 55
2.7
Service Quality Satisfaction 58
2.8
IT-Assisted Communication in Patient Care 60
2.9
Performance measurement approach in an outpatient 60
2.10 department
Community Hospital Healthcare System 61

2.11
Hospital & Physicians 63
2.12
Competition between hospitals and physicians 64
2.13
Quality in Healthcare – measuring the gap 64
2.14
Manager and Patient Perception 65
2.15
Research Gap 74
2.16
OBJECTIVES HYPOTHESIS AND RESEARCH 76
3
METHODOLOGY
vi
Objectives 77
3.1
Statement of Hypothesis 77
3.2
Research Methodology
3.3 78
4 GLOBAL HEALTHCARE SCENARIO 81
4.1 The global healthcare services market 81
4.2 Healthcare adapts to a global outlook 81
4.3 Global Healthcare Industry 82
4.4 Key Market Segments 83
4.5 Market Overview 84
4.6 Market Segmentation 84
4.7 Geography segmentation 84
4.8 Healthcare in the Global Market place 85
4.9 International Healthcare Ventures 86
4.10 Global Healthcare Strategies 87
4.11 Health Insurance 89
4.12 Preparing the 21st century global healthcare workforce 89
4.13 Movement of Personnel 91
4.14 Push and Pull Factors 92
4.15 Nursing Shortage: A global problem 93
4.16 Outsourcing in the Healthcare sector 97

Medical Tourism: Globalization of the Healthcare
4.17 Marketplace 101
INDIAN HEALTHCARE INDUSTRY 106

5
Healthcare market size 106
5.1
Government Ventures 107
5.2
vii
Healthcare sector growth 109
5.3
Per-capita healthcare expenditure 110
5.4
111
Trends in Healthcare Industry in India
5.5
Conventional models of business 112
5.6
Comparative low costs and Medical Tourism 114
5.7
Rural India's healthcare 115
5.8
Indian Healthcare Industry 117
5.9
India‟s Healthcare Achievements 121
5.10
Health care expenditure in India 122
5.11
Healthcare services for the rural and s emi- 124
5.12 urban segments in India
Hospital Services Market in India 128

5.13
Key Stake Holders of any Health and Hospital setup 130
5.14
Major Hospitals in India 132
5.15
CUSTOMER SATISFACTION 136
6
Importance of Customer Satisfaction 136
6.1
Customer Satisfaction Surveys 140
6.2
Customer Satisfaction and Brand Equity 142
6.3
Customer delight 144
6.4
PATIENT SATISFACTION AND LOYALTY 147
7
Patient Satisfaction 147
7.1
Improving Satisfaction 149
7.2
The Effects of Patient-Centered Care on Satisfaction 151
7.3
Patient Loyalty 153
7.4
Patient satisfaction and its dimensions 155
7.5
viii
MAJOR FINDINGS AND CONCLUSIONS PART- I 160
8
160
8.1 Demographic Factors
Variables of Study 166
8.2
MAJOR FINDINGS AND CONCLUSIONS PART-II 180
9
Hypothesis Testing 180
9.1
250
SCOPE FOR IMPROVEMENT AND
10
RECOMMENDATIONS
BIBLIOGRAPHY 255
Annexure I
QUESTIONNAIRE FOR USERS 293
Annexure II
STATISTICAL TABLES OF SPSS FINDINGS 297
Annexure III
ix
List of Tables
Table No Title Page

No
1. Sample size (Hospitals) 79
2. Sample size (Respondents ) 79
3. Type of Hospital 160
4. City 161
5. Age group 162
6. Gender 163
7. Frequency of visit 164
8. Monthly Income 165
9. Tangibles 167
10. Tangible score 168
11. Tangible level 168
12. Reliability 169
13. Reliability score 170
14. Reliability level 171
15. Responsiveness 172
16. Response score 173
17. Response level 173
18. Assurance 174
19. Assurance score 175
20. Assurance level 176
21. Empathy 177
x
22. Empathy score 178
23. Empathy level 178
24. Association between type of hospital and „tangibles‟ 180
25. Association between type of hospital and „reliability‟ 182
26. Association between type of hospital and „response‟ 183
27. Association between type of hospital and „assurance‟ 184
28. Association between type of hospital and „empathy‟ 186
29. ANOVA for Type of hospital 187
30. Mean 188
31. Association between different cities and „tangibles‟ 190
32. Association between different cities and „reliability‟ 192
33. Association between different cities and „response‟ 193
34. Association between different cities and „Assurance‟ 195
35. Association between different cities and „empathy‟ 197
36. ANOVA 198
37. Mean 199
38. Association between male and female respondents and 201

„tangibles‟

„Reliability‟

„Response‟

„Assurance‟
xi
„Empathy‟
43. ANOVA 209
44. Mean 210
45. Association between different age groups and „Tangibles‟ 212
46. Association between different age groups and „Reliability‟ 214
47. Association between different age groups and „Response‟ 215
48. Association between different age groups and „Assurance‟ 217
49. Association between different age groups and „Empathy‟ 218
50. ANOVA 220
51. Mean 221
52. Association between different income groups and 223

„tangibles‟

„Reliability‟

„Response‟

„Assurance‟

„Empathy‟
57. ANOVA 232
58. Mean 233
59. Association between patients frequency of visits and 235

„tangibles‟

„Reliability‟
xii
„Response‟

„Assurance‟

„Empathy‟
64. ANOVA 244
65. Mean 245
66. Type_of_Hospital Monthly_Income Crosstabulation 247
67. Correlations 249
xiii
List of Diagrams
S. No. Title Page

No.
1. Human resource management 47
2. Market Segmentation 84
3. Geography segmentation 85
4. Healthcare Spending as a percentage of GDP 86
5. The Future of Nursing: Focus on Education 95
6. Total healthcare revenue value wise. 109
7. Total healthcare revenue percentage wise. 109
8. Total healthcare expenditure value wise. 110
9. Total healthcare expenditure percentage wise. 110
10. Pyramidal structure of healthcare in India 113
11. Rural healthcare system in India 116
12. Base of Pyramid 126
13. The Key Stake holders of any Health and Hospital set up 131
14. Customer Satisfaction Surveys 140
15. Customer Satisfaction 146
16. Responsibility for Improving Patient Satisfaction 150
17. Diagram of respondents according to type of hospital 161
18. Diagram of respondents according to city 162
19. Diagram of respondents according to age group 163
20. Diagram of respondents according to gender 164
21. Diagram of respondents according to frequency of visit to 165

hospital
22. Diagram of respondents according to monthly income of 166
xiv
respondent
23. Diagram of respondents according to satisfaction for 'tangible' 169
24. Diagram of respondents according to satisfaction for 'reliable' 171
25. Diagram of respondents according to satisfaction for 'response' 174
26. Diagram of respondents according to satisfaction for 176

'assurance'
27. Diagram of respondents according to satisfaction for 'empathy' 179
28. Diagram of respondents according to type of hospital and level 181

of satisfaction of tangible

of satisfaction of reliability

of satisfaction of response

of satisfaction of assurance

of satisfaction of empathy
33. Diagram of scores of satisfaction according to type of 189

hospitals
34. Diagram of respondents according to city (Tangibles) 191
35. Diagram of respondents according to city (Reliability) 192
36. Diagram of respondents according to city (Response) 194
37. Diagram of respondents according to city (Assurance) 196
38. Diagram of respondents according to city (Empathy) 197
39. Mean 200
40. Diagram of respondents according gender (Tangibles) 202
xv
41. Diagram of respondents according to gender (Reliability) 203
42. Diagram of respondents according to gender (Response) 205
43. Diagram of respondents according to gender (Assurance) 206
44. Diagram of respondents according to gender (Empathy) 208
45. Mean 211
46. Diagram of respondents according to age group (Tangibles) 213
47. Diagram of respondents according to age group (Reliability) 214
48. Diagram of respondents according to age group (Response) 216
49. Diagram of respondents according to age group (Assurance) 217
50. Diagram of respondents according to age group (Empathy) 219
51. Mean 222
52. Diagram of respondents according to income group(Tangibles) 224
53. Diagram of respondents according to income group(Reliability) 226
54. Diagram of respondents according to income group(Response) 227
55. Diagram of respondents according to income group(Assurance) 229
56. Diagram of respondents according to income group(Empathy) 231
57. Mean 234
xvi
58. Diagram of respondents according to frequency of 236
visit(Tangibles)
59. Diagram of respondents according to frequency of visit 238

(Reliability)

visit(Response)

visit(Assurance)

visit(Empathy)
63. Mean 246
64. Diagram of respondents according to income group and type of 248

hospital
xvii
LIST OF ABBREVIATIONS
1. (AHC) : Academic health center

2. (AIIMS) : All India Institute of Medical Sciences
3. (AMA) : American Marketing Association
4. (AMI) : Acute Myocardial Infarction
5. (ANDA) : Abbreviated New Drug Application
6. (ASC) : Ambulatory Surgical Centers
7. (BoP) : Bottom of Pyramid
8. (BPL) : Below The Poverty Line
9. (CAGR) : Compound Annual Growth Rate
10. (CLGs) : Credit-Linked Groups
11. (COB) : Customer-Oriented Bureaucracy
12. (DCI) : Dental Council of India
13. (DIPP) : Department of Industrial Policy and Promotion
14. (EFQM) : European Foundation for Quality Management
15. (ERP) : Enterprise Resource Planning
16. (FTE) : Full Time Equivalent
17. (GDP) : Gross Domestic Product
18. (GPs) : General Practioners
19. (HIT) : Health Information Technologies
20. (HIWS) : High Involvement Work Systems.
21. (HPI) : Human Performance Improvement
22. (HPWS) : High Performance Work System
23. (HRM) : Human Resources Management
24. (IMG) : International Medical Graduates
25. (IMS) : Institute for Healthcare Informatics
26. (IOM) : Institute of Medicine
27. (IPHS) : Indian Public Health Services
28. (JV) : Joint Ventures
29. (LPC) : London Patient Choice Project
30. (M&A) : Mergers and Acquisitions
31. (MCI) : Medical Council of India
32. (MoU) : Memorandum of Understanding
xviii
33. (NCI) : Nursing Council of India
34. (NHS) : National Health Service
35. (OOP) : Out Of Pocket
36. (PCC) : The Patient centered care
37. (PCI) : Pharmacy Council of India
38. (PHI) : Protected health information
39. (PPP) : Public Private Partnership
40. (QM) : Quality Management
41. (RN) : Registered nurses
42. (RSBY) : Rashtriya Swasthya Bima Yojana
43. (STGs) : Standard Treatment Guidelines
44. (TCs) : Treatment Centers
45. (UHIS) : Universal Health Insurance Scheme
46. (WHO) : World health organisation
xix
Executive summary
It is a known fact that managing a Hospital to serve its purpose requires specialized
knowledge and skills. A Hospital administrator is a manager of resources. These
resources in a country like India are scarce. The success of a Hospital depends upon
how well it utilizes these available resources to get optimum results.
It is of utmost importance, for the Hospital authorities to understand the processes

involved which contribute to a favourable overall experience for the patients. The
overall experience for the patients involve a number of factors such as doctor‟s
competence, his interaction with the patients, behaviour of the paramedical staff,
various facilities offered by the hospital, behaviour of support staff and overall
hygiene and ambience of the hospital.
It is observed that because of cut throat competition and mushrooming of service

organizations there is an urgent need to look beyond customer satisfaction, i.e.
towards customer retention and loyalty. As such organizations are striving hard to
redesign and reinvent their operational methodologies by building strong and effective
organization cultures so as to have a focus on the consumer loyalty and relationship
management like all other service sectors.
Today there is tremendous pressure of competition and society is quickly

transforming itself into a consumer - centred market. Consumers are making choices
that promote their effective value and companies work hard to establish marketing
strategies that promote such effective value perceived by consumers in order to
enhance customer satisfaction and corporate performance. The same is applicable in
the Health care industry also.
Studies indicate that the organizations which endeavour to measure relationship and
patient loyalty, have a lot of advantages such as sustaining competitive pressure,
increasing loyalties, reducing the need to compete solely on price basis and increasing
new patient base by referrals. This study will help the providers in developing
stronger and more comfortable relationships with the consumers i.e. the patients and
instil more confidence in them so that they avoid seeking out and evaluating other
providers.
xx
Thus it is seen that that healthcare should make genuine efforts to have a better
understanding of how to develop and nurture long-term patient-provider relationships.
The patients in general develop loyalty towards hospitals and these are based on
significant interpersonal experiences they have with the doctors and nurses and the
quality of services of the hospital.
The Healthcare industry in India offers many challenges for healthcare professionals.
Our country has a weak regulatory system in checking healthcare institutions. At least
two-thirds of healthcare expenditure is on outpatient care, and lifestyle diseases are
being seen as a new area in the field of medicine. Less awareness of Medical
Insurance has resulted in people paying from their pockets for medical treatment.
Therefore, a very different and dynamic effort is required to get into the domiciliary
healthcare segment.
It is observed that in the recent past Hospitals had very little familiarity with
marketing research. That has changed dramatically in recent years. Today hospitals
are increasingly adopting marketing strategies and research to help them understand
opportunities and problems. Hospitals need to pay more attention and invest more in
market research activities. Today health care executives are under tremendous
pressure and have to put in a lot of effort to increase revenues, reduce costs and
develop partnerships with other providers.
It shows as a result that, nearly all health care organizations have developed strategic
plans to create strategies for coping with the ever-changing nature of the industry. As
part of the core planning process, health care organizations have resorted to marketing
research as a means to achieve these goals. Marketing research is basically the
objective and systematic method of gathering, analyzing, and interpreting data which
caters to a specific situation or problem facing the Healthcare organization.
It is proved that Research is the cornerstone of good marketing planning. Like other
different types of business, hospitals have existing services, new service ideas, and
patients who affect business. It has been observed that, the hospital's customer has a
choice and knows his or her importance. Knowing the needs, wants, and decision-
making processes of potential customers is extremely important for the success of a
Hospital.
xxi
Review of literature
The review of the literature reveals many studies that have shown a positive
relationship between satisfactions and measures of buying intention and between
service quality perceptions and satisfaction. Researchers have identified several
possible variables that may result in patient‟s satisfaction with the doctor‟s services.
Some studies state 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
tend to be more satisfied with medical care services than their younger counterparts.
According to researchers Fred David, Garner C. Alkin (2006), variables like

perceived physician‟s competence, care and concern towards patients, cost of
treatment and communication between physician and patient are of utmost
importance. Many studies reveal that a lower priority is placed on patient‟s perception
on patient‟s run clinical expectations of service quality.
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. Results also show that the pattern of
relationships between service quality and patient satisfaction was similar across the
gender, age and service type sub groups.
It is understood that Organizations are striving hard to redesign and reinvent their
operational methodologies by building strong and effective organization culture so as
to have a focus on the consumer loyalty and relationship management. Hospitals are
facing competitive situations due to globalization and the open-door policy for the
Health care market. The economic growth and changed appreciation toward health
have continuously increased particular wants and needs of the general public. Hence,
large-sized hospitals are striving hard to expand medical facility investment, top
quality human resources and additional services in order to develop competitive
power. Such investments however, may increase cost and inefficiency to a great
extent.
xxii
Patient Care
It is observed that Patient centred care also looks into enhancing patient input and
taking care of patient‟s opinion on issues ranging from mealtimes to treatment
schedules. According to Rather et al. (2009) patient centred care is also made to
improve the functioning of frontline work and increase employee outcomes. Whereas
Shaller (2007) feels that at the heart of Patient centred care is the effort to establish a
care delivery system that can take care of the critical patient needs and preferences
while also structuring work in a way that will enhance frontline staff results, such as
turnover and job satisfaction.
There are studies which also show that internal and external customer orientation
allows an examination of both internal and external capabilities, just like learning
orientation does. Regarding internal customer it is quite obvious that they are the most
appropriate source of information, since they are the ones to embrace or reject
organizational values. As per Schneider et al. (1996), regarding quality of medical
care although patients are the obvious source of information, previous evidence has
shown that employee surveys are also valid when trying to predict customer
perceptions of satisfaction and service quality, as employee and customer perceptions
of service quality are positively related.
In their research Peabody et al, (1999) found that quality of care comprises of
structure, process and health outcomes. The concept of quality notes different
meanings to different stakeholders such as government, service provider, hospital
administration and patients. Managing service processes has a very special
significance in service industry as it offers a process for delivery of the services.
Efficient service offering creates unique customer experiences which would make the
consumers use the services.
Researchers Lovelock and Wright, (1999) asserted that consumers do believe in

moment of truth, it is a point in service delivery where customers meet and there is
interaction with the employees of the hospital and the outcome may affect the
perceptions of service quality. Hence, the hospitals must ensure that the front end and
back end processes are aligned in a manner that they demonstrate a positive moment
of truth for the customer.
xxiii
Marketing in Hospitals
It is a known fact that Health care executives are under constant pressure to increase
revenues, reduce costs and develop possible alliances with other providers. As a
consequence, virtually all health care organizations have developed strategic plans to
develop proactive strategies for coping with the dynamic nature of the industry. As
part of the strategic planning process, health care organizations have increasingly
turned to marketing research as a means to achieve these goals.
Marketing Research
In the recent past Hospitals had very little familiarity with marketing research. That
has changed dramatically in recent years. Today hospitals are increasingly adopting
marketing strategies and research to help them understand opportunities and
problems. As part of the core planning process, health care organizations have
resorted to marketing research as a means to achieve these goals.
It is understood that Marketing research is basically the objective and systematic

method of gathering, analyzing, and interpreting data which caters to a specific
situation or problem facing the Healthcare organization. Earlier unheard of in health
care, marketing research today is the norm in hospitals, particularly among larger
Hospitals located in highly competitive urban areas. Research applications are
particularly catering to for-profit institutions and those Hospitals which are involved
in care programs. The use of marketing research in other industries is prevalent since
many years, but only in the last two decades have hospital marketers made
widespread use of these strategies.
According to researchers the primary goal of the research being done is to help
hospital administrators take better decisions. Research should add to Hospitals base of
knowledge, whether it understands the patient‟s perceptions, evaluating the Hospitals
position in the marketplace, identifying problems and their sources, or testing
proposed solutions or better services. Research is the cornerstone of good marketing
planning. Like other different types of business, hospitals have existing services, new
service ideas, and patients who affect business. It has been observed that, the
hospital's customer has a choice and knows his or her importance. Knowing the needs,
xxiv
wants, and decision-making processes of potential customers is extremely important
for the success of a Hospital.
The use of marketing research in general industry predates the 1950s, but only in the
last two decades have hospital marketers made widespread use of these tools. The
primary goal of the research being done is to help hospital executives make better
decisions. Research should add to an institution's base of knowledge, whether it be
understanding consumer perceptions, evaluating an institution's position in the
marketplace, identifying problems and their sources, or testing proposed solutions or
new services. More than ever, the hospital's customer whether patient, physician, or
managed care organization has a choice among providers.
Findings suggest that knowing the needs, wants, and decision-making processes of
potential customers is critical to success. Market research is one source of information
that, if done well and interpreted correctly, can provide the extra competitive edge
that can mean the difference between success and failure in today's environment.
Hospitals can, and have, used marketing research for many purposes. For example, it
helps them better understand
How buyers will respond to potential new business lines.
How buyers define quality, service, convenience, and value, and the relative
importance of these features in the purchase decision.
The institution's perceived strengths and weaknesses in the opinion of buyers,
consumers, and providers.
What the market wants and needs and how best to meet those needs.
It is seen nowadays Hospitals also are using marketing research to address broader
problems and strategic issues such as competitive vulnerability, new markets for
existing products in alternative delivery systems, hospital image and identity. There
are many examples of marketing research being used successfully in the health care
industry to assess the strengths and weaknesses of specific services, measure
advertising effectiveness, guide recruitment and retention campaigns and develop new
product lines. There are examples that show the demise of hospital programs that
were instituted without the benefit of market research.
xxv
A mid-1980s study reported that two-thirds of the nation's hospitals relied on the
results of research studies they commissioned. Individual hospitals conducted market
research to update existing benchmark studies to determine the feasibility of new
services, determine the target market for new services, and evaluate reasons for lack
of acceptance of current programs. The size of the institution greatly affected research
use, with twice as many hospitals with 100 or more beds conducting marketing
research studies as hospitals with fewer than 100 beds. A survey of 200 hospital
administrators in the mid-1980s found that 72% of the hospitals routinely surveyed
patients, 62% routinely surveyed physicians, and only 55% routinely surveyed staff.
It was observed that despite the widespread use of patient and physician surveys, the
relative lack of employee surveys was surprising, given the low cost of conducting
such studies and their relevance to participatory management. In terms of involvement
of external groups, only 10% of the hospitals reported involvement with an
advertising agency. A more recent study examined the relationship between hospital
marketing activities, including the use of market intelligence activities. Market
intelligence activities included survey-oriented activities, analysis of competitor‟s
strengths and weaknesses and control activities including evaluating performance
against marketing objectives. The results suggested that higher usage levels of
marketing intelligence activities are much more likely to be related to higher
operating margins.
Findings of yet another study of hospital‟s use of marketing research concluded that,
although there has been some increase in usage since 1982, hospital market research
still appears to be underutilized. Patient satisfaction surveys and demographic profiles
were the most widely used research techniques used in these hospitals. The perception
that research is costly and time consuming, as well as uncertainty about how to use
the results, were mentioned most frequently as reasons for not utilizing research.
Research Gap
It is seen 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, behaviour of doctors and staff, cost of services, hospital
xxvi
infrastructure, physical comfort, emotional support and respect for patient
preferences. Mismatch between patient expectation and the service received is related
to decreased satisfaction.
According to the World Health Organization, Report (2000) assessing patient‟s

perspectives 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 and few studies in the developing settings were conducted to understand
the types of relationships that exist between patient - loyalty and service quality hence
the need to conduct a study in these areas is very important. . The hardworking
competitive scenario and mushrooming growth of service organization have
invigorated the need to look beyond customer satisfaction towards customer retention
and loyalty.
Objectives
The objectives of this study are based on the five generic parameters of SERVQUAL.
1. To study the patient satisfaction of Public and Private Hospitals for all five
parameters.
2. To study the patient satisfaction between all five parameters and five different
cities.
3. To study the patient satisfaction of all five parameters with demographic factors.
4. To study the patient satisfaction of all five parameters and frequency of visits to the
Hospital.
This study was limited to select public and private hospitals in the area of Mumbai,
Statement of Hypothesis
Based on the above objectives the following Hypothesis were formulated.
H01: There is no significant difference of all the five parameters in public and private
hospitals.
H11: There is significant difference of all the five parameters in public and private
hospitals.
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H02: There is no significant difference in satisfaction of all five parameters in five
different cities.
H12 There is significant difference in satisfaction of all five parameters in five

different cities.
H03 There is no significant difference in satisfaction of male and female patients for
all five parameters.
H13: There is significant difference in satisfaction of male and female patients for all
five parameters.
H04: There is no significant difference in satisfaction of patients of different age

groups for all five parameters
H14: There is significant difference in satisfaction of patients of different age groups

for all five parameters
H05: There is no significant difference in satisfaction of patients of different income

groups for all five parameters.
H15: There is significant difference in satisfaction of patients of different income

H06: There is no significant difference in satisfaction of patient‟s frequency of visit for

H16: There is significant difference in satisfaction of patient‟s frequency of visit for all
five parameters.
H07: There is no association between type of hospital and monthly income of patients.
H17: There is association between type of hospital and monthly income of patients.
H08: There is no correlation between five parameters of study.
H18: There is correlation between five parameters of study.
Research Methodology
Data Collection: In this study, data collection was done in two stages. In the first stage
a pilot survey was done to ascertain the research parameters and to test the validity
and the reliability of the instrument used in the study. In the second stage the primary
data was collected through using the instruments in the study. The instrument used
was a self administered questionnaire. The Secondary data was collected by scanning
literature, professional magazines, research papers and various research reports.
xxviii
Sample Size and Design
The study was conducted at Mumbai, Navi Mumbai, Thane, Pune and Surat in 12
Public and 89 Private Hospitals. A total of 350 patients participated in the survey
using a self administered questionnaire.
The global healthcare services market
Various reports indicate that one of the primary development goals of many countries
is the establishment of a comprehensive, modern healthcare system for all citizens.
Health services will be one of the global growth markets of the 21st century.
Providing health services internationally usually requires a long-term presence in the
foreign market than that needed for the sale of medical devices.
It is observed that the world is getting "flatter"; people, information, technology, and
ideas are increasingly crossing national borders. An international workforce requires
leaders to confront the legal, financial, and ethical implications of using foreign-
trained personnel. Cross-border institutional arrangements are emerging, drawing
players motivated by social responsibility, globalization of competitors, growth
opportunities, or an awareness of vulnerability to the forces of globalization. Forward-
thinking healthcare leaders will begin to identify global strategies that address global
pressures, explore the opportunities, and take practical steps to prepare for a flatter
world.
The global healthcare services market is forecast to reach $3 trillion by 2015,

according to research from Global Industry Analysts. Investment in sectors such as
home healthcare, healthcare IT and telehealth are expected to continue fuelling market
expansion. Findings state that outpatient care is the largest segment of the global
healthcare providers sector, accounting for 37% of the sector's total value. Findings
suggest that the political and economic environment has become increasingly
favourable for global healthcare ventures. Private sector participation in healthcare
reform efforts has received increasing support. Foreign investments generate
resources to modernize and upgrade healthcare infrastructure and technologies, create
employment, and provide expensive and specialized medical services that may not be
otherwise affordable.
xxix
Indian Healthcare Industry
It can be analysed and concluded that over the years, India has made significant
strides in the advancement of healthcare and the quality of life. Recently in India, the
life expectancy of a person is 64.4 years, a notable increase compared to the situation
in the early 1990s. However, the WHO estimated in 1999 that the percentage of the
Indian population having sustainable access to essential drugs was within the 0-49
range, resulting in India being categorized as a country with a low-level access to
healthcare. It is often held that the main obstacles preventing consumer access to
medicine are economic constraints, particularly as a majority of Indians reside in rural
areas.
It is an achievement for India as it has been awarded a „Polio Free‟ status by way of
an official certification presented by the World Health Organization (WHO). India is
among other countries in the South East Asian region which have been certified as
being free of the polio virus. Healthcare in India today provides existing and new
players with a unique opportunity to achieve innovation, differentiation and profits.
India's primary competitive advantage over its peers lies in its large pool of well-
trained medical professionals. Also, India's cost advantage compared to peers in Asia
and Western countries is significant, cost of surgery in India is one-tenth of that in
the US or Western Europe.
In India, the diagnostics sector has been witnessing immense progress in innovative
competencies and credibility. Technological advancements and higher efficiency
systems are taking the market to new heights.
Hospital Services Market in India
Experts state that the hospital services market represents one of the most lucrative
segments of the Indian healthcare industry. Various factors such as increasing
prevalence of diseases, improving affordability and rising penetration of health
insurance continue to fuel growth in the Indian hospital industry. According to new
research report "Booming Hospital Services Market in India", the Indian hospital
service industry is projected to grow at more than 9% during 2010-2015. Currently,
the market is dominated by unorganized investors, and this is likely to continue in
near future as well.
xxx
It is observed that high private sector investments will contribute significantly to the
development of hospital industry. It has been found that there is a strong demand for
hospital beds in the country and a major part of this demand comes from rural and sub
urban areas. It is anticipated that most of this demand will be met by private
investments as majority of government investments will be focused on primary
healthcare segment.
It is seen that Hospitals play a major role in the society as they provide healthcare
services to patients. Increasing population and healthcare requirements and the
complexity of diseases brought about by radical changes in the concept of healthcare
services in the country. Public healthcare system alone is unable to do justice in such
a scenario. Healthcare services witnessed a tremendous growth with the entry of
private multi-specialty hospitals. More and more hospitals were built to bridge the gap
between demand and supply of healthcare services in a growing economy. As
management of hospitals became a core issue, the demand for trained and efficient
staff increased.
The Hospital industry accounts for half the healthcare sector's revenues. There is a
huge pent up demand for quality healthcare and increase in healthcare spending in the
long-term are fundamentally strong drivers in this market. An analysis of this sector
explains factors contributing to the huge potential based on healthcare consumption,
increasing instances of lifestyle-related diseases, medical tourism, and growing health
insurance. The key challenges identified include significant capital requirements and a
shortage of medical professionals. Major Private Players in the industry are also
identified as well as new domestic and international entrants in the market.
Surveys indicate that the future outlook covers the nature of private equity investment
and buyouts by large hospital chains, emergence of "health cities" and telemedicine
initiatives. Hospital Market in India 2014 captures the largest segment of the overall
domestic healthcare market. The emerging Indian economy is witnessing rapid
expansion of the hospital market. The growing burden of disease, along with
unhealthy lifestyles, aging population, growing affordability and widespread health
insurance penetration comprise some of the key factors propelling the hospital sector.
xxxi
Importance of Customer Satisfaction
It is a known fact that Customer satisfaction is the best indicator of how likely a
customer will make a purchase in the future. In a competitive marketplace where
businesses compete for customers, customer satisfaction is seen as a key
differentiator. Businesses who succeed in these cut-throat environments are the ones
that make customer satisfaction a key element of their business strategy. A study by
Info Quest found that a „totally satisfied customer‟ contributes 2.6 times more revenue
than a „somewhat satisfied customer‟. Furthermore, a „totally satisfied customer‟
contributes 14 times more revenue than a „somewhat dissatisfied customer‟.
Satisfaction plays a significant role in how much revenue a customer generates for
your business. Customer lifetime value is a beneficiary of high customer satisfaction
and retention.
It is seen, that Customer delight is surprising a customer by exceeding his or her

expectations and thus creating a positive emotional reaction. This emotional reaction
leads to word of mouth. Customer Delight directly affects sales and profitability of a
company as it helps to distinguish the company and its products and services from the
competition. Customer satisfaction is only a stepping stone to customer delight. We
have to provide a service that exceeds the customer expectations, that surprises the
customer in a positive way.
Patient Satisfaction
It is seen that there are correlations amongst medical services quality, patient
satisfaction, value of care and re-visit intention. Patient satisfaction is affected by the
characteristics of the service provider and medical services and patients demonstrate
distinct behaviour toward each of those characteristics. The evaluation of a patient on
value of care has an influence on the future re-visit intention and other behavioural
intentions. Customer satisfaction is not a sufficient condition for re-visit intention, but
a necessary condition indeed.
Earlier studies indicate that patients in general develop loyalty towards providers
based upon the significant interpersonal experiences they have with the doctors and
nurses, and about the operational quality of the hospital. Therefore, while patients do
form overall global impressions of their experience, they also evaluate the quality of
xxxii
each of their interpersonal experiences and about the administrational operations of
the hospitals. Thus, it is important to determine the most meaningful way of tracking
patient perceptions over the time as well as diagnosing where care delivery needs to
be improved.
It is observed that Patient satisfaction is routinely measured at the Hospitals through

patient feedback forms. The data for each Hospital is periodically analyzed to
compare its historic patient satisfaction trends as well as compare the patient
satisfaction levels against a benchmark across all Hospitals. It is seen that Customer‟s
expectations are rationalized, based on the current healthcare standards in India.
Given the superior quality standards that Hospitals have set, feedback results have
typically shown higher levels of satisfaction as compared to the market. In order to
ensure that there is no compromise on service quality levels, Hospitals also conduct
periodic service quality audits with follow-up by the local teams to ensure that
deficiencies on clinical and non-clinical quality are removed. Repeat patient visits are
a good indication of the level of customer satisfaction. Benchmarking is used to
analyze visits and repeat visits during the year.
Outpatient Services
The out-patient department is usually located at the Ground Floor of the Clinical
Division. It is a unit in the hospital where walk-in patients are attended to and treated.
Its primary objective is to render health service at minimal cost. It serves as a training
ground for residence, interns, clerks, and other paramedical trainees. It likewise
provides health education, moral and spiritual guidance to patients and their relatives.
Lastly, it offers opportunities for research. The outpatient services provide the main
linkage of the hospital with the public. This department interacts and communicates
with the neighbourhood. Today the outpatients are very important for any Hospital.
The scope of services in OPD is 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.
xxxiii
The OPD department is the showroom of the Hospital. This department is the entry
point for future prospective patients. The focus of this study is on the Out Patient
Department, of Public and Private Hospitals.
Major Findings and Conclusions - 1
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. The findings from this study are based on SERVQUAL
model developed by Parsuraman et al. In this study the following observations were
noted.
1. Mean score of Tangibles is 84.34, which is very high and therefore it is overall
indication that most of the equipments are available at the hospitals. Patients are at
ease when it comes to utilising the services of the hospital, i.e. pathology, pharmacy,
OPD, casualty, etc.
2. Mean score of Reliability as 82.65, which is very high and therefore it is an overall
indication that the reliability at the hospitals is very high i.e. the ability to perform the
services is high. This indicates the trust the patients and their relatives have for all the
services provided by the hospital.
3. Mean score of Responsiveness as 80.55, which is very high and therefore it is an

overall indication that the overall responsiveness is high i.e. the willingness to help
patients and promptness is very high. A very important factor to analyse the
satisfaction levels of patients, because in case of an emergency the expectations of
responsiveness are very high.
4. Mean score of Assurance as 81.066, which is very high and therefore it is an
overall indication that assurance is high i.e. the ability to convey trust and confidence
is high. Patients and their relatives always look for comforting words and assurance
from doctors and paramedical staff; hence this factor needs a lot of attention.
xxxiv
5. Mean score of Empathy as 79.31, which is high and therefore it is an overall
indication that empathy level is high i.e. level of caring the Hospital provides its
patients is high. In today‟s dog eat dog world, a few soothing words, genuinely from
the heart go a long way in satisfying the consumer.
Major Findings and Conclusions - 2
Hypothesis Testing
The Hypothesis which were formulated in the study were tested and the respective
conclusions were obtained as follows.
H01: There is no significant difference in all five parameters in public and private
hospitals.
H11: There is significant difference in all five parameters in public and private
hospitals.
Finding of Hypothesis:
Out of five parameters for first four parameters (tangible, reliability, response and
assurance) null hypothesis is rejected. Alternate hypothesis is accepted. For fifth
parameter null hypothesis is accepted.

different cities.

different cities.
Out of five parameters all the parameters (tangible, reliability, response and assurance
and empathy) null hypothesis is rejected. Alternate hypothesis is accepted.
five parameters.
xxxv
and empathy) null hypothesis is accepted and the Alternate hypothesis is rejected.


for all five parameters.

Out of five parameters tangible and assurance null hypothesis is accepted. And
alternative hypothesis is rejected. Reliability, Response and empathy null hypothesis
is rejected and Alternate hypothesis is accepted.

all five parameters
five parameters
Out of five parameters response and empathy null hypothesis is accepted. And
alternative hypothesis is rejected. For Tangibles, Reliability, and assurance null
hypothesis is rejected and Alternate hypothesis is accepted.
xxxvi
From this hypothesis conclusion is that there is association between type of hospital
and monthly income of patients. This indicates that patients of high income prefer
private hospital for medical treatment. Patients of low income prefer public hospitals.
Correlation is significant at the 0.01 level (2-tailed).There is significant correlation

between the five parameters of study.
Recommendations
Today Hospitals are being forced to develop a better understanding of what service
quality means to the patient and how it could be best measured. A key factor in
designing and delivering quality services is the need to understand the patient‟s
requirements and needs in order to provide services which meet those needs as per the
resources available. While patients of hospitals are making decisions based on their
perceptions of the quality and satisfaction with hospitals, health care managers need
to understand how patients evaluate health services. If health care providers
understand what attribute patients and their relatives use to judge the hospital quality,
steps may be taken to monitor and enhance the performance of those areas.
Service quality is of utmost importance in marketing of services because of the fact

that both production and consumption of services occur at the same time. It is
extremely difficult to standardize services and also to present services on quality
dimensions. The service quality dimensions include reliability, responsiveness,
assurance and empathy. The quality of a service will make a patient extremely happy
only when it exceeds the service expectations of the customers.
xxxvii
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 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.
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,
behaviour 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 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 service received.
Though patient relationships have found to be part of reputed hospitals more efforts in
patient relationship management is still to be taken.
Patients attending each hospital are responsible for spreading the good image of the
Hospital. Studies of outpatient services have highlighted problematic areas like delay
in getting appointments, delay in consultations, attitude of staff and doctors. Hence it
can be concluded that OPD services are extremely important in a Hospital and
immediate remedial measures must be taken on patient feedbacks. Surveys of (OPD)
outpatient‟s services have elicited problems like overcrowding, delay in consultation,
proper behaviour of staff, logistic arrangements, support services, nursing care,
doctor‟s consultation, etc. If there are delays in consultation it has to be explored to
xxxviii
elicit the lacunae. Finally continuous research in developing services of a hospital
may be necessary for further improvement in our Public and Private Hospitals.
xxxix
CHAPTER I
INTRODUCTION
The overall process for a patient can be seen in three areas i.e. before he meets the
Doctor, during the meeting and after consulting the doctor. It is important for the
marketer to understand the processes involved which in fact is the experience of the
patient. The experience for the patient involves a number of factors such as doctor‟s
skill, his communication with the patients, behavior of the paramedical staff, various
services offered by the hospital, behavior of support staff, cleaniness and ambience of
the hospital.
According to Kotler (1998) consumer loyalty is an indispensible performance

measurement tool for profit as well as non-profit organizations to sustain competitive
advantage and enhance business and service performance measures. Because of cut
throat competition and mushrooming of service organizations there has been an
urgent need to look beyond customer satisfaction, i.e. towards customer retention and
loyalty. As such the organizations have been striving very hard to formulate and
reinvent their operational procedures by building strong and effective organization
setups so as to have a grip on the consumer loyalty and relationship management.
It is seen that like all other services sectors, the patients have received more
importance; particularly in private healthcare units i.e. they have been given more
importance to relationships. The Hospitals effort to measure relationship between
patients and Hospital staff has offered a lot of benefits such as surviving competitive
pressure, increasing loyal customer base, reducing the need to compete solely on price
basis and increasing new patient base by referrals.This study will help the patients in
improving and developing stronger and more comfortable relationships with
Hospitals, and instilling more confidence in them towards Hospitals.
Thus it is observed that it is mandatory that healthcare should make genuine efforts to
have a better understanding of how to develop and nurture long-term patient- Hospital
relationships. The patients in general develop loyalty towards hospitals based on
significant interpersonal experiences they have with the doctors and nurses and about
the quality of services of the hospital. Patients create their own impressions of their
experiences about the administrational systems of the hospitals they visit and thus it is
1
important to determine the most practical way of finding patient perceptions over time
as well as diagnosing where care for patients needs to be improved and fine tuned.
Today, there is tremendous pressure of competition and society is quickly

transforming itself into a consumer-centred market. Choices are made by consumers
that promote their effective value and companies work hard to establish marketing
strategies that promote such effective value perceived by consumers in order to
enhance customer satisfaction and corporate performance. The same is applicable in
the Health care industry also.
It is seen that an increasing number of Hospitals are facing competition and the
attention towards health has continuously increased particular wants and needs within
the general public as more and more people are becoming health conscious. Hence
hospitals are working hard to expand medical facility investment, high-quality human
resources, latest system designs, and medical services in order to develop and enhance
competitive power. Such investments however, may increase cost and inefficiency if
they are not planned and implemented systematically.
Thus, it will be possible to make investment and increase output at a minimised cost if
the quality of medical services with high customer value is created. This implies
efficient distribution of medical resources. The importance of consumer-centred
marketing has tremendous importance in today‟s Healthcare services. Kotler & Clarke
(1992) in their study observed that consumer-centred marketing concerns the creation
of customer value and customer satisfaction and sets the comprehension of a
customer‟s wants and needs and the satisfaction of them as its primary objectives.
This increases customer base and ensures total competitive advantage.
According to Bopp (1990), earlier studies recognise the importance of customer

satisfaction for ensuring customer loyalty but fail to consider the value perceived by
patients. In healthcare services, the quality of service is affected the most by how the
patient evaluates the available services in a hospital. The implication of this issue
shall be taken into consideration from the perspective of the value of care that a
customer perceives. The purpose of this study is to analyse very carefully the
relationship between the quality of medical services, satisfaction level and re-visit
intention of patients and to advise various marketing solutions for private and public
2
hospitals.This study will also help Hospitals to offer patients the best medical services
and enhance their position in today‟s very competitive environment.
1.1 Service Process of Hospitals in India

It is seen that many hospitals are facing competitive situations due to globalization
and the open-door policy for the Health care market. The economic growth and
changed appreciation toward health have continuously increased particular wants and
needs of the general public. Hence, large-sized hospitals are striving hard to expand
medical facility investment, top quality human resources and additional services in
order to develop competitive power. Such investments, however, may increase cost
and inefficiency to a great extent.
In their study Holbrook (1994), Lindgreen & Wynstra (2005) feel that understanding
and creating customer value is fundamental to marketing activities, but Ravald &
Grönroos (1996) feel that the concept of value is multifaceted and complicated and
there is an evident risk that the concept is used without any efforts or commitments to
understand what it means. Inspite of these difficulties, Heskett, Jones, Loveman,
Sasser, & Schlesinger, (1994), Quinn, Doorley, & Paquette (1990) Treacy &
Wiersema (1993) have found that the effective provision of value represents one of
the most successful strategies a company can adopt to develop a sustainable
competitive advantage.
According to Vargo & Lusch (2008), value is contextually bound and subjectively
experienced, thus every person applies his or her own meanings and interpretations to
his or her experiences. According to Batra & Ahtola (1991), Mano & Oliver (1993), it
may offer both extrinsic and intrinsic benefits and finally according to Sheth,
Newman & Gross (1991), Sweeney & Soutar (2001) it comprises multiple,
interdependent or independent dimensions, such as the experiences of the patient, his
own beliefs and emotions, his relationship with others, which all play a part in judging
the idea of value.
1.2 Human Resource Management in Indian Hospitals

In order to be competitive and improve their services, Human Resource Management
is being acknowledged by Hospitals today. Tremendous care is taken in selection,
3
high-quality training, empowerment, teamwork, appropriate measurement, rewards
and recognition.There is a need for Hospital staff to be focused in interactive service
works which are known as the high involvement work systems.
It is observed that the healthcare industry is going through a significant change. The
Doctor is no longer the superior person; this position has now been taken by the
patient. The Patient is now the King. Of late the focus is on patient satisfaction in
terms of the facilities provided rather than the type of medical treatment given. This is
basically for Hospitals which aim at providing world-class care. Today Hospital
Human Resource departments go for standardization of nursing activities, appraisal
systems, effective communication channels and compensation structures, which are
related and linked to the quality of service provided in a hospital.
Townsend & Wilkinson (2010) analysed and concluded that there has been a lot of
restructuring of Healthcare organizations in the last decade. Health reforms in the last
25 years have focused largely on bringing in structural changes, cost containment, and
introduction of market mechanisms while the importance of HR management has
often been overlooked. Freidson (1984) also felt that to improve and maintain service
delivery in Hospitals it is extremely important to have an efficient Human Resource
department. In many cases, these changes can be best conceptualized as a movement
away from the domination of healthcare organizations by professionals and
professional knowledge, through a simultaneous increase in 'customer' orientation.
According to Korczynski (2002), the consumer is the king and he also stresses on the
importance of cutting costs to increase efficiency.
It is observed that staff is kept at minimum levels by most hospitals without

compromising on the quality of patient care. Hospital employees have expectations
from their employers i.e. they want better infrastructure, human resource practices and
support which will motivate them to give better performance. Hyde et al, (2009)
insists that effort has been maintained towards immediate patient care even when
employee expectations remain unmet. There are very few studies that look into the
healthcare sector in India and most of them are of either rural or public hospitals. The
existing studies according to Pathak, Ketkar, & Majumdar (1981), Bhandari & Dutta
(2007), Sharma & Narang (2011) are mostly on healthcare facilities of rural India and
4
education about health in urban India. But as per Maheshwari, Bhat & Dhiman
(2007), there are very few studies in the Indian public healthcare context which focus
on influence of HR practices on doctor‟s work attitudes, including professional and
organizational commitment.
1.3 Emerging Healthcare in India

It is observed that the Healthcare industry in India offers many challenges for
healthcare professionals. Our country has a weak regulatory system in checking
healthcare institutions. Atleast two-thirds of healthcare expenditure is on outpatient
care, and lifestyle diseases are being seen as a new area in the field of medicine.There
is less awareness of Medical Insurance which has resulted in people paying from their
pockets for medical treatment. Therefore, a very different and dynamic effort is
required to get into the domiciliary healthcare segment.
Apollo Hospitals, one of the leading healthcare groups in India, has created a network
of primary healthcare centers to cater to a very big requirement. It has given an
opportunity to entrepreneurs in our country, by adopting the franchising format.
Franchising, in Healthcare is a challenging business venture. The Apollo Clinic has
the largest network of primary clinics in India; all of them operate as Franchisees. It
started with a single hospital in 1980 in Chennai, today Apollo Hospitals Group is the
largest network of secondary and tertiary care hospitals in India, with more than 8,000
beds in 41 hospitals across all major cities in India.
The Apollo group also leads in other areas of healthcare including pharmacy, health
insurance, medical business process outsourcing, nursing education, clinical research
and corporate wellness programs. In early 2000, with a target to tap the large
domiciliary healthcare market, Apollo Hospitals initiated the Apollo Clinic. Apollo
Group felt that while such a clinic has an important role to play.
The Apollo Clinic provides a day-to-day healthcare delivery through a single facility
set up which is about 4,000 square feet area. It has all the requirements for
consultations, diagnosing, screening and a round the clock pharmacy all under one set
up. The Clinic also offers a range of services such as second opinions from a panel of
experts via telemedicine and giving opinions on various lifestyle parameters.
5
1.4 Understanding Indian Healthcare
In India, there are 16,000 hospitals with nearly one 1 million beds. The average
number of beds in a private hospital is 22, which are much less then the hospitals in
developed economies. The provision of healthcare in India differs from state to state
i.e. private healthcare accounts for more than 50 percent of all inpatients and 80
percent of all outpatients. The development of private sector Hospitals is a new trend
and it concentrates mainly on large super speciality Hospitals in urban areas.
According to an industry report by McKinsey, outpatient care is nearly two-thirds of

the total healthcare spends by patients. And the domiciliary healthcare market, even in
large cities, is small and unorganized. Indians in cities are subject to a large number of
lifestyle diseases and India is leading the world in diabetes and cardiac ailments. It is
also observed that less than 5 percent of the people are covered by health insurance in
India and 65 percent of healthcare spending is out of pocket.
Health is accepted world-wide as a social goal, to maintain it is a huge investment.

Health is multi dimensional and emphasizes as the central idea to the concept of
quality of life. Health on one hand is seen as a very big personal responsibility and on
other hand a huge public concern. It thus is seen as a joint effort of the individual, the
community and the government to protect and promote health. Hospital is a special
institution created by man which, as an operating system could be seen as a synergy
of various sub-systems, comprising of cure and patient care. It also has areas like
administrative, environment and technical factors.
Health care organizers and providers put in lot of efforts to continuously bring in
improvement in the performance of medical care delivery system through out the
world. In today‟s world, health has come up as a product of human biology,
environmental factors, lifestyles, economic status and health services. The patient‟s
health is influenced by many factors like accessibility, affordability, quality and
availability of medical services. The consumers have demands of better services from
healthcare institutions. Globalization and liberalization have brought in changes in the
patients i.e. they are more organized, conscious of their rights and demanding by
nature.
6
It is seen that this change has made all the hospital administrators to sit down and
ponder about quality management services to please patients. Good Health services
when offered in hospitable environment, leads to a patient being satisfied. Patient
satisfaction, which being the base of quality health services in todays competitive
world, includes a variety of services and among all services provided by hospital,
inpatient facility heads in achieving the very motive of patient satisfaction. It is for
this purpose that the wards have now been standardized in various categories from
general ward, economy ward to deluxe ward. This has led to increasing cost of
building and infrastructure. However, it is extremely important for health care
organizations to manage its assets like building, furniture and machines in an effective
way so that it can serve the organization in the long run with improved quality of care.
Bennett et al. (1997) found that in many low and middle-income countries, the
balance between private and public-sector provision of health care over the past
decade or so has tilted heavily towards the former. According to World Bank (1993),
Preker et al. (2000) and WHO (2000) this trend has been endorsed, subject to steps to
address issues of equity by some international agencies on the grounds that an
expanding private sector reduces the burden on the state of ever-increasing demand
for health care, offers consumer‟s choice and stimulates competition. Garner and
Thaver (1993), Baru and Jessani (2000), Sauerborn (2001) and Mills et al. (2002) feel
that it has also evoked concerns about the poor quality of private services and calls for
greater regulation.
Rohde and Vishwanathan (1993) and Berman (1998) state that the debate in India is
complex because the country‟s healthcare system is characterized by the co-existence
of several systems of medicine and by an abundance of unqualified practitioners.
Uplekar and Rangan (1993), Kamat (2001) and Uplekar et al. (2001) are of the
opinion that poor quality and lack of public health relevance of private health care
have been documented, particularly in the treatment of tuberculosis and
malaria.However, inspite of a number of studies on healthcare care systems in India, a
detailed study of comparision of the public and private sector is lacking in India. Such
a study is extremely important to bring in dramatic changes in the overall care in both
the sectors. This study is an effort in this direction and will help in analyzing both the
sectors and recommending significant changes to improve services to out patients.
7
1.5 Surveys of inpatients and outpatients widely used
Today hospitals are increasingly adopting marketing strategies and research to help
them understand opportunities and problems, but Hospitals need to pay more attention
and invest more in market research activities. Today health care executives are under
tremendous pressure and have to put in a lot of effort to increase revenues, reduce
costs and develop partenerships with other providers.
It is seen that as a result, nearly all healthcare organizations have developed strategic
plans for coping with the everchanging nature of the industry. As part of the core
planning process, health care organizations have resorted to marketing research as a
means to achieve these goals. Marketing research is basically the objective and
systematic method of gathering, analyzing, and interpreting data which caters to a
specific situation or problem facing the Healthcare organization.
Earlier unheard of in health care, marketing research today is the norm in hospitals,
particularly among larger Hospitals located in highly competitive urban areas.
Research applications are particularly catering to for-profit institutions. However,
when most of the hospitals were surveyed, they indicated that they do not invest in
marketing research to track the effectiveness of their own Hospitals promotional
activities.The use of marketing research in other industries is prevalent since many
years, but only in the last two decades have hospital marketers made widespread use
of these strategies.
The primary goal of the research being done is to help hospital administrators take
better decisions. Research adds to Hospitals base of knowledge, whether it
understands the patient‟s perceptions, evaluating the Hospitals position in the
marketplace, identifying problems and their sources, or testing proposed solutions for
better services. Research is the cornerstone of good marketing planning. Like other
different types of business, hospitals have existing services, new service ideas, and
patients who affect business. It has been observed that, the hospital's customer has a
choice and knows his or her importance. Knowing the needs, wants, and decision-
making processes of potential customers is extremely important for the success of a
Hospital.
8
It is observed that market research is one area which can provide source of
information that, if done well and interpreted correctly, can give the extra competitive
edge that can make the difference between success and failure in today's very
competitive world. Hospitals can, and have used marketing research for various
purposes. For example, it helps Hospitals analyse and understand why patients will
respond to potential new business ventures. How patients define quality, service,
convenience, and value and the relative significance of these factors in the purchase
decision.
Studies show that Hospitals also are using marketing research to solve tough problems
and strategic issues such as cut throat competition, vulnerability, new markets for
existing products and hospitals brand image and goodwill. There are many instances
of marketing research being used successfully in the healthcare industry to analyse
strengths and weaknesses of their services. Lot of instances show the demise of
hospital programs that were instituted without the help and benefit of market research.
A mid-1980s research showed that two-thirds of the countrys hospitals depended
solely on the results of research studies they commissioned. Individual hospitals
conducted market research to get an idea about benchmarking and to determine the
feasibility of new services, determine the new target market and new services.
It is seen that the size of the institution greatly affects the research use, with twice as
many hospitals with 100 or more beds conducting marketing research studies as
hospitals with fewer than 100 beds. A survey of 200 hospitals in the mid-1980s found
that 72% of the hospitals regularly surveyed patients, 62% regularly surveyed
consultants and only 55% regularly surveyed hospital staff. Though there were many
surveys of patients and consultants there were a relative lack of employee surveys
which was surprising, given that conducting these surveys were very economical and
such studies were very relevant and helpful to participatory management.
In terms of hiring outside agencies, only 10% of the hospitals showed involvement
with an advertising agency. Market research activities include surveys, analysis and
strategies of competitors, strengths and weaknesses, and evaluating performance
against marketing objectives.Yet in another study of hospitals use of marketing
research concluded that, although there has been some spurt in the use of marketing
research activities since 1982, hospital market research still appears to be used very
9
less. Patient satisfaction surveys and demographic analyses were the most widely used
research methods in the hospitals. The reason given most of the time was that research
is costly and time consuming; as well as they felt it was uncertain how to use the
results.
Patient satisfaction is getting tremendous attention as a result of the methods adopted

by Hospitals to pay as per performance. The nurse work environment is significantly
related to all patient satisfaction. Additionally, patient-to-nurse workloads are
significantly associated with patient‟s ratings and recommendation of the hospital to
other patients and with their satisfaction on discharge information. It has been
observed that by improving nurses work environments, including nurse staffing, it can
improve the patient experience and quality of care for the patient. It is also observed
that the patient‟s reports of satisfaction are much higher in hospitals where nurses
work in better work environments or with more reasonable patient-to-nurse ratios.
Hospitals now have started adopting financial incentives to improve their quality of
care so as to increase patient satisfaction. Patient satisfaction as seen in the research
literature is definitely affected with a variety of nursing factors, like payment
incentives to nurses. Many Hospitals have to still take note of this. Studies have
linked patient satisfaction with nurse-staffing levels, higher proportions of registered
nurses; nurses work environment and the registered nurses and physician
collaboration. Hence it is seen that the various studies provide evidence to guide
institutions in prioritizing interventions that could greatly improve patient satisfaction.
Donabedian (1985) found that the quality of care can be seen from both Hospitals and
patients perspectives and has three components: technical care, the interpersonal
relationship and the availability of amenities. As per Hibbard and Jewett (1996)
Zaslavsky et al. (2000) patient satisfaction is one of the most important indicators of
health care quality and is increasingly being used to assess the performance of health
care organizations. Not having the knowledge to assess technical care, patient‟s judge
quality mainly by the attributes of the interpersonal relationship with the consultants.
Hart (1996) states that, it is important to incorporate easily measurable indicators such
as waiting time in outpatient quality assessments. It is absolutely right if we can
debate that measurement of patient satisfaction is a challenging process. However,
10
despite these methodological difficulties according to Vuori (1987) it is important that
the assessment of patient satisfaction becomes central to every quality health care
assessment program. Many situations may influence patient satisfaction such as,
waiting time to receive the medical care services, availability of convenience facilities
in hospitals and doctor-patient communication and interaction. A study by Okotie et
al. (2008) states that waiting time to access health care may be associated with the
patient‟s socio economic background, as the wealthy patients usually do not want to
wait for a longer time and exert pressure to receive early appointments. But the poor
patients have no other option but to wait for a longer time.
Waiting time for a patient is in fact the time he spends waiting for the consultant and
it can be said that if the consultation process is undertaken in a timely manner as
perceived by the patients, it will give results of more satisfied patients, however, if the
process is delayed patient‟s may get upset and frustrated, which will thus reduce their
satisfaction to a great deal. Expectations of the patients, service quality and patient
satisfaction may also vary across different levels of Hospitals. While there is a lot of
literature on patient satisfaction and quality of health care, most studies are on some
particular disease or were done for family planning purposes in primary and
secondary level Hospitals. There are very few studies that measure satisfaction across
different specialties in a tertiary care setting.
1.6 Patient care Innovation
Review done by Porter and Teisberg (2006), Weinberg (2003), Clark (2002), Lee and
Alexander (1999), shows that inspite of growth and advances in the field of
Healthcare in much of the industrialized world, hospitals and other healthcare
organizations are in a state of crisis and faced with the high costs of giving healthcare
services in cut throat competition. Hospitals are struggling to give top quality patient
care and also remaining financially stable. Kohn et al. (2000) feels that concerns for
the quality of care given by Hospitals in the United States have received extensive
public and academic attention. In an effort to address this problem and improve the
quality of patient care, hospitals and other healthcare organizations have been
experimenting with different work and patient care delivery initiatives. Many
Hospitals in fact, have tried to benefit from work place models in industry that have
11
been more prevalent in manufacturing and service industry; these are high
involvement work practices as per Scotti et al. (2007) and Westet al. (2006).
Batt (1999) and Preuss (2003) state that there are a number of workplace innovations
that are new in Hospitals, such as patient centered care for patients satisfaction, which
are not like the traditional high performance or high-involvement models developed
in other places. The study of work organization in Hospitals can push work place
efficiency to a higher level. Wolf et al. (2008), Bergeson and Dean (2006) Epstein et
al. (2005) and Flach et al. (2004), found that it entails a shift from institutional and
physician focused care, emphasizing professional roles and hierarchies to patient-
centered care emphasizing client‟s needs and preferences.
Patient centered care also looks into enhancing patient input and taking care of
patient‟s opinion on issues ranging from meal times to treatment schedules. Rathert et
al. (2009) feels that patient centered care is also made to improve the functioning of
front line work and increase employee outcomes. Shaller (2007) researched and found
that at the heart of Patient centered care is the effort to establish a care delivery
system that can take care of the critical patient needs and preferences while also
structuring work in a way that will enhance frontline staff results, such as turnover
and job satisfaction.
Researchers who suggest Patient centered care say that it positively affects key
outcomes by improving the services patients receive and the working conditions
which are provided by Hospitals. This double benefit which patients and Hospitals
can get from Patient centered care programmes, has not yet been fully empirically
tested.
1.7 Patient Satisfaction

The Hospitals in today‟s scenario are restructuring in order to survive the cut throat
competition in an unforgiving environment resulting from maturation of the industry,
where there is less availability of funds and rapid increase in technology. The changes
have focused on arriving at different ways to satisfy the needs and desires of the
patients. This patient centered health care service method is different from the earlier
one formed by the preferences and decisions of medical professionals. It is now
12
shaped by the views and needs of its patients. Patient satisfaction is the basic
requirement for health care providers.
Patient satisfaction is of prime importance when patients themselves make selection

decisions. In order to understand various factors affecting patient satisfaction,
researchers have explored many service quality areas which patients consider while
evaluating the quality aspects of hospitals such as latest equipment, physical
facilities, ease of supplementary services, nature and response of doctors and medical
staff. The word quality is often thought of in different ways by people depending
upon the situation. The actual meaning of quality is related to innate excellence i.e. a
mark of top most standards and high achievement. It debates that people learn to
organize quality only through the experience.
The product based approach sees quality as an exact and measurable variable.
Differences in quality show the differences in the level of attributes possessed by the
product or service. These definitions show quality as something with the maximum
satisfaction. In manufacturing, emphasis is on supply of raw materials and
engineering. When value comes in the picture then quality is seen in terms of value
and price. Service quality has become very important in private sector competition.
Patients today demand increasingly higher quality services and accordingly the
pressure to provide the quality services to survive in today‟s era has become
imperative.
Thus today Hospitals are being forced to develop a better understanding of what
service quality means to the patient and how it could be best measured. A key factor
in designing and delivering quality services is the need to understand the patient‟s
requirements and needs in order to provide services which meet those needs as per the
resources available.While patients of hospitals are making decisions based on their
perceptions of the quality and satisfaction with hospitals, health care managers need
to understand how patients evaluate health services. If healthcare providers
understand what attribute patients and their relatives use to judge the hospital quality,
steps may be taken to monitor and enhance the performance of those areas.
Service quality is of utmost importance in marketing of services because of the fact

that both production and consumption of services occur at the same time. It is
13
extremely difficult to standardize services and also to present services on quality
dimensions. The service quality dimensions include reliability, responsiveness,
assurance and empathy. The quality of a service will make a patient extremely happy
only when it exceeds the service expectations of the customers.
1.8 Service Encounter

It is observed that service quality is very important area in services marketing. The
service quality framework differs from service to service, as services are
heterogeneous. Scholars argue that the clear cut nature of services requires a very
distinctive approach in defining and measuring management service quality. The
service marketing experts take into account various areas like service quality, patient
satisfaction and behavioral intentions while planning and developing the management
strategies. Extensive Research has been done to conceptualize service quality.
Researchers suggest that customers do not perceive quality in a uni dimensional way
but they perceive it as multi dimensional and at multi-levels. According to Brady and
Cronin (2001), Marley, Collier and Goldstein (2004), Lehtinen and Lehtinen (1991),
process quality is one of the important dimensions of service quality. Health care is
one of the service areas where there is very high-contact encounters. The level of
involvement between the patient and consultant is very high. The process quality is
also very critical to evaluate the service delivery process. In the case of Hospitals
services, quality judgments may be attributed to either the clinical outcome quality or
the process quality of the service delivery.
While the outcome quality in some cases can be evaluated by the patient in the form
of relief from his or her problem, the judgment is difficult in many cases. However, it
is easier to judge the quality of services if the patients are in a reasonably fit condition
and usually most of the out patients are in such a condition. Most of the studies have
included some blend of the clinical and process quality criteria but have not separated
their effects.
In their surveys, Lehtinen and Lehtinen (1991), Boshoff and Gray (2004), Shemwell
and Yavas (1999), McAlexander, Kaldenberg and Koenig (1994), Lytle and Mokwa
(1992), found that the theoretical and empirical findings across the different health
care settings emphasize the relative importance of process quality in determining
14
patient satisfaction and future intentions. Since the quality and satisfaction are only
seen and experienced by the patient, it is right to judge them from the point of view of
the patient. Hence, the studies should be based on the perceptions of the patients.
Surveys should aim at the major service encounters that the outpatients undergo in a
hospital and then goes on to investigate how higher perceived service encounter
related process quality achieves higher patient satisfaction, and the formation of
repeat visit and recommendation intentions.
Services are deeds, processes and performances and include all activities whose result
are not a physical product and are generally consumed at the time of production and
provide different value in forms eg, convenience and comfort that are essentially
intangible concerns of its first purchaser. The Service sector consists of different
dimensions and among them we have „health care‟ which deals with different services
such as, hospital services, diagnosis services, physicians consultancies and some other
emerging fields.
In their study Saha and Bartleman (1998) found that public provision for health care
services at no charge or nominal cost is common in low-income countries.
Government, providers and clients at times also agree that the quality of these highly
subsidized services is inadequate and because free services, medicines and medical
equipment are often under-funded or insufficient to meet demand, they are vulnerable
to agents who collect unofficial charges.
It is observed that the poor performance of Hospitals is attributed to staff not being
regular at work, essential supplies not available, infrastructure and facilities not
adequate and the staff not being up to the mark i.e. the quality is poor. There are
problems of supervision and accountability which affect services. Many Hospitals
have multiple unions of staff and their grieveances are at times not resolved. Health
care is extremely important for the wellbeing and good quality of a person‟s life.
Health services in Hospitals form a major chunk of a country‟s economy, in which
competition plays an important role in both the private and the public Hospitals.
Research shows that now day‟s people have started taking a lot of interest in seeking
information about Healthcare because they are faced with the decisions and questions
15
about their health in nearly every aspect of their livestyles. It is becoming very
important to understand and apply the latest techniques of marketing to survive
intense competition. In other words, stressing on the need to apply marketing
strategies and being customer centric is becoming very important in todays cut throat
competition. But today it is seen that a number of different groups working at
Hospitals i.e. physicians, employees, administration staff as well as students at
medical colleges most of the time underestimate their patients expectations regarding
medical health service quality.
Unlike in the past, when in most countries we could see the majority of health care
organizations were public, now days there are a growing number of those that belong
to the private sector. Today service providers, i.e. both at public hospitals and private
hospitals are seeing the necessity of having a marketing oriented approach in their
business ventures.
1.9 Healthcare Business Process

There is always a need to change today to improve the performance and output of
Hospitals in terms of productivity and also to look into the demands from patients
who are not satisfied by services. Today because of the latest technology there are
newly immerging expensive techniques of treatment and drugs, there is also an
increasing consumer expectation, i.e. the patient is expecting quality services. At the
same time, Hospital administrators and marketers are finding it extremely difficult to
cope with demand and quality of the patients expectations. Clinicians are upset as
they feel that their contributions are not recognized. Hospital Managers are upset as
they feel that there is communication gaps with clinicians which need to be resolved
and which has intensified the requirement for an effective change for a more efficient
system that will satisfy all arguments about cost effectiveness and sustaining with
quality services.
There are various strategies which were originally developed by other management
Researchers for product manufacturing industries, that have been applied to health
care industries i.e. Hospitals with variable success, which largely depends on the type
of Hospitals these strategies are applied. Business process re-engineering is seen as a
technique to examine management strategies using past and recent research
16
publications. Improving the quality of Hospital services has nowdays become very
important for patients, administration managers, and marketing professionals working
in developing countries, where many people find it difficult to have access to medical
services.
It is observed that nowdays patients with money, are paying more for their health
care, both in Public and Private Hospitals, but they often are not satisfied with the
improvements in health or service quality. Patients are increasingly expecting better
and better health care services in Hospitals and compare their experiences with
Hospitals in other countries. Accessible quality health care in Hospitals is one
determinant of a countries health scenario, which has been asssociated directly to the
countrys wealth by the World Health Organization. Although there is a lot of pressure
in increasing and improving quality, there are many challenges; for example,
countries need support, low cost loans and medical professionals with Healthcare
management skills.
There is also the challenge to encourage Private enterprises to enter the Health care
sector and at the same time ensure they adhere to regulations that stimulate improved
quality of medical services. There are plenty of new ideas to improve quality, and
many different approaches are put into practice by different business groups. One
major hurdle is the lack of evidence about which method should be employed so that
it will be feasible and cost effective in different situations.
Studies show that many health care institutions are confronted with long waiting
times, delays, and queues of patients. Hospital managers are faced with challenging
questions like, how should they optimally allocate their limited resources. How much
exam rooms do they need and how much physicians and support staff do they need. If
they increase or decrease the amount of exam rooms and staff, how would this effect
patient waiting time, the length of a medical treatment and the total time spent in
clinic by patient.
Torres & Guo (2004), feel that to improve patient satisfaction, the performance of key
processes has to be improved. There is no doubt that health care institutions need to
become high performers. Jennings & Westfall, (1994) also state that in order to gain
17
high performance, the organization has to determine its performance indicators,
measure its performance, derive the performance gap and initiate actions to close the
gap. Improving the quality of health services means to focus on the patient and his
needs. Assessing processes by means of performance indicators is a prerequisite for
process control and serves as a basis for process optimization. Sometimes business
processes are fully supported by an operative system like an enterprise resource
planning (ERP) system, collecting data from which process performance information
can be extracted automatically and free of additional cost.
What is a Business Process?

A business process is a sequence of steps which transform inputs into outputs. It is
customer focused and is activated by market and external or internal customer needs.
It 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.
Process Orientation
According to Reijers (2006), Process orientation means focusing on business
processes ranging from customer to customer instead of placing emphasis on
functional structures. Davenport (1993) also states that process orientation does not
only work for process industry, but can be applied to service industries as well. As per
Vera & Kuntz (2007), there is empirical proof that hospitals with a high degree of
process orientation are moderately but significantly more efficient.
Business Process Management

It has been observed by Armistead & Machin (1997), that business process
management deals with how to manage processes on an ongoing basis. This
management approach according to Gulledge & Sommer (2002) has gained much
advertence in industrial engineering and management literature, but less in public
sector management literature. 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.
18
Process Performance Measurement and Process Control
Lebas (1995) says that measurement and management are not separable. Harmon
(2003) too felt that Business process management integrates the measurement and
also ongoing improvement of business processes. By focusing measurement on
processes rather than functions, 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. It is a continuous course of action and consists of several steps.
1.10 ERP Systems in Healthcare Institutions

Healthcare organizations are complex and information intensive organizations which
require an integrated clinical and business management information system. The
integration of clinical and business management was hardly achieved by hospital
information systems in the 1980s and the 1990s. Stefanou & Revanoglou (2006) saw
that ERP software also often referred to as enterprise systems drastically changed
corporate IT and health care organizations were affected equally. Even Davenport
(1998) concluded that ERP systems are designed to solve the fragmentation of
information in large business organizations. A main characteristic of an ERP system
is that it attempts to integrate all departments and functions of an organization onto a
single computer system. Van Merode et al. (2004) found that an ERP system has a
modular structure and the functions of the system are integrated. When data is entered
into one function, this data is immediately available to all associated functions.
In their research Tomes (1995) and Fuentes (1999) concluded that the service quality
of healthcare has two aspects i.e. technical quality and functional quality. The
technical quality aspect refers to the capacity and capability of the hospitals and their
staff. It examines whether they can perform their medical tasks effectively and
efficiently. For technical quality, a hospital has rules and standards for all its
employees to follow.Within the hospital operations, the doctors and the relevant
associated staff are normally organised by the hospital authorities to hold regular
meetings to reflect, summarise past experiences for improving their medical
competence and service management. The functional quality aspect refers to the way
the medical service is conducted and delivered to patients.
19
It is seen that for this aspect, although there can be a few measuring criteria
technically applied i.e. the fulfilment of promised treatments on time and the speed of
attendance to the patients demand, the majority of the quality criteria are rather
subjective, subject to the patients expectation and perception before and after the
medical treatment delivered. Fuentes (1999) argues that the technical quality aspect is
result oriented, in that patients can only experience the technical quality when the
service has already been delivered, while the functional quality aspect is process-
oriented, patients can see how the medical service was delivered and they can have a
direct and informed judgement of the delivering manner and process.
Normally it is seen that, patients cannot evaluate a healthcare provider and its
employees from the technical quality aspect; however they can judge the functional
aspect of the quality, which is an outcome of the technical procedure followed by the
hospital staff performing the respective medical treatments. There is a claim by
Perrott (2011), that healthcare as a field is deserving of more research. Moreover,
service quality according to Manjunath and Ramachandran (2007), Rose (2004) is a
critical element to ensure an effective and efficient Hospital service quality
assessment criteria satisfying healthcare provision to patients.
Wang, et al., (2007) in his survey concludes that the funding allocated from the
government holds a very minor portion of hospitals income. The medical service
provision and medicine sales are their main source of revenue generation. Thus,
similar to other industries, the competition between hospitals becomes intensified
because of technology and globalization. The competition mainly focuses on
attracting more patients and retaining their loyalty, through improving the „hardware‟
and „software‟ of the hospitals operations. Service quality is obviously one of the
critical elements among them for ensuring a hospital‟s stronger competitive position
in the healthcare service marketplace. In general, the quality management and the
quality performance criteria in the healthcare sector according to Yang (2003),
Laschober, et al.(2007), Behara et al.(2002), Maddern et al.(2007), Ariffin and Aziz,
(2008) have been studied by researchers in both developed and developing countries,
although the amount of research as such is more abundant in the developed countries.
20
Healthcare in China
An empirical exploration of hospital service quality assessment criteria in China
Hospitals, as a main provider for healthcare services, is an indispensable part of
Chinese society, with a long existence. With the development of the economy and
technology, people‟s desire for efficient, effective and high quality healthcare has
risen continuously, which exerts great pressure on healthcare providers. The quality of
management in hospitals plays a very important role in maintaining and improving
their competitive position in the dynamic healthcare marketplace. Shen et al.(2009),
Yi, (2009), Zhang (2008), Zang (2006) in their research find China, as one of the
developing countries in the world which has a large number of hospitals i.e. there
were 20918 in total by end of 2010.
The China-based research on quality management and evaluation of the health care
service has also been seen in publications. However, the research and view points
reflected in these publications focus more on technical quality elements rather than
discussion on the functional quality elements, which are generally discussed in
publications outside of China. There is a need for more research on functional quality
issues to enrich the understanding of quality management in the Chinese healthcare
service industry, which can guide service improvement for both Chinese hospitals and
foreign healthcare providers entering the Chinese marketplace. Although the current
Chinese healthcare service marketplace is occupied mainly by local providers, the
authorities have already announced that the reform will be carried out on state-owned
hospitals and multiple types of healthcare provision are encouraged, including foreign
investments.
1.11 Gaining Patients Trust

The evolution of how professionals in the health care industry, viewed their patients
has been dramatic in the last few decades. It used to be that the word “customer” was
shunned. Patients were not customers but individuals who required the doctor‟s
expertise and would be grateful because, in most cases, doctors improved their health.
This evolution was inspired by a consumer revolution. Today the customer is the King
and is aware that he has many options available.
21
It can be seen and analysed that American health care, has been turned upside down
by this consumer mandate. As leaders of a service industry that has compassion and
caring at its roots, most health system CEOs would have a difficult time admitting
that, for the most part, the system has failed. One of the most effective ways to
significantly improve the patient experience is to learn from others who face the same
complex environment and challenges, day in and day out.
It is observed that economic pressures are creating an adversarial climate in some

areas and pushing physicians and hospitals together in others. Because many services
performed in hospitals can safely and conveniently be performed in ambulatory
settings, physicians have become owners of entities directly competing with hospitals
for patients in a new medical arms race. Hospitals and medical staff physicians face
growing tensions as a result of physicians growing reluctance to take emergency
department calls.
Although there are increasing expectations that health system challenges will lead
hospitals and physicians to collaborate, in many markets the willingness and ability
for hospitals and physicians to work together is actually eroding. Physicians have
been relatively independent of hospitals and have used them as "workshops" in which
to carry out their professional services. In the prevailing medical staff model,
physicians and hospitals did not have a typical market relationship. They neither
bought services from nor competed with each other. Rather, physicians and hospitals
informally exchanged physician‟s use of the hospital's facilities for carrying out
responsibilities, such as serving on quality and utilization review committees and
taking emergency department (ED) call, as obligations for having medical staff
privileges.
It is seen that as a response to manage care in the 1990s, new organizational

arrangements between physicians and hospitals were initiated but then largely
abandoned as the use of capitation to pay providers began a rapid decline by the late
1990s that continued into the new century. Hospitals began to shift their focus from
building physician-hospital organizations and related organizations to building
stronger relationships with specialist physicians, to benefit from high-margin
specialized services and to try to avert potential competition with physicians in
22
delivering outpatient services. This has taken the form of new approaches by hospitals
to branding, marketing, and providing services called a service-line strategy.
Although closely affiliated specialist physicians are central to hospital based service-
line products, other less closely affiliated specialists are competing directly with
hospitals by developing or expanding physician-owned specialty facilities of various
kinds. However, it is becoming evident that market factors were threatening not only
these new business-oriented affiliations but also long-standing collaborative
relationships between physicians and hospitals. Although competition over services
was a main source of tension between hospitals and some physicians, there were other
sources of conflict as well, such as physicians growing reluctance to take (ED)
emergency department call. These developments were working in concert to threaten
physician‟s long-standing orientation toward supporting hospitals social missions,
including caring for the uninsured.
It is observed that the increasing competitive environment threatens the long-standing

assumption that physicians and hospitals share common interests. There was a time
when Doctors used to feel that in return for having the hospital as a place to care for
their patients and earn income, they should contribute to the hospital, take emergency
department calls, participate in committees and improve quality. Now many don't
even come to the hospital anymore.
Out patient services in United Kingdom

What is unknown at present is how patients judge the quality of outpatient services.
A vigorous measurement to determine the expectations of patients and managers
views has never been undertaken. In a number of countries where health care is
publicly funded, policies to introduce greater patient choice are being implemented. In
most cases patient choice is seen as an instrument to reduce waiting times for elective
i.e. non-emergency, hospital services. An important issue is whether facilitating
greater patient choice will increase the demand for health care and thereby undermine
the achievement of reduced waiting times.
In the United Kingdom there is a small private healthcare sector but most health care
is supplied by the state-owned National Health Service (NHS). Most of the services
23
provided by the National Health Service (NHS) are free at the point of consumption.
The National Health Service (NHS) is funded from general taxation with the level of
funding being a political decision. To access non-emergency hospital services, a
patient must first visit their General Practitioner (GP) who acts as a gatekeeper to
secondary care. The patient may have to wait sometime before obtaining a
consultation i.e. outpatient appointment and if, after this consultation, non-emergency
or „elective‟ surgery is deemed appropriate, the patient will be added to the waiting
list at the National Health Service (NHS) hospital to which he or she has been
referred.
It is seen that there is no money price payable for access to the National Health
Service (NHS) but the elective patient must instead endure or „pay‟ a waiting time
before gaining access to non-emergency care. On its creation in 1948 the National
Health Service (NHS) inherited a waiting list of over 400000 patients and this list
has, by and large, increased steadily since then peaking at almost 1.3 million patients
in 1997. A long waiting list would be of little concern if the waiting time for each
patient was short but typically this has not been the case. According to Martin et al.
(2003), the list length tends to be positively correlated with waiting time so that long
lists are associated with long waits. From time-to-time public concern with waiting
times has led to various policy initiatives to reduce the length of wait. Typically, such
initiatives have met with some success but, once relaxed, previous gains are often lost.
It is further seen that permanent reductions in waiting times have proved elusive.
Faced with increasing public concern at the length of wait for both an outpatient
appointment and hospital admission, the New Labour administration offered a
considerable and sustained increase in real funding for the National Health Services
(NHS) in return for the achievement of some ambitious targets for maximum waiting
times. With a maximum wait of 18 months for inpatient admission in mid-2000, the
National Health Services (NHS) plan sought to reduce this to 12 months by March
2003 and to six months by December 2005. Similarly, the maximum waiting time for
a routine first outpatient appointment was to be halved from over six months (in mid-
2000) to three months by December 2005.
24
It is observed that against this national background, the government introduced a
number of policies to reduce waiting times in line with the new targets. One large
scale initiative was the London Patient Choice (LPC) Project. This had two main
features, first by creating additional surgical capacity in the capital and second by
offering patients a degree of choice over where and when they are treated. The
London Patient Choice Project encouraged hospitals in the capital to find additional
surgical capacity by offering them financial rewards for extra activity.
However, this approach identified little additional capacity but several new Treatment
Centres (TCs) were operating with considerable spare capacity. TCs differ from the
standard NHS hospital in that they do not accept emergency admissions and thus
avoid the disruption to elective surgery that can follow from the need to prioritize
avariable number of emergency admissions. The LPC Project purchased most of its
activity from these new TCs. The Project was administered by a central purchaser.
Hospitals supplied the Project team with the names of patients expected to breach the
six month target waiting time.
Studies reveal that each patient was then contacted by the Project office and offered
the choice of remaining with their scheduled hospital or of a shorter wait at one of two
other alternative hospitals with an agreed fixed date for admission. The first specialty
covered by the Choice Project was ophthalmology and this went live in October 2002.
The Project was extended to orthopaedics, ENT and general surgery during April
2003 and to most other routine acute specialties later in 2003. The initial plan was to
offer choice to 50000 London patients in a full year. As per Dawson et al. (2004) by
June 2004, 22500 patients had been offered choice and 15000 had accepted treatment
at another hospital. In principle, the LPC Project made NHS treatment more
convenient. Patients were offered a shorter expected waiting time and an agreed fixed
date for admission.Transport to the hospital of choice was also provided.
1.12 Human Performance Improvement in the Health Care Organizations.

It is observed that implementation of quality principles in health care organizations, as
well as their improvement is necessary for the growth of patient satisfaction. A
number of studies have suggested that approximately 30% to 40% of the patients do
25
not receive necessary care. According to current scientific evidence 20% to 25% of
care provided has been medically unnecessary and potential harmful. Improvement
should be understood as an action intended to achieve excellence, which is expressed
in the organization's objectives. In this context, the importance of Quality
Management (QM) is recognized and the principles are defined by the European
Foundation for Quality Management (EFQM). The principles include achieving
balanced results, adding value for customers, leading with vision, inspiration and
integrity, managing by process, succeeding through people, nurturing creativity and
innovation, building partnership and responsibility for a sustainable future.
It is seen that with regard to human resources management (HRM), these principles
are the basis of high performance work system (HPWS), which is oriented to achieve
better reliability, safety and performance. The structure of (HPWS) has evolved from
QM and HRM theory and is related to Human Performance Improvement (HPI),
which is mostly defined as a systematic approach to identification, pointing at and
implementation of solutions eliminating the barriers which make the execution of
work difficult. The rules of Human Performance Improvement (HPI) concept are
based on the results of activities, concentrating on of work effects and system
approach. The use of Human Performance Improvement (HPI) concepts in
management practice requires a change in thinking about people and their work.
Surveys indicate that it requires storing knowledge about the impact of the effects of
workers on the results achieved by the organization. Factors of quality in health
services, conversations with physicians, physical dimension of the external and
internal appearance of hospitals i.e. aesthetics, cleanliness, appearance of personnel
and medical equipment, facilities for patients i.e. elevators, ramps, automatic doors.
It is observed that reliability is the ability to implement appropriate services in

accordance with ethical and medical standards, ensuring the personal safety of the
patient. The speed of action and responsiveness to the expectations of the patient,
showing concern for the welfare of the patient. Empathy is an individual approach to
patient care for the mental comfort of the patient, understanding of the patient needs
and expectations and paying attention to each patient.
26
A new generation of patient satisfaction studies investigates how patients combine
their attribute reactions to arrive their overall satisfaction, how the factors influencing
patient‟s perceptions of quality health services are presented. Most of the presented
factors refer to the relation between the physician and the patient. The systematic
measurement allows determining the level of excellence of health care services.
It is proved that the application of Human Performance Improvement (HPI) model

into HRM practice helps in the achievement of improvement by identifying the fields
which require improvement and the design of effective and efficient improving
activities. The concept of improvement requires parameterization of activities in the
field of HRM. According to West et al. (2002), Human Performance Improvement
(HPI) in the Health Care Organizations leads to activities achieving balanced results,
leading with vision, inspiration and integrity. It is responsible for sustainable future
results of activities, performance appraisal system approach and sophistication of
training.
Research done by Harmon et al. (2003) and Scotti et al. (2007) shows that the Human
Performance Improvement (HPI) adds value for customers, manages by processes,
builds partnerships and encourages employee participation. The (HPI) leads to
alignment in concentration of work effects, teamwork, trust, creativity, involvement
performance based rewards, work design for low skilled workers, system approach
succeeding through people, nurturing creativity and innovation.
1.13 Retaining Customers

Research done by Berry et al. (1989), Reichheld and Sasser (1990), Rust and Zahorik,
(1993), Cronin et al. (2000), Kang and James (2004), Yoon and Suh (2004) has
shown that good service quality leads to the retention of existing customers and the
attraction of new ones, reduced costs, an enhanced corporate image, positive word-of-
mouth recommendation and enhanced profitability. Moreover, securing and
increasing loyalty is central to many corporate strategies because obtaining new
customers is costly and customer retention is connected to long-term profitability.
Therefore as per Lim and Tang (2000) and Kuei (1998), service quality can be used as
a strategic differentiation weapon to build a distinctive advantage.
27
The analysis of service quality would enable management to better direct financial
resources to improve hospital operations in those areas that have the most impact on
customer perceptions of service quality. According to Pakdil & Harwood (2005) this
evaluation is essential in today's competitive, cost-conscious healthcare market. For
over two decades, researchers have been studying service quality and its relationship
to critical business outcomes. In their studies Gotlieb et al., (1994), Kang and James
(2004), Oliver (1997) and Pollack (2008) have addressed the relationship between
service quality and customer satisfaction and according to them; it is generally
believed that higher levels of service quality lead to higher levels of customer
satisfaction.
Research done by Thi et al. (2002), Hiidenhovi, et al. (2002), Hall and Doran (1988),
Lim and Tang (2000), DeMan et al. (2002) and Pakdil & Harwood (2005) shows that
the concept of quality improvement has become more important year by year in the
service industry and more importance is given to patients views as an essential tool in
the processes of monitoring and improving quality of healthcare services. Patients
service quality perceptions are believed to influence patient satisfaction positively,
which in turn positively influences the patient's decision to choose a specific
healthcare provider.
In an earlier study, Donabedian, A. (1988) indicated that patient satisfaction is a key

outcome of care. Patient satisfaction enhances hospital image, which in turn translates
into increased service use and market share. Satisfied customers are likely to exhibit
favorable behavioral intentions, which are beneficial to the healthcare provider's long-
term success. Measuring the degree of patient satisfaction can help facilitate hospital
service provision and management, as well as increase and maintain the quality of the
service provision.
Patient‟s quality perceptions have been shown to account for 17 - 27 percent of

variation in a hospital's financial measures such as earnings, net revenue and asset
returns. Moreover Strasser et al. (1995), Pakdil & Harwood (2005), Naidu, A. (2009)
feel that negative word of mouth can cost hospitals $6,000-$400,000 in lost revenues
over one patient's lifetime. There is evidence that several factors make up the overall
28
care quality and satisfaction model. Many researchers have called for empirical cross-
cultural studies of healthcare quality and patient satisfaction.
Earlier work also suggests that patient's expectations and priorities vary among
countries and are highly related to cultural background and to the healthcare system.
Furrer et al. (2000) indicated that weak customers in large power distance cultures
placed less importance on reliability, empathy and responsiveness. Studies indicated
that customers in different countries evaluate good service in different ways.
Differences in service quality perceptions are there between customers and therefore,
measures and scales developed in one culture may not always work as well in other
cultures. The studies further noted that due to differences in response styles and
interpretation of items, not all measures of service quality and satisfaction are
equivalent across cultures.
Donabedian (1988) thus suggests that patient satisfaction should be as indispensable

to assessments of quality as to the design and management of health care systems. It
has been observed that patient satisfaction should also find its way into the design of
services in developing countries.The relationship between perceived service quality,
satisfaction, and trust addresses three principal research questions: First, What are the
dimensions of patient's perception of healthcare quality and how valid and reliable are
they? Second, what is the nature of the relationship between patient perception of
healthcare quality, patient satisfaction and patient trust? Third, do demographic
variables affect patient perception of healthcare quality, patient satisfaction and
patient trust?
It is important that Hospitals should deliver quality and 'zero defect' service to their
customers. So patient satisfaction becomes the most important indicator because
satisfying patients can save hospitals money by reducing the amount of time spent
resolving patient complaints. According to Pakdil & Harwood (2005), the annual cost
of dissatisfaction with hospital services for a hospital with 5000 annual discharges has
been estimated at more than $750,000.
According to Friesner et al (2009), satisfaction measurement is important for three

fundamental reasons: first, high levels of patient satisfaction with healthcare services
29
lower the cost associated with new client acquisition. Second, satisfied patients are
more easily retained, and the value of an existing client usually increases with tenure.
As a result, patient satisfaction is a leading indicator of future financial performance.
Lastly according to Powers and Bendall-Lyon (2003), Nelson et al. (1992), the quality
of customer care can only be enhanced when care providers are aware of how well
they perform on key patient criteria and unless healthcare quality improvement
becomes a priority, the consequences will be worrying.
1.14 Customer orientation for delivering service quality to patients

According to a study by Baker, Sinkula (1999) and Slater, Narver (1995), learning
and market orientation are two organizational values that have attracted considerable
attention with regards to both their inter relationship. Evidence suggests that emphasis
on gathering and disseminating market information along with the ability to develop,
share, and utilize knowledge are the basis for designing internal processes which
produce superior values to customers, yielding in turn a competitive advantage.
This also appears to be the case for the health care industry. Kaissi et al. (2004) claims
that the culture of organizations influences the quality of care to a great extent, while
Hendricks et al. (2002) suggests that the patient - centered operation is currently more
critical then ever before. Yet, building strong relationships with patients necessitates
adopting an internal marketing strategy and embracing a patient-focused perspective,
as well.
It is seen that, within the health care setting, customers are no others than patients,
paying directly or indirectly for and receiving the medical services offered. Regarding
quality of medical care, however, although patients are the obvious source of
information, previous evidence has shown that employee surveys are also valid when
trying to predict customer perceptions of satisfaction and service quality.
1.15 Factors affecting patient satisfaction and healthcare quality

Studies done by Devlin and Dong (1994) confirm that high quality services are
directly linked to increased market share, profits and savings. Generally, service
quality is also recognized as a corporate marketing and financial performance driver.
Healthcare quality is difficult to measure owing to inherent intangibility,
30
heterogeneity and inseparability features. Butler et al. (1996) in his study found that
patients participating in production, performance and quality evaluations are affected
by their actions, moods and cooperativeness.
Healthcare is dynamic, considerable customer changes have taken place and

competition is increasing. Consequently, healthcare quality evaluations raise problems
owing to service size, complexity, specialization and expertise within healthcare
organizations. Patients may be unable to assess medical service technical quality
accurately hence, functional quality is usually the primary determinant.
According to Eiriz and Figueiredu (2005), healthcare quality is more difficult to

define than other services such as financial or tourism mainly because it is the
customer himself or herself and the quality of his or her life being evaluated. Some
authors suggest that healthcare quality can be assessed by taking into account
observer, i.e. friends and family perceptions. Moreover, these observer groups
represent potential future customers and major influencers of patient healthcare
choices.
1.16 The service quality dimensions and patient satisfaction relationships

The health care industry in recent years has restructured its service delivery system in
order to survive in an unforgiving environment resulting from maturation of the
industry, reduced funding, and increased competition. The restructuring has focused
on finding effective ways to satisfy the needs and desires of the patients. This patient-
centered health care service approach shifts the culture of the health care system from
one formed by the preferences and decisions of medical professionals to one shaped
by the views and needs of its users.
It is observed that consumer satisfaction is a fundamental requirement for health care

providers. Satisfaction is important when patients themselves and institutional health
care service buyers make selection decisions. In addition to its positive impact on
patient retention and customer loyalty, patient satisfaction influences the rates of
patient compliance with physician advice. In order to understand various factors
affecting patient satisfaction, researchers have explored various service quality
dimensions considered by patients when evaluating health care quality, such as
31
physician expertise, convenience, degree of concern shown by the physicians and
other medical staff i.e. nurses and receptionists.
Several recent studies have shown that many of these health service quality
dimensions significantly influence patient satisfaction. In order to allocate limited
health care resources effectively, it would be essential for health care providers to
identify patient‟s priorities among various service quality dimensions and to improve
these dimensions for patient satisfaction. However, patients as customers are not
homogenous in terms of the expectations they bring to a care provider and their
reactions to various service quality dimensions. They have heterogeneous views on
what constitutes good medical care. Broadly speaking, patient needs and wants are
shaped by the socio cultural system upon which the health care system is founded and
therefore should vary across different socio-cultural environments.
Furthermore, different nations and cultures have instituted more or less distinct health
care delivery systems. For example, compared to the state-funded health care systems
adopted by most European countries, the health care system of the USA is more
market-based. Nonetheless, patients in the USA do not have as much freedom in
health care provider selection as those in Japan or South Korea, where the private
sector plays an even more dominant role in health care delivery. Given the diversity
there is of the socio-cultural environments and health care delivery systems across
different nations and cultures, it is conceivable that health care consumer behavior
may also vary from one culture and nation to another.
Research shows that understanding satisfaction and service quality is critical to

developing service improvement strategies. The inaugural quality assurance work of
Donabedian (1980) identified the importance of patient satisfaction as well as
providing much of the basis for research in the area of quality assurance in healthcare.
In the healthcare sector, the importance of measuring patient satisfaction is well
articulated with patient satisfaction having been studied and measured extensively as
a stand alone construct and as a component of outcome quality and in particular in
quality care assessment studies.
32
Furthermore, according to Heidegger et al. (2006), the literature tells us that the
concept of satisfaction is complicated irrespective of the area in which it is studied. It
is a multi dimensional concept, not yet tightly defined and part of an apparently yet to
be determined complex model. Significant divergence can be found in the recent
healthcare literature, for example Gonzales et al. (2005) noted that satisfaction
questionnaires have been the most commonly used method to survey patient
perceptions of healthcare for more than 30 years, but only over the previous five
years, had studies tried to ensure that the validity of the instrument was well
grounded. Yet in contrast, the main finding of a 2006 reviewof the patient satisfaction
literature concluded that none of the instruments reviewed could be considered
satisfactory. Hawthorne indicated that there were thousands of patient satisfaction
measures available, which have been developed on an “ad hoc” basis, with
insufficient evidence of their psychometric properties.
Further, quality in healthcare has been studied largely from the clinical perspective,
excluding the patient‟s perception of service quality. According to Crowe et al.
(2002), the subjective affective component of the patient satisfaction construct makes
its measurement “probably a hopeless quest” and its study is largely fraught as it has
lacked precision, at the expense of exact science, with many researchers having
undertaken studies of a purely exploratory nature.
33
CHAPTER II
LITERATURE REVIEW
A review of the literature reveals many studies that have shown a positive relationship
between satisfaction and measures of buying intention 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
physician‟s competence, care and concern towards patients, cost of treatment and
communication between physician 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
34
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. Ovretveit, (1992) identified three
“stake-holder” components of quality: client, professional and managerial.
According to Atkins, Marshall and Javalgi (1996), from the clients view point it is the
meeting of the patient‟s unique need and want at the lowest cost provided with
courtesy and on time. Brown et al, (1998) states that professional quality involves
carrying out of techniques and procedures essential to meet the client‟s requirement
and managerial quality entails optimum and efficient utilization of resources to
achieve the objectives defined by higher authorities. Meeting the objectives of both
physicians and patients has been equated with the concept of quality in healthcare by
researchers Morgan and Murgatrod, (1994).
In a research study done by Peabody et al (1999), quality of care comprises of

structure, process and health outcomes and there are eight dimensions of healthcare
service delivery: effectiveness, efficiency, technical competence, interpersonal
relations, access to service, safety, continuity and physical aspects of healthcare. The
concept of quality notes different meanings to different stakeholders such as
government, service provider, hospital administration and patients. Managing service
processes has a very special significance in service industry as it offers a process for
35
delivery of the services. Efficient service offering creates unique customer
experiences which would make the consumers use the services.
It is seen in the study of Lovelock and Wright (1999) that consumers do believe in
moment of truth, it is a point in service delivery where customers meet and there is
interaction with the employees of the hospital and the outcome may affect the
perceptions of service quality. Hence, the hospitals must ensure that the front end and
back end processes are aligned in a manner that they demonstrate a positive moment
of truth for the customer. 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.
As per the research of File et al, (1992) there are certain services which rely heavily
on consumer‟s word of mouth for new business generations. Previous research has
established the value of word of mouth in regard to obtaining travel agents, lawyers,
hotels, financial planning, insurance agents, banks and car mechanics. The research
points out that the intensity and variety of customer participation during the service
delivery process is predictive of positive word of mouth and referrals. The study was
done on 331 service recipients and it was found that four dimensions of client
participation are highly predictive of both word of mouth and new client referrals. The
four important participation factors are tangibility, empathy, attendance and
meaningful interaction. Their findings support interactive marketing management for
providers of complex services.
36
There is another researcher Shostac (1984) who observed that customer service can be
regarded as a process that consists of actual steps to satisfy customer requirements.
For analyzing customer expectations and designing customer service process model is
required. A better service design provides the solution to market success and growth.
Patient satisfaction surveys are useful in gaining an understanding of user‟s needs and
their perception of the service received. In a survey conducted by Department of
Public Health, Ireland the level of satisfaction among the OPD attendees were 94%.
Doctors and nurses were perceived as friendly by 61% and 72% and rude by 1%
patients respectively. The study highlighted the areas for improvement from the
patient‟s perspective.
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.
It is usually seen that Patients use associated facilities and human factors related to the
quality measures to gauge the quality of hospital services and influence customer
satisfaction. This was evaluated in a study done by Ostwald, Turner, Snipe S and
Butler, (1998). The study also used four other variables namely physician service
performance, nursing service performance, operational quality and overall service
quality to supplement the patient loyalty measure to have a better insight into the
process. Even Bennet et al (1997) states that in many low and middle income
countries, the balance between private and public sector provision of health care over
the past decade or so has tilted heavily towards the former.
37
In their research, Rohde, Vishwanathan (1993) and Berman (1998) have stated that
the debate in India is complex because the country‟s healthcare system is
characterized by many systems of medicines and plenty of unqualified practitioners.
Another observation byYesudian (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.
As per medical services quality is concerned John (1991) in his survey explained that
it can be improved by fine tuning communication between patient and doctor, and
referred to the concept of technical care and emotional care based upon the definition
set forth by Brook and Williams (1975). Technical care implies the accuracy of
diagnosis and treatment process, while emotional care, including the physical
environment of the hospital, implies the behaviour of the service provider and
communication between patient and doctor.
There is a survey which is done by Lytle and Mokva (1992) where they have
emphasised that medical services quality satisfies the needs of patients and patients
evaluate service quality derived from service process and physical i.e. tangible,
environment. Babakus and Mangold (1992) used the concept of medical services
quality developed by Brook and Williams (1975) and John (1991) and then proposed
and assessed the feasibility of SERVQUAL indices to measure medical services
quality perceived by patients. As a result, each item to assess medical services quality
demonstrates high internal consistency, and the items adequately measure expectation
level and performance level when their validity is examined.
2.1 Studies done on medical services quality in Hospitals.

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
38
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. Even Woodside et al. (1989) defined the Hospital medical
services quality as a gap between patient‟s expectations and the real performance and
very confidently verified a practical model leading to satisfaction and intention to buy
a particular service based upon medical services quality measurements using the
SERVQUAL model.
In (1990) Bopp felt that the medical services regarding quality in Hospitals from the
patient‟s perspective is mostly a type of technical quality which is assessed by the
patient as he perceives the services. He said that patients analyse the quality of
medical services highly when they are provided with better services as expected, and
positively verified this through his newly developed 72 expectation and performance
items. In (1989) Woodside et.al. classified medical services in Hospitals as per quality
in a narrow sense and in a broad sense, where medical services quality is seen as
narrow then the performance toward medical services is for a short period, while the
quality in a broad sense shows that the attention and behavior for a longer period
toward medical services provided.
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 an explaination by John (1991) where he states that medical services quality
can be improved by improving the communication between patient and doctor and
suggests the concept of technical care and emotional care based upon the definition
set by Brook and Williams (1975). Technical care means the accuracy of diagnosis
and the process of treatment, while emotional care, means the physical environment
of the hospital, which implies the behaviour of the staff and communication between
patient and medical doctor.
Lytle and Mokva (1992) felt that medical services quality in Hospitals satisfies the
needs of patients and patients analyse the service quality which is derived from
39
service output, service process and the physical environment. In addition, they further
segregated Hospital medical services quality in three dimensions i.e. relationship with
a medical doctor, relationship with other Hospital staff and the physical environment.
Further Babakus and Mangold (1992) used the concept of medical services quality
developed by Brook and Williams (1975) and John (1991) and analysed whether
SERVQUAL is practical to measure the Hospital medical services quality perceived
by patients.
It was observed that each item which is used to assess medical services quality in
Hospitals demonstrates high internal consistency and the items are adequate to
measure expectation level and performance level when their validity is checked. The
classification of factors of Hospital medical services quality perceived by patients
varies by different researchers. Literature shows that Reidenbach and Sandifer-
Smallwood (1990) developed 41 survey items derived from 10 dimensions as
suggested by Parasuraman et al. (1985) and then conducted research with 219 test
patients. In their study, medical services quality is classified into: (i) trust of patient,
(ii) reliability of hospital, (iii) quality of treatment, (iv) subsidiary facilities and
services, (v) physical facilities, (vi) queuing time, and (vii) mental care. Amongst
these, only four dimensions i.e. trust of patient, reliability of hospital, quality of
treatment and physical facilities are determined adequate to measure medical services
quality.
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-focussed 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.
40
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.
According to the American Marketing Association (AMA), customer satisfaction is

the degree to which a customer‟s expectations are fulfilled or surpassed by a product.
Oliver (1980) felt that patient‟s satisfaction means an overall mental state derived
from a combination of emotions which were caused by a patient‟s actual experience
and disconfirmation of expectation and emotions before going in for the buying
experience. According to the finding, a disconfirmation between prior expectation and
product performance affects customer satisfaction and dissatisfaction and customer
satisfaction is determined based upon a customer‟s internal determinants and
perceived performance.
The Malcolm Baldrige National Quality Award was given to the best hospital in 1994,
when the concept of customer satisfaction was introduced into Hospitals. This study is
done and follows the usual expectation-dissatisfaction theory and defines customer
satisfaction in medical services as the perceived value judgement and continous
response toward service related stimuli before, during or after the experiencing of
medical services by a patient in a Hospital. Heskett et al. (1997) concludes in his
research that, what the patient buys is not only the service, but rather the outcome
after the service is provided. In other words, the patient decides to buy in order to
satisfy his or her intention and the quality of delivery process and outcome constitute
the majority of customer value.
Surveys indicate that, a service outcome is the desired or intended result of that
service and means not only a tangible outcome but intangible utility as well.
Intangible utility has a correlation with changes in a customer‟s mind set i.e. the
patients mental and physical state after the medical service is provided. Consequently,
the value of service quality given to a service outcome varies on the size of service or
the importance of the outcome perceived by the patient. On the other hand, patients
41
also perceive the value of service by analyzing the cost and benefit incurred by the
service provided i.e. the value in this case, represents the value of care. Therefore, the
value can be defined as a customer‟s analysis of the cost a customer paid in order to
obtain a particular service and the benefit a customer received from that particular
service.
It is seen that, „the cost paid‟ and „the benefit received‟ may be interpreted differently
by different persons, but the value emerges as a result of the offset effect between the
cost and benefit. Correlations should be amongst medical services quality, patient
satisfaction, value of care and re-visit intention in their research on the correlation
between medical services quality and satisfaction level.
Ware et al. (1978) initially conducted a content analysis on existing studies on patient
satisfaction in order to extract indirectly a definition of patient satisfaction. In their
analysis, patient satisfaction is affected by the characteristics of the service provider
and medical services, and patients demonstrate distinct behaviour toward each of
those characteristics. In the earlier studies, service quality is identified to affect the
value. Heskett et al. (1997) felt that the value perceived by a customer is affected by
the service outcome and quality of service process. There is further analysis by
Zeithaml (1988), on the correlation between the quality of product and its value
perceived by a customer, he verified that the quality of product perceived by a
customer affects its value, and this value in turn, affects the service outcome.
Further, Gooding (1995) in his study on the correlation between medical services
quality and its value with 260 test medical services consumers, explained that a
medical services consumer evaluates the value through service quality. Moreover, the
value of care perceived by a patient is shown to precede customer satisfaction in
established studies. Moss et al. (1986) explained in their study on females in
childbirth that a sudden decrease in the satisfaction level toward maternity clinics
arises from a decrease in the value toward the services after childbirth compared with
before childbirth and thus the value of care perceived by a medical services consumer
is a preceding variable of satisfaction, which directly affects satisfaction and
dissatisfaction.
42
The evaluation of a patient on the satisfaction has an influence on the future re-visit
intention and other behavioural intentions. Customer satisfaction is not a sufficient
condition for re-visit intention, but necessary condition. In recent studies, researchers
Y.K. Kim et al and Gooding (1995) have been placing a significant emphasis on value
as an important antecedent to the loyalty intention of a patient. Even Ostrom (1995)
argued that a better value in fact increases the preference for re-utility and the value of
care, likewise affects the re-visit intention of consumers to hospitals. In the preceding
studies Fisk et al., (1990) Gooding (1995), O‟Connor et al. (1991) and Woodside et
al., (1989) state that medical services quality perceived by a patient is identified to
induce satisfaction and re-utility. Woodside et al. (1989) verified that the satisfaction
level serves as a medium between medical services quality and re-visit.
2.2 Value in the word-of-mouth

Thus 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.
In his study Evans (1984) found that patients do not want the health care services only
from the point of view of the service itself, but rather as a means to achieve better
health for them and their families, which sometimes requires them to use a Hospital to
aid that process. Taner & Antony (2006) felt that there is usually a very high quantam
of risk associated with the very nature of the medical service. Hogg, Laing, &
Newholm (2004) are of the view that there is high patient involvement, whereas Jadad
(1998) is of the opinion that there exists a high degree of emotional vulnerability.
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
43
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.
In their study, de Brentani & Ragot (1996), state that when selling healthcare services
Hospitals must also consider the value from the point of view of the patient i.e from
the patient‟s perspective. 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 inspite 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.
44
Herzlinger (1997) and 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.
As per Journal of Marketing Management, Volume 27 (1992) word of mouth is an

exchange of thoughts, ideas or comments between two or more consumers, none of
whom is a marketing source. According to Fisher & Anderson (1990), Gombeski,
Carroll & Lester (1990) Murray (1992) and Williams & Hensel (1991) patient word
of mouth in particular is very important in the health care industry. Harris (2003) too
suggests that patient word of mouth in particular is becoming increasingly important
for hospitals and treatment providers because patients can play an important role in
achieving optimal health by taking an active and informed role in treatment decisions
and switching physicians if care is unsatisfactory.
Bikhchandani, Hirshleifer & Welch (1991), observed that consumers use word of
mouth referrals for reassurance or confirmation that they are making the right
decision, such as „What do you think of that doctor?‟ or to sort through multiple
alternatives, such as „Which birthing hospital do you think is best?‟ Belkin (1978)
Buckland (1991) and Dervin (1990) also state that referrals provide information that
can reduce uncertainty which should be important for a high-risk decision such as
health care. 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.
There are health care professionals who advise on parent‟s attempts to conceive.
During pregnancy, there are general practitioners, dietary advisers, and ultrasound
operators. During the birth, hospital and medical staff (e.g. anaesthetist, general
practitioner and paediatrician) and specialist staff are on hand for any complications
45
that may arise. With a new baby, the list of health care professionals expands to
include general practitioners, paediatricians, obstetricians and other health care staff.
If the babies or pregnant mothers suffer health problems, the range of health care
professionals may be extended to include specific professionals (e.g. diabetes
specialists) and support staff related to those health problems (e.g. blood testing,
dieticians).
Thus it is seen that a mother confronts a vast number of health care providers and
must sort through the array of alternatives on behalf of both herself and her children.
Hoerger & Howard (1995), Lupton, Donaldson & Lloyd, (1991), observed that to ease
this difficult decision process, patients might not engage in rational information
searches to select physicians but instead rely on recommendations from family and
friends, which constitutes a limited search for alternative physicians.
2.3 Role of HRM in Healthcare Organizations

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.
These in turn lead to customer perception of low service quality and to a lack of
customer loyalty. A key stepping stone for a new set of HRM practices is the concept
46
of workforce satisfaction mirror according to Schneider & Bowen (1985) and Heskett
et al. (1997). The idea behind the satisfaction mirror is that customers will receive
higher quality service and be more satisfied when the front-line workforce themselves
are satisfied in their jobs. A key part of the mirror is the inter-relatedness of the
satisfaction of the two parties. Another aspect of reflective mirror is the argument that
front-line workers feel more satisfied because they are able to satisfy customers. To
foster workforce satisfaction, new service management school prescribes the adoption
of a range of HRM practices.
Diagram 1
Source: HR Management: Hospital Management System (2013).
Human resource management (HRM or simply HR) is the management of an

organization workforce or human resources. This module is responsible for adding
new employee, new doctor, new nurse, search particular employee detail from the
hospital database. Hospital staff can apply as well as view the employees who are on
leave and who have applied for leave using this module. Effective HRM enables
47
employees to contribute effectively and productively to the overall company direction
and the accomplishment of the organization's goals and objectives.
According to Schlesinger & Heskett (1991), the 'Cycle of capability' HRM practices
would include careful selection, high-quality training, well-designed support systems,
empowerment, teamwork, appropriate measurement, rewards and recognition, and the
development of a service culture. Climate for service and employee well-being are
both highly correlated with the overall customer perception of service quality. Service
climate includes incentives to reward service excellence, tangible evidence from the
organization that customer service is critical, emphasis on the retention of existing
customers, support equipments and practices necessary for service delivery.
The climate for employee well-being can be measured through worker perception of
the following HRM practices: work facilitation, supervision, organizational career
facilitation, organizational status, new employee socialization and overall quality of
HRM practices. However, the concept of satisfaction mirror has little research
support. Many service industries show systematic low wages, low training, restricted
career paths and high turnover. The model for achieving cycle of success in
interactive service works is known as high involvement work systems (HIWS). It
includes high relative skill requirement from the employees, jobs designed to provide
the opportunity to use these skills and an incentive structure in organizations to induce
discretionary effort as per a study by Batt (2000).
Research indicates that, High involvement work systems (HIWS) are expected in
many service organizations, especially in the ones that rely on the knowledge and
ability of their workforce. The HR elements of this work system are careful selection,
realistic previews of job and organization, focus on early job experiences of
employees, employee empowerment and latitude, employees awareness of their role
in customer satisfaction, score keeping and feedback, integration of employees in a
winning team, focus on aggregate labour costs instead of average wage levels and
concentration on quality at the service core.
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
48
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.
In order to establish a relationship between the human resource policies and the
quality of service delivery, it is important to first identify the parameters of good
quality. Under the concept of High involvement systems (HIWS), higher self-
perceived service capability is expected. This self-perceived service capability can be
understood in terms of SERVQUAL (Service Quality), a concept of quality that has
five dimensions, which was researched by Parasuraman, Zeithaml, & Berry (1985).
The dimensions or parameters are Responsiveness, Assurance, Tangibles, Empathy,
and Reliability.
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.
According to (AIHW 2005), the pressure for efficiency and effectiveness is

particularly pronounced in the hospital sector, which is the most resource - intensive
component of the health care system. Thus, maintaining SERVQUAL is the primary
responsibility of the doctors and the nurses. They are entrusted with the task of patient
satisfaction and it is their collective responsibility to ensure that patient needs are
fulfilled. From the HR perspective, different HR practices and policies are required
for doctors and nurses because they create different components in the service value
chain. Therefore, while in the case of doctors, policies such as revenue sharing would
be of more importance, for nurses, training to help them perform dual objectives of
quality and quantity of service would be of higher relevance.
49
It is often seen that, the contradictions between the bureaucratic imperative to deliver
healthcare efficiently and the desire of healthcare workers to give meaningful,
personalized care to patients create the central tension of work (CoB - Customer-
oriented Bureaucracy). The socially embedded relationship with patients provides a
space for real pleasure and meaning for healthcare workers. A significant
development in the healthcare sector has been the concept of 'primary care'. Wicks
(1998) found that Primary nursing is patient centred rather than task-centred and is
characterized by each patient having a single, identified, qualified nurse who is
responsible for their care during the entire period of their hospital stay.
In his research Bauman (1989) found that most profit-maximizing organizations,

however, emphasize technical rationality and quantitative efficiency. The bureaucratic
hyper specialization of healthcare is the medical manifestation of the wider
phenomenon of the dehumanizing effects of bureaucracies. The analytical lens of the
customer-oriented bureaucracy also highlights the contested nature of authority in
healthcare. The idea that the 'consultant is king' clearly speaks about the dominance of
the authority of medical knowledge. This prioritizes theoretical knowledge of
medicine above the object (the patient) to which this knowledge is applied.
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.
Thus it can be said that the customer‟s needs and comfort are increasingly becoming
very essential for the hospitals. The non-medical managers also in fact formulate HR
and administrative policies keeping the patients in the forefront. Another facet of the
medical professional that needs to be understood is that in this field, professional
identification, commitment and ethics are stronger in comparison with organizational
identification, commitment, and ethics. The doctors and nurses are answerable to their
profession first and their organization later. In any conflicting situation or otherwise,
50
it is always their professional ethics that will drive them. These are instilled into the
healthcare professionals even before they join any organization.
2.4 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.
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2.5 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.
It is observed, that the focus on patient input and voice is one of the characteristics
that makes Patient centered care a unique workplace innovation and distinct from
other sets of practices, such as High involvement work practices (HIWP) and similar
employee-centered systems. Transforming the relationship between the hospital and
the patient requires other important changes, such as the organization of work for
direct care frontline staff. Patient centered care according to Davis et al. (2005) and
Corrigan et al. (2001) is founded on the notion that information should be shared
between physicians and patients and more importantly, that decision making is based
on patient involvement so that viable treatment or medication options take into
account patient preferences and perspectives. The PCC model also entails a
restructuring of workplace practices in order to facilitate greater levels of interaction
between frontline staff primarily nurses and nurse‟s aides and clinicians.
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.
It is seen that Patient centered cares, emphasis on coordination across disciplines and
professions is in fact, similar in many ways to relational coordination practices that
52
have been linked to a variety of positive organizational outcomes. It is the
combination of staff coordination and patient engagement that is unique to Patient
centered care. Patient centered care also represents a distinct workplace innovation
separate from HRM.
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.
The combination of these Patient centered care dimensions is intended to shift

fundamental aspects of how healthcare organizations operate and provide care for
patients. As is evident, four of this patient centered care dimensions are intended to
alter the traditional relationship between hospital patients and those who provide them
with care. For example, the focus on increased patient education is designed to
enhance the patients understanding of their conditions as well as the advantages and
disadvantages of different treatment options. One of the five Patient centered care
dimensions, coordination of care, is specifically related to the manner in which
frontline staff are organized in order to deliver care.
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.
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2.6 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.
Many studies reveal that a lower priority is placed on patient's perception on patient's
non clinical expectations of service quality. Some professionals contend that
consumer's perception of quality service in health care is distorted due to the inability
of patients to judge the technical competence of medical practitioner with any
accuracy. Medical courses focus on imparting technical knowledge to the students and
doctors do not receive any soft skill training which will enable them to get closer to
their patients.
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. Results show that the pattern of
relationships between service quality and patient satisfaction was similar across the
gender, age and service type sub groups. It was also found that the level of
satisfaction on the other hand was not the same for sub groups when divided by age
and the types of services received. Many of these health service quality dimensions
significantly influence patient satisfaction. The dimensions for evaluating health care
quality are convenience, degree of concern shown by the doctors and medical staff
and physical facilities.
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
54
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.
2.7 Patient Satisfaction and Behavioral Intention

According to Taylor, Baker (1994) and Cronin, Taylor (1992) Service quality should
be conceptualized and measured as an attitude. Extensive research has been done to
conceptualize service quality as perceived by the service provider and the customer.
Service quality is perceived as a customer‟s subjective interpretation of his or her
experience. Lehtinen and Lehtinen (1991) have applied the two-dimensional
approach, i.e. process quality (production process) and output quality (result of
production process) in dance restaurants. Marley, Collier, and Goldstein (2004), have
divided the service quality framework into clinical quality (medical outcome and
„what‟ is delivered) and process quality („how‟ the service is created and delivered) in
hospitals.
Lehtinen and Lehtinen (1991) have also applied the three dimensional approach, i.e.
physical quality, interactive quality, and corporate quality in dance restaurants. The
servqual model developed by Zeithaml, Berry, and Parasuraman (1988) has five
dimensions: tangibles, reliability, responsiveness, assurance, and empathy. They have
also developed a ten dimensional model, i.e credibility, security, access,
communication, understanding the customer, tangibles, reliability, responsiveness,
competence, and courtesy. Besides this they have also perceived a service quality
model based on 4 gaps, i.e. knowledge gap, standard gap, delivery gap and
communication gap.
Based on theoretical and empirical evidences, researchers still claim that the service
quality construct is complex. Health care is one of the people processing services
55
which involve high contact encounters. The level of involvement of the patient as well
as the doctor in the health care process is high. The health care service delivery
process includes both the medical treatment as well as other related factors, like
physical structure, encounter and interaction with service personnel, service culture,
etc. Considering all these aspects, V. Dalvi, N. Rajanala, and K. Nizomadinov state
that a patient as well as his family members may evaluate the level of the service
quality. A problem arises when patients are asked to evaluate the quality of those
services that are high in credence characteristics, such as complex medical treatment,
which they find difficult to evaluate even after the treatment is completed.
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. Consumer
satisfaction is the core concept in service marketing literature. Most studies on
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customer satisfaction are based on the confirmation and disconfirmation of customer‟s
expectations.Taylor and Cronin (1994) too feel that satisfaction is seen as a function
of confirmation or disconfirmation of expectation and is best conceptualized as an
attitude toward service performance. Satisfaction can be defined as an attitude, like
judgment following a purchase act or a series of consumer product interaction. In a
health care setting, the customer is a patient. Patient satisfaction is the dominating
area in health care research, management and marketing.
Mummalaneni and Gopalkrishna (1995) in their study observed that there is a

consensus regarding the close relationship between service quality and consumer
satisfaction. Increased demand and competition has posed a challenge to service
marketers. Singh (1990) too felt that it will be a wise move on the part of the medical
practitioner to analyze patient satisfaction as well as dissatisfaction in order to
maximize patient satisfaction. Patient‟s satisfaction and dissatisfaction may have an
impact on the financial performance of the healthcare provider. Success in retaining
or attracting patients may result from patient satisfaction with the medical care they
receive. A satisfied customer may or may not become a loyal customer. A loyal
customer is more important than a satisfied customer.
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.
Review of literature indicates that the casual relationship between clinical quality,
patient satisfaction and behavioral intentions may be proved correct if related to the
clinical outcome, i.e. cure, which may be tangible, but it is difficult to generalize the
relationship between process quality, patient satisfaction and behavioral intentions
with heterogeneous socio demographic groups and cross-country hospital settings, as
the process quality outcome is more emotional, i.e. care. The patients and the family
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members do expect a cure as well as the care of a hospital setting. The service
encounter related process quality influences the future decision making. The
behavioral intention dimensions, which are more relevant to the service encounter
related process quality are repeat visits and recommendations.
2.8 Service Quality Satisfaction
In their study Chen, et.al. (1994) and Johnson et.al. (1988) state that the service
sector is expanding at an increasing rate and is becoming intensely competitive. As
such, service quality has become a very important issue in marketing and has received
much attention since the deregulation and thus increased competition of many service
industries e.g. health care, banking and telecommunications in the 1980‟s and utilities
in the 1990‟s. Service quality has become so important that some businesses, not only
need high levels of service quality for success, but in some cases need it for survival.
Hauser and Clausing (1988), Phillips et.al. (1983) and Zeithaml et.al. (1990) in their
research have found that service quality is so important that companies have gone to
great efforts to evaluate and keep records of service quality levels. By offering high
levels of service quality, the Hospital Corporation of America and Ford Motor
Company are another two well know companies that have benefited in terms of higher
returns on investment and higher profits. According to Kettinger and Lee (1995),
researchers have varying suggestions for uses of service quality measurement
instruments. Some researchers recommend using service quality instruments in order
to spot problems, determine how to correct the problems and to evaluate the
improvements.
Zeithaml, Berry and Parasuraman (1996) found that companies should use service
quality surveys to warn of possible problems that could lead to departing customers.
Additionally, these same researchers suggest using the survey to modify service
offerings to be consistent with what the customer wants. Given the importance of
service quality to the services sector, Taylor and Baker (1994) encourage further
operationalization of service quality. Service quality is defined as how well the
service meets or exceeds the customer‟s expectations on a consistent basis. The
difficulty, however is that service quality unlike product quality, is more abstract and
elusive, because of features unique to services: intangibility, inseparability,
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heterogeneity and perishability and is therefore difficult to measure. To remedy this
difficulty, Parasuraman, Zeithaml and Berry (1985) established the “gap model”.
Parasuraman, Zeithaml and Berry (1985) conducted focus groups and interviewed
executives. In doing so, they identified five “gaps” that can cause quality problems in
organizations. The first gap is the consumer expectations - management perceptions
gap. This gap resulted from discrepancies between the perceptions of executives and
the perceptions of consumers on things like privacy and security issues. Basically, the
executives did not understand the customer‟s expectations. Service firms also
experienced problems in providing services as quickly as the customers wanted.
It was noticed that, this created the second gap which is called the management
perception - service quality specification gap. The third gap is the service quality
specifications - service delivery gap. Executives realize that this gap includes the vital
role of the contact personnel. This is a difficult aspect of providing services, because
of the inconsistency in the behavior of personnel. The fourth gap is the service
delivery - external communications gap. This gap forms, based on the capability of
the firm to deliver what is promised and to completely inform consumers of all the
things the service firm is doing that benefit customers. It is the difference between the
expectations customers have and the perceptions of service actually received and is
pertinent to providing high levels of service quality.
It is observed that Gap 5 is the expected service perceived, service gap. Parasuraman,
Zeithaml and Berry (1988) attempted to measure this fifth gap by developing the
SERVQUAL instrument. They performed exploratory research to examine quality in
four service settings (retail banking, credit cards, securities brokerage, and product
repair and maintenance) in order to understand an area that is under researched and
difficult to define. These researchers found 10 dimensions (reliability, responsiveness,
competence, access, courtesy, communication, credibility, security, understanding the
customer and tangibles) that customer‟s use across varying service industries to form
expectations and perceptions of services received.
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2.9 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.
Donabedian defines quality as “a reflection of values and goals current in the medical
care system and in the larger society of which it is part”. He follows up by noting that
more than 80 criteria have been provided to assess quality in patient care, concluding
that it is likely not a unitary concept. Instead, Donabedian argues for a broader
framework within which to evaluate quality that includes elements of structure,
process and related outcomes. In his assessment, structure should facilitate the actual
care delivered, which manifests in outcomes that are the result of the processes
employed.
According to Donabedian (1980) high quality care is that kind of care which is
expected to maximize an inclusive measure of patient welfare, after one has taken
account of the balance of expected gains and losses that attend the process of care in
all its parts. More recently, the Institute of Medicine (IOM) published its own
definition of quality, which resulted from a literature review of more than 100
previously used definitions of quality. The IOMs definition of quality is “the degree to
which health services for individuals or populations increase the likelihood of desired
health outcomes and are consistent with current professional knowledge”.
2.10 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
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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).
Business Process Management

Business process management according to Armistead & Machin (1997) deals with
how to manage processes on an ongoing basis. This 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.
According to Lebas (1995), measurement and management are not separable.

Business process management integrates the measurement and also ongoing
improvement of business processes as per Harmon (2003). 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.
2.11 Community Hospital Healthcare System

With the enactment of Patient Protection and Affordable Care Act in March 2010 and
President Obama's professed goal of making health care in the United States more
accessible and affordable, the next few years are sure to be very turbulent in the
United States healthcare industry. According to a survey done by New Jersey Hospital
Association (2010), the Health Act is expected to provide healthcare coverage to 95%
of Americans, which will include an additional 32 million persons nationally. The
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Health Act goes into effect in 2010 with many of its requirements not becoming
effective until 2019. The survey done by Wall Street Journal (2010) indicates that
directly because of the enactment of the Health Act, insurance premiums are expected
to increase anywhere from 2% to 9% depending on who is quoting them.
According to Adamy (2010) and Pear (2010) the Health Act as per the Journal of the
International Academy for Case Studies (2012), requires children to remain on their
parents health plans until age 26, eliminates copayment for preventive care, bars
insurers from denying coverage to children and adults with pre-existing conditions,
eliminates lifetime caps on insurance coverage and requires setting up of insurance
exchanges in all states, through which individuals, families and small business can
buy coverage. United States spends approximately $2 trillion annually on healthcare
expenses. Johnson (2010) in his study found that this amount is more than any other
industrialized country in the world and counts for 16% of the U.S. GDP. This
percentage is higher than any developed country in the world.
It is seen that despite the substantial healthcare spending, access to employer-

sponsored insurance has been on the decline among low-income workers and health
premiums for workers have risen 114% in the last decade. Furthermore, healthcare is
the most expensive benefit paid by U.S. employers. Despite this outlay Abelson
(2010) and Kavilanz (2009) state that approximately 49 million Americans are
uninsured and about 25 million underinsured, those who incur high out-of-pocket
costs, excluding premiums, relative to their income, despite having coverage all year.
Flier (2009) states that, the healthcare industry in America is besieged with high cost,
uneven access and quality. The intractable issues of high cost, uneven access and
quality have made everyone unhappy from patients, hospitals, doctors to employers.
The findings of Goldhill (2010) suggest that the American healthcare industry is
composed of approximately six major interest groups: hospitals, insurance companies,
professional groups, pharmaceuticals, device makers, and advocates for poor with the
Physicians who are part of the professional group shaving the biggest influence on the
industry. According to the U.S. Department of Labor (2010) although hospitals
constitute only 1 percent of all healthcare establishments, still hospitals, nursing and
residential care facilities, offices of physicians & dentists, home healthcare services,
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office of other healthcare practitioners, and ambulatory healthcare centers employ
35% of all healthcare workers.
2.12 Hospital & Physicians

It is observed that Hospitals are competing by aggressively branding specialty
services, such as heart, cancer, and orthopedic spine centers. As part of the service-
line branding, physicians often were emphasized in marketing materials and in some
cases, played major management roles in running the service-line products.
Physician-hospital competition: At the same time that some physicians were

affiliating with hospitals in the service-line strategy, other physicians were
aggressively competing with hospitals over services, sometimes for traditional
inpatient services with stand-alone specialty hospitals and more commonly, with
ambulatory- based facilities, such as ambulatory surgical centers and imaging centers.
Researchers identified a few factors that were encouraging physicians entrepreneurial
interest in competition over services i.e. seeking additional sources of income,
increasing consumers expectations of "one-stop shopping" for physician services and
growing physician demand for control over their own work environment.
Purchaser’s expectations: Research shows that private and public purchasers have
new expectations that hospitals would improve patient safety and quality of care
through a number of initiatives, including the publication of comparative quality
information. The Centers for Medicare and Medic aid Services (CMS's) Hospital
Reporting Program, in particular seems to have generated a positive hospital response
to improve performance for conditions such as pneumonia and acute myocardial
infarction (AMI). To improve their performance on quality and safety, hospitals need
to engage physicians in measuring and improving quality.
Hospital medical staff has responded positively to having a focused set of clinical
priorities on which to work and to physician-specific performance data. However,
some hospitals have found that it is easier to work on these issues with a relatively
small number of physicians who are employed than with a much larger medical staff
made up of many physicians who now rarely and reluctantly participate in hospital
activities.
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2.13 Competition between hospitals and physicians
It is seen that there is a growing competition between hospitals and physicians over
services that had once been within the hospital domain. There is more and more
shifting of services from hospital control to physician control. The intensity of
competition between hospitals and physicians also varies across the sites. For the
most part, in Boston, Cleveland and Seattle, which have large numbers of employed
specialists, as part of either academic health center (AHC) based faculty practices or
multispecialty group practices, hospital-physician competition over service lines has
not had a broad impact.
It is observed that, in the markets dominated by relatively small, single specialty

practices, competition has become intense. Although the issue of specialty hospital
competition between community hospitals and physician-owned specialty hospitals
has received national-level policy attention, more widespread competition is taking
place over services that once were performed in hospitals but now can be safely
performed either in specialized ambulatory facilities or in physicians offices.
It was further noticed that some hospital professionals saw the role of new and
anticipated technologies, such as cyber knives, gene therapy, and minimally invasive
surgery as accelerating the relocation of care away from hospitals. Ambulatory
surgical centers (ASCs), often involving physician-ownership, are certainly not new
and respondents in many markets report that the reliance on Ambulatory surgical
centers (ASCs) as an important source of care has mushroomed in recent years.
2.14 Quality in Healthcare – measuring the gap

According to a senior nursing lecturer by the name Hogston (1995), there was no
formally accepted definition of quality nursing and he undertook a small qualitative
study by interviewing 18 nurses. From the responses given by the nurses, Hogston
concluded that nursing quality fell into three categories, process, structure and
outcome. Interestingly Hogston did not mention Parasuraman et al (1985) and their
quality Service Model and he also had no patient perception of quality nursing within
his research. Brown and Swartz (1989) realised the need to examine professional
service quality. Having studied the service Quality Model presented by Parasuraman
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et al (1985), Brown and Swartz felt a simpler model is more appropriate for
evaluating professional services such as healthcare.
There is no standard definition of quality that applies and it depends on the

organisation and the individual circumstances within the environment. This is
somewhat surprising when healthcare talks of quality, within almost everything it
presents. It can be concluded that individual circumstances require an individual
definition. What is less clear is whether determining a definition is important and
whether once agreed, the definition serves any useful purpose. The work of
Parasuraman is undoubtedly one of the most major pieces of academic work to
influence the study of service quality. It is the most helpful in providing a structure
from which to consider how a healthcare setting might start to comprehend and
measure quality. The researcher‟s gap model is easy to understand and widely
discussed within the academic literature.
2.15 Manager and Patient Perception

SERVQUAL instrument is one of the most popular for measuring service quality but
very few have just measured expectations. O‟Connor et al (1994) describe themselves
as being the first to do so, with their healthcare study. Therefore, although not widely
tested the SERVQUAL instrument offers the most appropriate starting point from
which to measure expectations alone. The literature suggested that it was more
appropriate to start by closing any gap identified between customer and manager
before attempting to examine the other gaps.
The literature review suggests that patient‟s perspectives are important but the
professionals view when combined, can add additional insights where change is
needed. The levels of staff to be involved in this study needs additional consideration.
There is evidence within a healthcare study, that bigger gaps appear between
physicians and patient expectations compared to other healthcare staff. The managers
are defined as non-front-line staff not directly involved in delivering care but
responsible for making decision in relation to the service to be studied. The
administrators are administrative and clerical staff working at a senior level, also
involved in decision making at a management level.
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In today‟s competitive marketplace delivering high quality service and having
satisfied customers is considered necessary to gain competitive advantage. It is
generally agreed that a loyal customer base is more profitable than new customers.
The literature is unanimous in concluding that there are benefits to understanding and
measuring quality although they vary on how best to undertake this exercise. Service
quality is a central issue in services marketing and has been discussed in a number of
writings even before the well-known SERVQUAL research by Parasuraman et al.
According to Pollack B, L, (2008) Service quality is recognized as a multi-

dimensional construct and researchers have listed a variety of service quality
determinants. Gronroos (1984) postulated two types of service quality: technical
quality (i.e. what the customers actually received from the service) and functional
quality (i.e. the manner in which the service is delivered). He even proposed that
service quality can be described in terms of professionalism and skills, attitudes and
behaviour, accessibility and flexibility, reliability and trust worthiness, service
recovery reputation and credibility.
Lehtinen and Lehtinen (1991) claimed that there are three service quality dimensions,
namely, physical quality, corporate quality and interactive quality. The last dimension
according to Svensson (2006) recognizes that service quality arises from the
interaction between the service provider and service receiver and is therefore
necessary to supplement the customer-centered view of service quality which has
been the dominant paradigm to date. Building upon Rust and Oliver (1994) work,
Brady and Cronin (2001) advanced the hierarchical conceptualization of service
quality i.e. it consists of three dimensions: outcome quality (refers to the customer's
assessment of the core service.), interaction quality (refers to the customer's
assessment of the service delivery process) and physical environment quality (refers
to the consumer's evaluation of any tangible aspect related to the service.
The most popular conceptualization of service quality SERVQUAL features five

dimensions: tangibles, reliability, responsiveness, empathy and assurance. According
to the model, service quality can be measured by comparing the service expectations
of customers with their perceptions of actual performance using 22 questions. The
physical service aspects such as appearance of employees, equipment and facilities
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are classified as tangibles. Reliability refers to accurate, dependable and consistent
performance of the service. The remaining three represent aspects of interaction
quality: responsiveness means being prompt and willing to serve the customer,
empathy involves caring and personalized attention as well as understanding customer
needs and convenient access to the service. Lastly the dimension of assurance
comprises the competence, courtesy and credibility of staff which generate customer
trust and confidence.
Gronroos (1984) defined perceived service quality as the outcome of an evaluation

process, whereby the consumer compares his expectations with the service he has
received, i.e. he puts the perceived service against the expected service. The result of
this process will be the perceived quality of service. Perceived quality thus differs
from objective quality, which involves an objective assessment of a thing or an event
on the basis of predetermined standards that are measurable and verifiable. Perceived
quality is a global judgment, or attitude relating to the service. In short, perceived
quality involves the subjective response of people and is therefore highly relativistic.
Some authors suggest that healthcare quality can be assessed by taking into account
observer, i.e. friends and family perceptions. More over Strasser et al. (1995) and
Naidu, A. (2009) feel these observer groups represent potential future customers.
Quality has been defined as perceived satisfaction as per Smith and Swinehart (2001).
According to Lim et al., (1999) quality is continually satisfying patient requirements.
He postulated two aspects of healthcare quality: (1) the technical aspect of care, which
refers to the competence of the providers as they go about performing their routines.
These include thoroughness, clinical and operating skills of the doctors, clinical
outcomes. (2) The interpersonal aspect of care, which represents the humane aspect of
care and the socio-psychological relationships between the patient and the health care
providers.
It is further observed that this involves explanations of illness and treatment, the
availability of information, courtesy and the warmth received. Internal checks on
quality are not evident to patients. Vinagre & Neves (2008) observed that patients
cannot judge the technical competence of the hospital and its staff; i.e patients have
no "skill" to evaluate exactly the service's technical reliability. This result is also
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consistent with Donabedian's (1989) statement that patients often are in no position to
assess care process technical quality and they are sensitive to interpersonal
relationships. Hence, a patient makes a judgment of a hospital based on the
interpersonal aspect of care that he receives, the manner in which medical care is
delivered.
Therefore patient may use non technical characteristics such as the length of time
waiting for a procedure or the pain they experience to evaluate service quality. These
aspects of the service are directly experienced and their evaluation requires no
technical expertise. Peyrot et al., (1993) identified several non medical aspects of the
service encounter as likely candidates for producing increased satisfaction and use,
e.g, information, convenience, and interpersonal warmth. Patient satisfaction is
considered as one of the most important quality dimensions and key success
indicators in health care. Pakdil, Harwood (2005) and Zineldin (2006) defined
satisfaction as an emotional response.
It is thus observed that despite being seemingly alike, perceived service quality and
consumer satisfaction are distinct constructs that may be defined and evaluated in
different ways. According to Zeithaml & Bitner (2000) while service quality and
consumer satisfaction have certain things in common, satisfaction is generally viewed
as a broader concept while service quality assessment focuses on dimensions of
service. Usually, service quality is considered mostly a cognitive construct while
satisfaction has been considered a more complex concept that includes cognitive and
affective components. Kane et al. (1997) too felt that satisfaction is believed to be an
attitudinal response to value judgments that patients make about their clinical
encounter. Satisfaction, however, is perceived as a global consumer response in
which consumers reflect on their pleasure level. Satisfaction is based on service
delivery predictions that depend on past experiences, driven by conceptual cues.
Although perceived service quality may be updated at each specific transaction or

service experience, it tends to last longer than satisfaction, which is understood as
being transitory and merely reflecting a specific service experience. Oliver (1997)
defines satisfaction as "the consumer's fulfillment response", a post consumption
judgment by the consumer that a service provides a pleasing level of consumption-
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related fulfillment, including under or overfulfillment. He identified a few major
elements that differentiate service quality and satisfaction. According to him quality is
a judgment or evaluation that concerns performance pattern, which involves several
service dimensions specific to the service delivered.
According to Priporas, et.al. (2008), a patient's expectations and perceptions are not
simply related because a medical or health service is not technically comprehensive.
Patients are therefore unable to have a clear idea of their expectations in a clinical
setting. Patient satisfaction constitutes a crucial aspect of quality of care. According to
Linder-Pelz (1982) patient satisfaction is defined as an evaluation of distinct
healthcare dimensions. It may be considered as one of the desired outcomes of care
and so patient satisfaction information should be indispensable to quality assessments
for designing and managing healthcare. Senarath, et. al. (2006) observed that patient
satisfaction with health care has been argued as a subjective and dynamic perception
of the extent to which expected health care is received. Satisfaction tends to mirror the
quality of health services delivered. It is a psychological notion that can be easily
understood but is difficult to define.
Priporas et. al., (2008) stated that the experience of satisfaction may be connected to
happiness, wealth, prosperity and quality of life. In its technical attribution, it is a
judgment set by the customers of a service, documented after the consumption
experience. Patient satisfaction is a moving target that must be monitored and
enhanced over time. Failure to do so ensures that rising patient expectations will go
unmet or present new opportunities for competitors to exploit. Understanding the
content and organization of patient expectations can allow any healthcare provider to
respond proactively.
It has been observed that the ability of any organization to satisfy its customers are
most easily realized when those expectations are managed so as to be consistent with
the product and processes provided. Jackson et al. (2001) suggests that immediately
after the visit, patient satisfaction is strongly influenced by patient-doctor
communication.
According to them, patient satisfaction is used for four purposes:
(1) To compare different health care programs or systems
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(2) To evaluate the quality of care
(3) To identify which aspects of a service need to be changed to improve patient
satisfaction.
(4) To assist organizations in identifying consumers likely to disenroll.
According to Tucker and Adams (2001) patient satisfaction is predicted by factors

relating to caring, empathy, reliability and responsiveness. As per Fowdar (2005)
other dimensions have been introduced to capture patient‟s healthcare evaluations,
including: core services, customization, professional credibility, competence, and
communications. The majority of definitions for trust describe it as the belief by one
firm that a partner will perform actions producing positive results for the former. As
Sirdeshmukh et al., (2002) stated trust is the expectations held by the consumer that
the service provider "can be relied on to deliver on its promises". Anderson and Weitz
(1989) defined trust as one party's belief that its needs will be fulfilled in the future by
actions undertaken by the other party.
As Morgan and Hunt (1994), stated trust exists when one party has confidence in an
exchange partner's reliability and integrity. Trust is important because it provides a
basis for future collaborations. Kramer (1999) stated that trust has both thinking and
feeling aspects to it and that trust is socially oriented. He defined trust as the rational
choice based on recognizing the motivations of others. Hall (2005) explains that those
who trust have an expectation that the trusted person will behave with goodwill
towards them and with competence in the domain in which he or she is trusted.
According to Anderson and Narus (1990) once trust is established, firms learn that
coordinated, joint efforts will lead to outcomes that exceed what the firm would
achieve if it acted solely in its own best interests. It seems that if partners in a
relationship trust each other more they are more emotionally involved and less
consciously weighing the benefits against the costs of that relationship. Mishra et al.,
(2008) said that there are four dimensions of trust (i.e., reliability, openness,
competence, and concern) and found that communication is critical for demonstrating
all aspects of trust.
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It is observed that Patient safety concerns may lead customers to stop using a
particular hospital's services owing to negative word-of-mouth. According to
Entwistle and Quick's (2006), trusting patients are vigilant, i.e. trust is not simply a
vague hope or thinking optimistically, health service providers must keep patients
alert to errors in the course of their care. Some checking by the patient is appropriate
even when there is trust particularly when honest mistakes are possible, which may be
easily spotted and corrected and Patients may continue to trust even if harmed.
According to Glen (2002), Doney and Cannon (1997), May (2004) Sharma and
Patterson (1999), empirical work shows that the lack of concreteness of services high
in credence attributes increases the importance of perceived functional service quality
in forming consumer trust .
Healthcare quality and SERVQUAL scale research indicates that perceived service
quality is contingent upon service type, which implies that one generic service quality
measure is inappropriate for all services. According to Choi et al., (2004) authors use
different healthcare quality indicator terms. Even though they were not unique, many
commonalities could be identified: care process convenience, concern, satisfaction,
value, communication, cost, facility and tangibles, competence, empathy, reliability,
assurance and responsiveness.
The studies show that the SERVQUAL dimensions have been found to be useful and
relevant in studying service quality in the healthcare industry. However, they focus
largely on the measurement of service quality for service improvement purposes.The
research literature on service quality and satisfaction is copious, with various
contributions from numerous researchers across the world over decades. However, all
of them have been primarily built on the SERVQUAL scale, which forms the
keystone for all the other works. According to Lim et al., (1999) one of the most
important elements of the SERVQUAL analysis, is the ability to determine the
relative importance of the five dimensions in influencing patients overall quality
perceptions. The researchers measured quality dimensions including access,
personnel, clinical outcome and patient satisfaction. Thus, the model brings out
patient satisfaction as a multi-dimensional concept needing to be operationalized and
considered under the relevant contexts.
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In the research work of Tucker and Adams (2001), integrative patient evaluation
shows how caring, empathy, reliability, responsiveness, access, communication and
outcome dimensions predict satisfaction and quality as moderated by the patient‟s
socio demographic characteristics. Conway and Willcocks (1997) integrated model
applies service quality to healthcare settings. It incorporates influencing factors such
as patient personality and socio-economic factors with measurement issues i.e.
reliability and responsiveness. In their study Gotlieb et al., (1994), Buttle (1996),
Zeithaml and Bitner (1996) and Lee et al., (2000) have found that Healthcare quality,
Patient satisfaction and Patient trust researches have indicated that service quality is
an antecedent of the broader concept of customer satisfaction. Whereas Caruana
(2002), Fullerton and Taylor (2002) are of the opinion that the relationship between
service quality and loyalty is mediated by satisfaction.
In their findings Vinagre and Neves (2008) show empirical evidence about the effect
of service quality on patient's satisfaction with healthcare services. Priporsa et al.
(2008) also aimed to assess the quality of Greek hospitals by focusing on patients
perceptions. Hospitals performance was measured using the patient satisfaction
survey approach including four dimensions: tangibles, reliability, assurance,
interpersonal communication and responsiveness.
In his research Andeleeb (1998) stressed how the public is inclined to pay more for
care from quality institutions with which they were satisfied. His argument postulates
that a positive association exists between patient satisfaction and patronage. Further
the study done by Messina et al., (2009), Woodside, Frey, and Daly (1989) provided
early evidence to support the premise that patient satisfaction may directly affect
volume. Even Rust and Zahorik (1993) in their research identified elements of service
satisfaction that may significantly affect customer loyalty and market share; however
the focus of their research was on retention of existing business versus new customer
development. It is also evident in a study done by Naidu. A. (2009), where he finds
empirical support, that Patient satisfaction is a multi-dimensional healthcare construct
affected by many variables; he also found that healthcare quality affects patient
satisfaction, which in turn influences positive patient behaviors such as loyalty.
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In their study Eisingerich and Bell (2007) examine the differential effects of perceived
service quality, trust, and loyalty on repurchase intentions. The research found that
perceived service quality had a significant effect on customer loyalty and trust, and
trust had a significant effect on customer repurchase intentions. In accordance with
Geyskens, Steenkamp and Kumar (1999), it may be assumed that satisfaction acts as a
conditioning factor of trust, which is an antecedent of affective commitment.
In their study Priporas et al. (2008) found that males and young patient tend to rate
satisfaction a little higher than females and older patients. Tucker (2002) found
significance of patient's demographic variables in moderating their satisfaction.
Consistent with previous studies, patient age was found to be the most frequent
predictor of satisfaction of all the socio-demographic factors considered. Older
patients tend to be higher in rank, more educated, and married. Individual factors
positively associated with patient satisfaction are health status and education.
Younger, less educated, lower ranking, married, poorer health and high-service use
were associated with lower satisfaction. Angelopoulou et al. (1998) found that patient
in private hospitals were more satisfied than patient in public hospitals. On the
contrary, Jabnoun and Chaker, (2003) found that public hospitals have higher overall
healthcare quality than private hospitals.
Another study found that the patient's health quality assessment appeared to change
with the introduction of patient's socio-demographic characteristics. Butler et al.
(1996) found gender and age significantly predicted patients quality perceptions, but
on only one dimension i.e. facilities. Females valued this dimension more than males.
Perceived facility-related quality was found to be better for older than younger
respondents. Mummalaneni and Gopalakrishna (1995) found that, from socio-
demographic characteristic like age, gender, occupation, employment status,
education and income, only income was characteristic that influenced patient
satisfaction.
Tucker and Adams (2001) integrative patient evaluation model shows how caring,
empathy, reliability, responsiveness, access, communication and outcome dimensions
predict satisfaction and quality as moderated by the patient‟s socio-demographic
characteristics. Conway and Willcocks (1997) integrated model applies service
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quality to healthcare settings. It incorporates influencing factors such as patient
personality and socio economic factors with measurement issues i.e. reliability and
responsiveness. A study conducted in Ohio by Janssen et al. (2000) reported better
patient assessments in non teaching hospitals and in hospitals with fewer beds, fewer
deliveries and fewer caesarean deliveries.
2.16 Research Gap

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
gaining an understanding of user‟s needs and their perception of the services received.
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.

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.
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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 analyse 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.
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CHAPTER III
OBJECTIVES, HYPOTHESIS AND RESEARCH

METHODOLOGY
The researcher feels that there is tremendous scope to improve the OPD services of
Public and Private Hospitals as there is hardly any research done in this area. Patient
satisfaction is of utmost importance in today‟s very competitive enviornment when
patients most of the times, themselves take decisions to select a hospital. In order to
understand various factors affecting patient satisfaction, studies have been conducted
to explore many service quality areas which patients consider while evaluating the
quality aspects of hospitals such as latest equipment, physical facilities, ease of
supplementary services, nature and response of doctors and medical staff. The word
quality is often thought of in different ways by people, as per the situation. The actual
meaning of quality is related to excellence: a mark of top most standards and high
achievement.
One service quality measurement model that has been extensively applied is the
SERVQUAL model developed by Parasuraman et al. SERVQUAL as the most often
used approach for measuring service quality and has been used in this study to
compare customer‟s expectations before a service encounter and their perceptions of
the actual service delivered. The instrument has been the predominant method used to
measure consumer‟s perceptions of service quality. It has five generic parameters or
factors and is stated as follows.
(1) Tangibles: Physical facilities, equipment and appearance of personnel.

(2) Reliability: Ability to perform the promised service dependably and accurately.
(3) Responsiveness: Willingness to help customers and provide prompt service.
(4) Assurance: (including competence, courtesy, credibility and security). Knowledge
and courtesy of employees and their ability to inspire trust and confidence.
(5) Empathy: (including access, communication, understanding the customer).
Caring and individualized attention that the firm provides to its customers.
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3.1 OBJECTIVES
The objectives of this study are based on the five generic parameters of SERVQUAL.
1. To study the patient satisfaction of Public and Private Hospitals for all five
parameters.
2. To study the patient satisfaction between all five parameters and five different
cities.
3. To study the patient satisfaction of all five parameters with demographic factors.
4. To study the patient satisfaction of all five parameters and frequency of visits to the
Hospital.
This study was limited to select public and private hospitals in the area of Mumbai,
3.2 STATEMENT OF HYPOTHESIS
Based on the above objectives the following Hypothesis were formulated.
H01: There is no significant difference of all the five parameters in public and private
hospitals.
H11: There is significant difference of all the five parameters in public and private
hospitals.

different cities.

different cities.
five parameters.
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five parameters.
3.3 RESEARCH METHODOLOGY
Research Design: The research design is a plan, structure and strategy to answer a
problem. In this study, Health care services are the independent variable and patient
satisfaction is the dependent variable.
Data Collection: In this study, data collection was done in two stages. In the first
stage a pilot survey was done to ascertain the research parameters and to test the
validity and the reliability of the instrument used in the study. In the second stage the
primary data was collected through using the instruments in the study. The instrument
used was a self administered questionnaire. The Secondary data was collected by
scanning literature, professional magazines, research papers and various research
reports.
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Sample Size and Design: The study was conducted at Mumbai, Navi Mumbai,
Thane, Pune and Surat in 12 Public and 89 Private Hospitals. A total of 350 patients
participated in the survey using a self administered questionnaire. The patients and
their relatives were assured that their responses will be kept confidential.
Type of Hospital Mumbai Navi Thane Pune Surat Total

Mumbai
Public Hospital 7 1 2 1 1 12
Private Hospital 66 5 8 3 7 89
Total 73 6 10 4 8 101
Table 1 Sample size (Hospitals)
Respondents Mumbai Navi Thane Pune Surat Total

Mumbai
Public 152 50 38 54 56 350

Private
Hospitals
Table 2 Sample size (Respondents)
Method to find sample size (source of formula is sample size calculator)
Example The margin of error = 1 and the standard deviation = 6.95. Using the
formula for sample size, we can calculate :
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So we will need to sample at least 186 (rounded up) randomly selected households.
With this sample we will be 95 percent confident that the sample mean will be
within 1 minute of the true population of Internet usage.
Sample size
Consider z = 1.96 (it is standard for 95% level of confidence)
Standard deviation calculated from pilot study = 15.01 (app)
Margin of error = 0.5
Sample size = (1.96 * 9.5/ 1) ^2 = 346.70 (347 rounded)
Minimum requirement of data is of 347 respondents
So approximately the sample size is of 350 respondents.
The data collected was then analysed using SPSS 20 and certain statistical tools like
Anova and Chi square were used in this research.
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CHAPTER IV
GLOBAL HEALTHCARE SCENARIO
4.1 The global healthcare services market
It is observed that one of the primary development goals of many countries is the
establishment of a comprehensive, modern healthcare system for all citizens. Health
services will be one of the global growth markets of the 21st century. The most
familiar method through which US healthcare firms export services is the treatment of
foreigners in American healthcare facilities. Several dozen US companies also
maintain on the ground commercial operations abroad. Providing health services
internationally usually requires a long-term presence in the foreign market to a greater
extent than that needed for the sale of medical devices.
Review of literature indicates that as living conditions improve and lifespans increase
in countries around the world, consumers are increasingly demanding better medical
care. One of the primary development goals of many countries is the establishment of
a comprehensive, modern healthcare system for all citizens. The combination of these
forces will make health services one of the global growth markets of the 21st century.
It is seen that geographically, the countries of Europe and Asia are in the forefront of
health service firm‟s global focus, with the Middle East also emerging as an attractive
market. Moreover, U.S. service providers have established over a dozen arrangements
in the former Soviet Union and Eastern Europe. In 1993, Europe accounted for over
53 percent of all health service sales to foreigners by U.S. foreign affiliates, with the
United Kingdom alone accounting for over one-quarter of the total. China's recent
vigorous growth and the scale of out-of-pocket payment for treatment in Asia have
also spurred health service firm‟s interest in this region.
4.2 Healthcare adapts to a global outlook
Research shows that the healthcare industry is relatively immune to the economic
cycle. People still get ill and need treatment, but it's an industry that has changed a lot
in the past few years. Pharmaceutical companies have merged and become more
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global in their outlook, they are also communicating with the general public and not
just medical professionals and also including major health education programmes. All
of these trends have had an impact on healthcare PR. The fact that there are fewer
new drugs, for example creates a need to give existing products more support. And
when a new drug is close to approval, greater effort is put into pre-launch publicity.
According to Edelman's chief executive, John Mahony, business has changed

dramatically. He feels that there are now distinct sectors. Each has huge opportunities
for growth and London according to him is seen as the hub for pan-European and
international campaigns. Demand for PR has grown, but global pharmaceutical giants
have tended to consolidate the number of agencies they work with, to show a greater
interest in international capability and in breadth of services.
If healthcare is seen in terms of business, there could be a break up of demand and

preference into smaller clusters, taking into account that patients are already
becoming more differentiated according to lifestyle and preferences. Moreover,
knowledge will become the new competitive advantage. Complementary factors,
which will influence the future of healthcare, are the growth, fragmentation and
ageing of the world population. Global population is projected to fluctuate between
9.5 and 12 billion, while the age range of healthcare professionals will span four
generations.
4.3 Global Healthcare Industry
According to research from Global Industry Analysts, global healthcare services

market is forecast to reach $3 trillion by 2015. Investment in sectors such as home
healthcare, healthcare IT and tele health are expected to continue fuelling market
expansion. Due to the world‟s aging population, the demand for home healthcare is
likely to continue climbing over the years to come. The healthcare services industry is
labor intensive and over burdened in many regions, making tele health and healthcare
IT attractive options. With medical technologies continually developing, these options
are proving beneficial to patients and the overall healthcare system.
The global healthcare services market is impacted by government legislation and

incentives. Spending in the sector continues to climb, partly due to the availability of
new drugs, higher health insurance premiums and advanced technology services.
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Demographic profiles also play an important role in the industry, with demand created
by lifestyle-related medical conditions. In addition, an aging population means that
age-related health conditions continue to create demand.
Studies show that spending on home healthcare is forecast to continue rising as

elderly and terminally ill patients opt for the ease of receiving healthcare at home
rather than in hospitals or clinics. As with many other industry sectors, information
technology is also affecting the area of healthcare services, with many healthcare
bodies concentrating their efforts on setting up or enhancing their electronic medical
records systems, electronic health records and personal health records.
4.4 Key Market Segments
It is observed that the sector facilitates interactive healthcare through tele

communication and technology. Market expansion is driven by the need to cut costs
within the medical sector, ease of penetration and wider availability of equitable
healthcare. Increasingly common conditions, such as diabetes, are also fueling
telemedicine market growth. The sector benefits from rising private and state
sponsorship.
There are technological developments within the healthcare sector which help to keep
costs down and elaborate more suitable methods to monitor and treat medical
conditions. The potential for wireless technologies remains vast, as it is relatively new
to the market. There were more than two million individuals using home monitoring
devices with integrated connectivity at the end of 2011.
It is seen that this relatively new sector encompasses many disciplines including stem-
cell biology, bioengineering, nano-science and tissue engineering. Factors fuelling
market growth include higher incidence of degenerative diseases, aging population
and technological innovation. The global healthcare system is increasingly
overburdened, with rising numbers of people suffering from chronic diseases and
lifestyle-related conditions. Expenditure continues to grow due to an expanding and
aging, global population. As budgets tighten and costs rise, technological
development is becoming increasingly important, with health practitioners likely to
continue making greater use of communications and information technology to treat
their patients.
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4.5 Market Overview
It is observed that the healthcare providers sector is valued as total expenditure on

healthcare in each country. This includes final consumption spending on healthcare
goods and services. Goods and services in this sector include inpatient, outpatient,
long-term medical care, medical goods including pharmaceuticals and supplies, and
collective services and capital formation such as administration requirements and
development costs. Public spending i.e. by national and local governments and social
security schemes and private spending i.e. payments made by private-sector health
insurers and individual out-of-pocket expenditures are both included.
4.6 Market Segmentation
Outpatient care is the largest segment of the global healthcare providers sector,
accounting for 37% of the sector's total value. The Inpatient care segment accounts for
a further 24.7% of the sector. (Global Healthcare Providers: Market line 2013).
Global Healthcare Providers sector category segmentation: % share, by value,

2013.
Diagram 2
Source: Global Healthcare Providers: Market line (2013)
4.7 Geography segmentation
America accounts for 49% of the global healthcare provider‟s sector value.
Europe accounts for a further 28.6% of the global sector.
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Global Healthcare providers sector geography segmentation: % share, by value,
2013.
Diagram 3
Source: Global Healthcare Providers: Market line (2013)
4.8 Healthcare in the Global Market place
It is noticed that the world is getting "flatter"; people, information, technology, and
ideas are increasingly crossing national borders, healthcare is not immune from the
forces of globalization. An international workforce requires leaders to confront the
legal, financial, and ethical implications of using foreign-trained personnel. Cross-
border institutional arrangements are emerging, drawing players motivated by social
responsibility, globalization of competitors, growth opportunities, or an awareness of
vulnerability to the forces of globalization. Forward-thinking healthcare leaders will
begin to identify global strategies that address global pressures, explore the
opportunities, and take practical steps to prepare for a flatter world. (Global
Healthcare Providers: Market line 2013).
As in most other industries, globalization is having a pervasive impact on the U.S.

healthcare system. Healthcare organizations in the United States are affected by the
movement of people, information, technology, and ideas across national borders. For
the managers of healthcare organizations, globalization presents opportunities as well
as threats.
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Diagram 4
Source: OECD Health Data 2010.
The above diagram gives a clear picture of Healthcare spending of seven countries, as
a percentage of their GDP, for the years 2005 to 2008.
4.9 International Healthcare Ventures
Findings suggest that the political and economic environment has become
increasingly favorable for global healthcare ventures. Private sector participation in
healthcare reform efforts has received increasing support. The World Health
Organization (WHO) has a history of ambivalence toward private sector involvement
in healthcare, but this uncertainty is all but gone. According to (WHO 2000) the
private sector has the potential to play a positive role in improving the performance of
the health system. Mutchnick, Stern, and Moyer (2005) suggest that the days of
antipathy to private market solutions in many developing countries have passed and
many now view the private market as a necessary tool for improving health services.
It is on record that the growing middle class is also providing support for global
initiatives. Since 1978, an estimated 400 million people in China have been lifted out
of poverty, a number larger than the population of South America. If current trends
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continue, there will be a 10 percent reduction in global poverty by 2015. The growth
of the middle class and concomitant demand for high-quality and accessible health
services is putting pressure on resource-constrained health ministries to improve
services. With greater disposable income, individuals have a greater willingness and
ability to pay for health services, or at least to share the cost of higher quality and
accessible care. Inviting foreign investment is one clear option to expand
infrastructure and services. However, as U.S. healthcare organizations consider
developing global markets, a variety of ethical issues and logistical problems emerge.
A fundamental question is whether a market-oriented private healthcare sector will

create two tiered health systems, where the better-off are served in a private system
while the poor remain in a poorly-funded public system. Global investment in health
services takes many forms. Broadly speaking, trade in health carries a long history,
including trade in pharmaceuticals, medical devices, and technology, as well as the
provision of foreign aid and humanitarian assistance. Many U. S. hospitals and health
systems have developed institutional affiliations with facilities abroad. Methodist
Health Care System, for example has a variety of affiliations and consulting
relationships with a global network of hospitals, while also providing services to
foreign patients who come to the United States for care.
It is observed that Johns Hopkins Health System has affiliations with hospitals in the
Middle East, South America, Europe, and Asia. While such relationships typically do
not involve out right ownership, they may include clinical consultation, institutional
policy development i.e. infection control policies and procedures, architectural design
and engineering, regulatory and accreditation support and staff training and
development. Affiliation relationships are not limited to the United States and other
developed countries moving into the developing world. A second generation of
affiliations and consultancies involve "south-south" relationships. The India-based
Apollo group of hospitals has invested heavily in hospital development in Malaysia,
Nepal, Bangladesh, and Sri Lanka.
4.10 Global Healthcare Strategies
There are studies which show that in the past years, global activity has largely been a
bottom-up process in which individuals, often as part of their professional and
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volunteer commitments, engage in global assistance. These types of activities will
clearly continue, but institutional arrangements are emerging in which the
organization makes a commitment to global activities. Motivations vary, and may
include consistency with social responsibility, globalization of competitors, growth
opportunities, and an awareness of vulnerability to the forces of globalization and thus
a need to explore global strategies.
There are reports which suggest that global involvement in health services is beset
with overwhelming obstacles but well-considered global affiliations have tremendous
potential benefits for the host country. Foreign investments generate resources to
modernize and upgrade healthcare infrastructure and technologies, create employment
and provide expensive and specialized medical services that may not be otherwise
affordable. An influx of foreign private capital may help to reduce the total burden on
government resources, freeing up financial resources to subsidize other health and
social needs. Affiliations and partnerships with reputed healthcare organizations can
help to improve services by introducing new management techniques, clinical
procedures, information systems, and technology.
Research in health sector shows that foreign investment in health services can also
pose difficulties for developing countries, and ethical questions for organizations in
the developed world. In some circumstances, large initial public investments and tax
incentives may be required to facilitate the entry of a foreign firm. Foreign investment
may also exacerbate disparities in situations in which the public primary care sector
remains underfunded while high-cost tertiary care expands. Furthermore, because
specialty hospitals are usually built in large cities, workforce distribution issues can
further deteriorate, because skilled professionals may internally migrate to health
facilities that offer higher compensation and better work arrangements.
It is seen that social insurance and state-financed health services are weak in many
countries, and private health insurance is relatively new and rare. However, as the
middle class grows, private health insurance will have more opportunities for
expansion. Further more, as insurance company profits shrink in developed countries,
global markets may become attractive. Multi-national corporations operating in
developing countries may also promote health insurance as a means of ensuring a
healthy and stable workforce.
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4.11 Health Insurance
There are findings which show great variation among regions in the development of
private insurance markets. Latin America has seen substantial growth in private health
insurance, while enrollment remains low in sub-Saharan Africa, with the exception of
South Africa, Namibia, and Zimbabwe. Asia clearly is an area of huge potential
growth in private health insurance. According to Drechsler and Jutting (2005)
between 1994 and 2004, the private insurance industry in developing countries grew
more than twice as fast as in industrialized countries. Innovations have also emerged
on ways for the poor to obtain private insurance, such as Thailand's Health Card
Programme in which the state fosters the growth of private risk sharing.
It is observed that one of the most important ethical issues involves foreign investors
marketing health insurance plans in developing countries that lack a regulatory
environment to restrict or outlaw risk or age rating and other "cream skimming"
techniques that result in dumping sicker patients onto the state. According to
Barrientos (2000), Drechsler and Jutting (2007) in Chile, a large segment of the
wealthy population opted out of the social insurance system, making the public
system the insurer of last resort. In their study Jack (2000) and Baeza (1998) state that
there is evidence of cream skimming, i.e. only 6.9 percent of people over 65 years of
age are members of a private scheme, compared with 26.7 percent in the 25 to 54-year
age group.
4.12 Preparing the 21st century global healthcare workforce
It is evident from the World Health Report (2004) that chronic conditions currently
account for more than half of the global disease burden and are a primary challenge
for 21st century healthcare systems.This is a dramatic shift from the health concerns
of the 20th century, when acute infectious diseases were the primary focus in every
country. While the world is experiencing a rapid transition from acute diseases to
chronic health problems, training of the healthcare workforce however, relies on early
20th century models that emphasise diagnosis and treatment of acute diseases.
Studies show that educational leaders, health professional bodies, and the World
Health Organization recognize such models as inadequate for health workers caring
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for a growing population of patients with health problems that persist across decades
or lifetimes. There is a global imbalance of human resources for health and in
particular, a shortage of healthcare workers in developing countries.
It is noticed that the scarcity of healthcare workers is cause for concern. Unchecked
migration of the workforce from rural to urban areas and from poor to wealthy
countries has dire consequences for the health of those living in abandoned
communities. The sole focus on the quantity of healthcare workers, however has
obscured a second but equally troubling issue: the quality of the training and
preparation of the workforce. There is an obvious mismatch between the most
prevalent health problems i.e. chronic conditions and the preparation of the workforce
to deal with them. Acute medical problems will always require the attention of
healthcare providers, but a training model focused exclusively on treating acute
symptoms becomes more inadequate by the year.
It is a fact that caring for patients with chronic conditions is different from caring for
patients with episodic illnesses. Effective care for patients with on going health
problems requires treatment that is continuous across settings and across types of
providers; care for chronic conditions needs to be coordinated over time. Healthcare
workers need to collaborate with each other and with patients to develop treatment
plans, goals, and implementation strategies that centre on the needs, values and
preferences of patients and their families. Self management skills and behaviors to
prevent complications need to be supported by a workforce that understands the
fundamental differences between episodic illness that is identified and cured and
chronic conditions that require management across years.
The reality, however is that patients consult multiple providers who lack coordination
among themselves and across settings, resulting in care that is, at best expensive,
confusing, and conflicting and at worst, harmful to patients. In addition to diagnosis
and treatment of acute illness and injury, today's healthcare workers need a core set of
competencies that will yield better outcomes for patients with chronic conditions. A
workforce for the 21st century must emphasise management over cure and long term
over episodic care.
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4.13 Movement of Personnel
Various studies suggest that the global movement of health personnel has a long
history. Perhaps in no other area are the ethical concerns more manifest than in the
conflicting goals of addressing global disparities in the supply of health personnel and
dealing with increasingly acute shortages of health personnel in developed countries.
Currently, the United States has about 2,202,000 registered nurses in the workforce,
with a shortfall in 2010 of 275,000 full-time equivalent (FTE) registered nurses
(RNs). About 90,000 U. S. nurses, or about 4 percent of employed nurses, are foreign
trained.
According to Brush, Sochalski, and Berger (2004), if the United States were to double
the percentage of foreign-trained nurses to 8 percent of the total nurse workforce, a
substantial deficit would remain, particularly in light of the estimate that the United
States will face a shortage of 800,000 FTE, RNs by 2020. Similar shortages are
expected in other developed countries and unless domestic capacity is dramatically
increased, demand for foreign-trained nurses will increase. Global inequities in work
force density are glaring. Using the crude measure of work force density, variations
among regions range from 2.3 health workers per thousand population in Africa, to
24.8 workers per thousand in the America. Within America, the variation is
substantial: Canada has 9.95 nurses per 1,000 population while Haiti has only one
nurse per 1,000 population. About 37 of 47 sub-Saharan countries have less than 20
doctors per 100,000 people
Statistics show that Health workforce supply has a direct relationship to such health
outcomes as maternal survival, child survival, and infant survival. The deficit of
health workers is made more acute by HIV/AIDS, which increases the need for care
while also shrinking the available health workforce through illness and death of health
providers. Demand for health workers is even more acute in those developing
countries facing acute infectious disease as well as chronic disease and long-term
disability, that is, the double burden of disease.
For the foreseeable future, developed countries are heavily invested in importing
health professionals. In the United States, 25 percent of physicians were trained
abroad, and in the United Kingdom, 28 percent were trained abroad. Closer
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examination shows that the effect of such migration falls hard on developing
countries. Over 60 percent of international medical graduates (IMGs) in the United
States and over 75 percent in the United Kingdom are from lower-income countries.
While physicians move among developed countries, these movements are often
temporary; physicians circulate between countries and eventually return to their
country of origin. However, physicians moving from developing to developed
countries often never return, and in these instances constitute a tremendous loss to
their country of origin both in skill and investment in training. South Africa provides
a unique example of a country facing the need to import health workers while also
losing its workforce through emigration. About 22 percent of the South African
medical workforce is from outside the country, many of them Africans.
4.14 Push and Pull Factors
According to Kingman (2006), pull and push factors account for the movement of
health workers. Pull factors are conditions in the destination country motivating
immigration, including higher remuneration, improved job satisfaction, safer work
environments, better-resourced health facilities, and professional growth
opportunities. Mirroring these are push factors encouraging emigration from the
country of origin, including poor quality of life, low pay, poor management, work
load, corruption, crime, conflict, political and economic instability and lack of
opportunity for children and other family members.
It is seen that the problem of emigration is within-country migration, typically

involving health workers from rural areas moving to urban areas that have better
facilities and working conditions. Improved working conditions may also be
associated with facilities that are better resourced, perhaps as a result of foreign
investment, donor contributions, as well as internal political pressures that favor
health service development in urban areas. Among the most powerful pull factors are
active and organized efforts in developed countries to import health professionals
from abroad. Global recruitment for health workers, particularly nurses-is widespread.
There are some questions that need to be answered, like: Is importing health
professionals an appropriate fix for workforce shortages in developed countries?
Some claim that the strategy, at best is a temporary fix for developed countries
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because they do not have to address the root causes of workforce shortages i.e.
compensation, quality of work life, professional advancement and burnout. The U.S.
healthcare industry is not immune from the forces of globalization. Hospital leaders
face the challenge of competition from medical tourism and rapid growth in the
number of undocumented aliens. Managers also face opportunities and risks in
establishing a commercial presence in other countries. As workforce shortages
continue to plague the U.S. healthcare system, hospitals face practical and ethical
issues in global workforce sourcing.
4.15 Nursing Shortage: A global problem
It is a known fact that the nursing shortage is one of the most pervasive problems
facing the global healthcare industry. In a 2002 report prepared by the Joint
Commission on Accreditation of Healthcare Organizations, the U.S. shortage
estimated to be around 120,000 nurses, or approximately 6% short of what is needed
to maintain quality healthcare. By the year 2015, the forecast is for a shortage of
around 450,000 nurses, or 20% below norm. If this trend remains unchecked, by the
year 2020 the shortage will balloon to nearly 800,000 nurses. Globally patients,
healthcare administrators, health researchers, and industry analysts all agree that
hospitals are in trouble and the future looks bleak.
A recent survey published in Commonwealth Fund Quarterly reported that doctors

from North America and Europe ranked the nursing shortage as one of their most
serious concerns for the provision of top-quality healthcare. Similarly, a recent report
by the Institute of Medicine highlighted the fact that nurse staffing had reached unsafe
levels. And while many medical organizations have made major changes in healthcare
delivery, the nursing shortage is a global problem.
The bottom line is that the nursing profession is no longer considered a lucrative,
satisfying, or desirable vocation and nursing shortages are typical across both North
American and European countries, with many of the same problems. It is observed
that increasing competition is attempting to lure nurses away from other healthcare
organizations via financial incentives. The solution is to focus on programs designed
to develop a loyal and committed team of nurses that‟s content to remain with their
current employer.
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There are a number of other ways healthcare organizations benefit from a higher
nurse retention rate. First, a loyal stable nursing staff creates continuity over time and
produces more consistent service delivery. The net result is higher quality care and a
reduction in the likely hood of medical errors. Second, patients often perceive
continuity of the healthcare staff as an indicator of consistency in care. Over time, the
staff builds trust and commitment with patients much the way physicians do.Third,
resources that might be needed toward the constant recruitment of nurses can be
allocated to other activities designed to improve the institutions quality of care.
Visibility: Good or Bad?
It is observed that the nursing profession is no longer attractive, its image i.e. the way
a person appears to others, or in the case of a profession, the way that profession
appears to other disciplines and to the general public, consumers of health care is not
very good. Image and the perception of the profession impact recruitment of students,
the view of the public, funding for nursing education and research, relationships with
healthcare administrators and other healthcare professionals, government agencies
and legislators at all levels of government and ultimately, the profession‟s self-
identity.
Studies indicate that, just like individuals may feel depressed or less effective if others
view them negatively, professionals can experience similar reactions if their image is
not positive. It impacts everything the profession does or wishes to do. Image is a part
of any profession. How nurses view themselves i.e. their professional self-image has
an impact on professional self-esteem. How one is viewed has an impact on whether
others seek that person out and how they view the effectiveness of what that person
might do.
According to Sullivan (2004), although nurses comprise the majority of healthcare

professionals, they are largely invisible. Their competence, skill, knowledge and
judgment are as the word „image‟ suggests only a reflection, not reality. The public
views of nursing and nurses are typically based on personal experiences with nurses,
which can lead to a narrow view of a nurse often based only on a brief personal
experience. This experience may not provide an accurate picture of all that nurses can
and do provide in the healthcare delivery process. In addition, this view is influenced
by the emotional response of a person to the situation and the encounter with a nurse.
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But the truth is that most often, the nurse is invisible. Consumers may not recognize
that they are interacting with a nurse, or they may think someone is a nurse who is
not.
The Future of Nursing: Focus on Education
Diagram 5
Source: Health Resources and services administration, (2011).
Transforming the health care system to provide safe, quality, patient-centered,

accessible, and affordable care will require a comprehensive rethinking of the roles of
many health care professionals, nurses chief among them. To realize this vision,
nursing education must be fundamentally improved both before and after nurses
receive their licenses.
Need for Highly-Educated Nurses
The ways in which nurses were educated during the 20th century are no longer
adequate for dealing with the realities of health care in the 21st century. As patient
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needs and care environments have become more complex, nurses need to attain
requisite competencies to deliver high-quality care. These competencies include
leadership, health policy, system improvement, research and evidence-based practice,
and teamwork and collaboration, as well as competency in specific content areas such
as community and public health and geriatrics.
An Improved Education System
Earlier studies indicate that much of nursing education revolves around acute care
rather than community settings that include aspects of primary care, public health and
long-term care. Nursing education frequently does not incorporate the intricacies of
care coordination and transitions. Many nursing schools have dealt with the rapid
growth of health research and knowledge by compressing available information into
the curriculum and adding layers of content that require more instruction. New
approaches and educational models must be developed to respond to burgeoning
information in the field. For example, fundamental concepts that can be applied across
all settings and in different situations need to be taught, rather than requiring rote
memorization.
Entering the Profession
It is further noted that the qualifications and level of education required for entry into
the nursing profession have been widely debated by nurses, nursing organizations,
academics and a host of other stakeholders for more than 40 years. Care within the
hospital continues to grow more complex, with nurses having to make critical
decisions associated with care for sicker, frailer patients and having to use more
sophisticated, life-saving technology coupled with information management systems
that require skills in analysis and synthesis. Care outside the hospital is becoming
more complex as well. Nurses are being called on to coordinate care among a variety
of clinicians and community agencies, to help patients manage chronic illnesses,
thereby preventing acute care episodes and disease progression and to use a variety of
technological tools to improve the quality and effectiveness of care. Improving the
education system and achieving a more educated workforce, specifically increasing
the number of nurses with baccalaureate degrees, can be accomplished through a
number of different programs and educational models.While 13 percent of nurses hold
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a graduate degree, less than one percent have a doctoral degree. Nurses with
doctorates are needed to teach future generations of nurses and to conduct research
that becomes the basis for improvements in nursing science and practice.
4.16 Outsourcing in the Healthcare sector
There are various reports and articles on outsourcing in the Healthcare sector. The
term outsourcing refers to contracting with a third party to provide goods and services
to the host organization that would otherwise have been available in-house. In
practice, these contractual agreements are lengthy, ranging from a single year to
more than 10 years. Outsourcing is not a new practice. Firms have been outsourcing
activities such as advertising, manufacturing and distribution for decades. The
practice has shifted in recent years from these traditional domains.
It is observed that business has seen tremendous changes in the breadth of activities
that can be effectively outsourced, the pace with which the practice is being adopted,
and the types of organizations participating. Outsourcing has had such a strong impact
on business of late that the popular press identified it as one of the most important
economic developments of the twenty-first century. The healthcare industry has been
increasingly involved in the practice of outsourcing and that growth is expected to
continue in the years to come.
Research shows that a key motivation for interest in outsourcing is the intense
competitive pressure healthcare institutions face with respect to improving quality and
productivity, although containing cost at the same time. Financial pressures increased
substantially in recent years as healthcare establishments experienced declining levels
of government funding, an increasing number of patients who are unable to pay for
healthcare services and greater levels of industry regulation. Evidence suggests this
pressure is likely to continue into the foreseeable future.
It is seen that Healthcare spending in the United States has tripled as a share of GDP
between the mid-1960s and 2005. It is projected to maintain this steep increase in the
upcoming decades as well. At the same time, hospitals faced greater financial
challenges i.e. the healthcare establishment encountered a competitive environment
necessitating greater quality of care, patient volume and access to scarce resources.
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One way in which healthcare organizations responded to these changes is through the
use of outsourcing. Looking more carefully at the overall trend, it can be seen that
healthcare institutions are outsourcing many types of Services.
Global Healthcare Overview
It is evident that across the globe there have never been more health care challenges
than there are today. However, these challenges can push stakeholders to innovate in
new and exciting ways and to generate scientific, medical breakthroughs that can
improve the health of people world wide. Most of the countries across the globe are
facing a formidable challenge to manage the rapidly increasing cost of health care.
There are studies which show that spending per head is anticipated to rise by an
average of 4.4 percent a year from 2014-2017. Life expectancy is projected to
increase from an estimated 72.6 years in 2012 to 73.7 years by 2017, bringing the
number of people over age 65 to around 560 million worldwide, or more than 10
percent of the total global population. In Western Europe the proportion will hit 20
percent and in Japan, 27 percent. The aging population will create additional demand
for health care services in 2014 and beyond. Concurrently, the number of high-income
households i.e. those earning over $25,000 a year, is expected to increase by about 10
percent, to over 500 million, with over one-half of that growth coming from Asia.
Governments in many emerging markets are taking note of this economic growth and
planning to roll out public health care services to meet consumers rising expectations.
There are findings which suggest that the year 2014 looks to be a positive but
challenging year for the global health care sector, one in which many historic business
models and operating processes will no longer suffice amid rising demand, continued
cost pressures, lack of or inadequate care facilities and rapidly evolving market
conditions. The outlook for global health care sector growth over the next few years is
generally positive. Emerging markets including China, India, Indonesia, Russia, and
Mexico are expected to see spending increase quickly over the next five years, due to
population growth, increasing consumer wealth, and government programs to expand
access to health care.
It is also seen that the specter of further economic woes and subsequent cost-cutting
measures in Western Europe is expected to slow annual average growth in health care
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spending despite the pressures of aging populations and chronic diseases. There are
four major issues that governments, health care providers, payers, and consumers face
in 2014: aging population and chronic diseases; cost and quality; access to care; and
technology. While facilitating increased health care access is an important and worthy
endeavor, more people in the system means more demand for services that numerous
health care systems are unable to accommodate due to workforce shortages, patient
locations, and infrastructure limitations, in addition to the cost issues identified
earlier.
Researchers are of the view that many countries across the globe are facing a
challenge to meet their required number of health care workers, a shortage that
directly affects the quality of care. Globally, the number of doctors per 1,000
population, is expected to remain virtually the same between 2012 and 2015. More
than one billion people worldwide lack access to a health care system, both for
caregivers and facilities. The United Kingdom, for example, had an estimated
shortage of 40,000 nurses in 2012, and has a shortage of other health care
professionals, including general practitioners (GPs). According to a European
commission, there will be a shortage of 2,30,000 physicians across the continent in
the near future.
It is evident that the number of caregivers in 36 countries in Africa is inadequate to

deliver even the most basic immunization and maternal health services. Rapid
economic development across Asia has led to hugely increased access to health care,
yet coverage across the region remains uneven. Developed Asian countries such as
Singapore, South Korea, Japan, and Taiwan offer world-class health systems while
poorer neighbors such as Indonesia, Vietnam, and India struggle to provide even the
most basic coverage.
The facts portray that the uneven distribution of care givers is also a problem. The
physician and mid-level care giver supply is increasing significantly in the U.S. due to
increased enrollment in existing medical schools and the opening of about a dozen
new medical schools. At the same time, India, Nigeria, and Pakistan have critical
health workforce shortages but also are in the top 25 countries for the number of their
doctors and nurses that are migrating to other countries. More than 50 percent of
foreign-born doctors and 40 percent of foreign-born nurses in the U.S. are from Asia.
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Technology
It is clear that across the world, health care systems are recognizing the need for
innovation; advances in health technologies and data management can help facilitate
new diagnostic and treatment options; however, these same advances are likely to
increase overall costs, prompting widespread efforts by public and private health care
providers and insurers to contain expenditure by restructuring care delivery models
and promoting more efficient use of resources.
Surveys indicate that Health care technology changes will be rapid and in some parts
of the world, disruptive to established health care models. Some exciting
advancements are taking place at the intersection of information technology and
medical technology, such as using 3D printing to help in preparing tissues for
transplants. In addition, the use of big data and analytics to gain insights is an active
industry trend. Providers can leverage vast amounts of patient data gathered from a
variety of sources to determine the clinical value of specific treatments and how to
make them better. Technology advancements are also connecting developed and
emerging markets and participants along the health care value chain. Adoption of new
digital health information technologies (HIT) such as electronic medical records
(EMRs), telemedicine, mobile health (mHealth) applications, and electronic medical
prescriptions is driving change in the way physicians, payers, patients and other sector
stakeholders interact.
It is further seen that, acquiring and leveraging technology innovations require

financial investments that many health care providers even in developed economies
may struggle to afford in an era of cost-cutting and reform. In addition, the increasing
use of mergers and acquisitions (M&A), joint ventures (JVs) and other collaborative
business models means that companies with disparate systems will need to synergize
their local operations with global requirements; this can be a challenge because
emerging markets often lack a reliable technology infrastructure. These and other
technology-based changes are shifting the power balance within the health care
system and driving different dialogues along the value chain.
Finally, the technology-enabled, transforming health care system is producing an

immense volume of information and more specifically, how to interpret and use that
data will be important. Much rides upon its availability, integrity, and confidentiality.
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However, new care and insurance models, electronic information transmission and
permeable boundaries among industry participants increase the complexity of
managing protected health information (PHI) and compound an already challenging
issue. In addition, networked medical devices and other mHealth technologies may be
a vehicle that exposes patients and health care provider organizations to safety and
security risks. Among the unintended consequences of health care‟s digitization and
increased networked connectivity are the risks of data breaches and vulnerability to
unauthorized access.
Healthcare
It is a known fact that Healthcare systems around world are facing unprecedented
change. While healthcare is primarily organized within national geographies, the
issues are truly global. Demographics, fiscal restraint, new technologies and consumer
expectations are creating significant challenges and opportunities. In these
unprecedented times, healthcare leaders require insight and guidance from an adviser
you can trust. Guidance in the following areas is required.
Care System Redesign: Working across regional health ecosystems to redesign

patient pathways and shift the provision of care to more appropriate settings.
Strategy, Transactions and Financing: Ensuring value is delivered through

mergers, acquisitions, divestments, joint ventures, shared services and outsourcing
arrangements
Quality and Margin Improvement: Helping organizations to adopt best practice

operational models, processes and cost management capabilities in order to enhance
both service quality and value for money.
Health IT: Helping to leverage enabling technologies and enhance performance

through systems selection, implementation project management, controls assessments,
business process improvement, and change management services.
4.17 Medical Tourism: Globalization of the Healthcare Market place
It is observed that Medical tourism has captured the interest of the media. Articles,
guidebooks, and broadcasts on medical tourism are being published and produced
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with increasing frequency. Individual practitioners and medical organizations must be
able to provide accurate information about this rapidly evolving trend. There is a
compelling need for all parties involved in healthcare to become familiar with medical
tourism and to understand the economic, social, political, and medical forces that are
driving and shaping this phenomenon.
In medical tourism, citizens of highly developed nations bypass services offered in

their own communities and travel to less developed areas of the world for medical
care. Medical tourism is fundamentally different from the traditional model of
international medical travel where patients generally journey from less developed
nations to major medical centers in highly developed countries for medical treatment
that is unavailable in their own communities.
It is seen that the term medical tourism does not accurately reflect the reality of the
patient's situation or the advanced medical care provided in these destinations.
Nevertheless, this phrase has come into general usage and it provides an unambiguous
way of differentiating the recent phenomenon of medical tourism from the traditional
model of international medical travel. According to The Economic Times (July 29,
2005), in 2004, 1.2 million patients traveled to India for healthcare and 1.1 million
medical tourists traveled to Thailand.
Medical Tourism Destinations
The medical tourism marketplace consists of a growing number of countries

competing for patients by offering a wide variety of medical, surgical, and dental
services. Many of these destinations boast modern facilities with advanced technology
and appealing accommodations. A substantial number of the physicians in medical
tourism destinations received post graduate training in industrialized nations, have
board certification and may have practiced in the country where they completed their
training. Medical tourists are presently traveling to far away countries for cosmetic
surgery, dental procedures, bariatric surgery, assisted reproductive technology,
ophthalmologic care, orthopaedic surgery, cardiac surgery, organ and cellular
transplantation, gender reassignment procedures and even executive health
evaluations.
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According to Stewart, Tabori & Chang (2006), a number of countries in Central and
South America have developed strong reputations for cosmetic and plastic surgery,
bariatric procedures, and dental care. There is a report inWashington Post (October
21, 2004), which states that India, Malaysia, Singapore, and Thailand are well-
established medical tourism destinations that have become popular for patients
seeking cardiac surgery and orthopaedic surgery. According to Kher U (2006),
medical services in India are particularly affordable, with prices as low as 10% of
those in the United States. Several highly developed nations including Belgium,
Canada, Germany, Israel, and Italy are attracting foreign patients under the banner of
medical tourism, offering sophisticated modern care with careful attention to patient
preference, service, and satisfaction.
The international healthcare marketplace emerged in the late 19th century when
patients from less developed parts of the world with the necessary resources to do so
began to travel to major medical centers in Europe and the United States to have
diagnostic evaluation and treatment that was unavailable in their own countries. The
situation is very different in the medical tourism model, where patients from highly
developed nations travel to less developed countries, by passing medical care that is
offered in their own community but is inaccessible or undesirable to them.
Reports show that Medical tourists would prefer to have major surgery in their home
town hospital or regional referral center if they felt that was a feasible or reasonable
option. However, these patients feel pressed to balance their health needs against
other considerations and medical concerns may be subordinated to other issues.
Modern technology enables potential medical tourists to investigate and arrange
healthcare anywhere in the world from their home computer directly or with the
advice and assistance of a medical tourism agency.
It is seen that for patients from countries where a governmental healthcare system
controls access to services, the major reason to choose off shore medical care is to
circumvent delays associated with long waiting lists. National health programs do not
typically pay for cosmetic surgery and similar type services; therefore, patients from
Canada and the United Kingdom desiring these procedures pursue medical tourism
for the same economic reasons as those from the United States.
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According to Dallas Morning News (May 29, 2007), patients travel to offshore
medical destinations to have procedures that are not widely available in their own
countries. For example, stem cell therapy for any one of a number of problems may
be unavailable or restricted in industrialized countries but may be much more
available in the medical tourism marketplace. Some patients, particularly those
undergoing plastic surgery, sex change procedures and drug rehabilitation, choose to
go to medical tourism destinations because they are more confident that their privacy
and confidentiality will be protected in a faraway setting.
Finally, some patients have medical care abroad for the opportunity to travel to exotic
locations and vacation in affordable luxurious surroundings. Although medical
tourism agents and travel professionals may promote the “tourism” aspect of offshore
care, the recreational value of travel has decreasing importance to patients with
complex, serious medical problems.
It is seen that the primary reason, medical centers in developing countries are able to
provide healthcare services inexpensively is directly related to the nation's economic
status. Indeed, the prices charged for medical care in a destination country generally
correlates with that nation's per capita gross domestic product, which is a proxy for
income levels. Accordingly, the charges for healthcare services are appropriate for the
level of economic development in which the services are provided.
Response to Medical Tourism
There are studies which show that the medical community in developed countries has
started to recognize medical tourism as a real phenomenon that involves the
profession, practitioners, and patients. The insurance industry has become an active
participant in medical tourism. In an effort to reduce the financial burden of employee
healthcare, several fortune 500 corporations are evaluating the feasibility of
outsourcing expensive medical procedures to offshore healthcare destinations.
It is also observed that Insurance provider networks are currently being expanded to
include physicians around the globe and it is anticipated that within a decade a
majority of large employer‟s health plans will include offshore medical centers.
Insurance companies are able to use a portion of their substantial savings to offer
incentives to beneficiaries willing to have care in medical tourism destinations,
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including waiving deductible and out-of-pocket health expenses and paying for travel
for the patient and even a family member. A particularly interesting response to the
migration of patients to offshore healthcare destinations is that some US medical
facilities are now accepting referrals from medical tourism agencies and providing
highly discounted services to American patients. In nations that have long waiting
lists for certain procedures, medical tourism provides a mechanism to clear backlogs
by sending patients to foreign countries without expanding local capacity.
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CHAPTER V
INDIAN HEALTHCARE INDUSTRY
Healthcare in India today provides existing and new players with a unique opportunity
to achieve innovation, differentiation and profits. In the next decade, increasing
consumer awareness and demand for better facilities will redefine the country‟s
second largest service sector employer. India's primary competitive advantage over its
peers lies in its large pool of well-trained medical professionals. Also, India's cost
advantage compared to peers in Asia and Western countries is significant, cost of
surgery in India is one-tenth of that in the US or Western Europe.
It is a fact that in India, the diagnostics sector has been witnessing immense progress
in innovative competencies and credibility. Technological advancements and higher
efficiency systems are taking the market to new heights. India is among other
countries in the South East Asian region which have been certified as being free of the
polio virus. According to World Health Organization (WHO) India has been awarded
a „Polio Free‟ status by way of an official certification.
5.1 Healthcare market size
According to a report by Equentis Capital Findings the healthcare sector in India is

expected to grow at a CAGR of 15 per cent to touch US$ 158.2 billion in 2017 from
US$ 78.6 billion in 2012. India being a country with a growing population, its per
capita healthcare expenditure has increased at a CAGR of 10.3 per cent from US$
43.1 in 2008 to US$ 57.9 in 2011, and going forward it is expected to reach US$ 88.7
by 2015. The factors behind the growth of the sector are rising incomes, easier access
to high-quality healthcare facilities and greater awareness of personal health and
hygiene. Healthcare providers in India are expected to spend US$ 1.08 billion on IT
products and services in 2014, a four per cent increase over 2013.
The private sector has emerged as a vibrant force in India's healthcare industry,
lending it both national and international repute. The sector‟s share in healthcare
delivery is expected to increase from 66 per cent in 2005 to 81 per cent by 2015. The
private sector's share in hospitals and hospital beds is estimated at 74 per cent and 40
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per cent, respectively. According to data released by the Department of Industrial
Policy and Promotion (DIPP), hospital and diagnostic centres attracted foreign direct
investment (FDI) worth Rs 11,272.32 crore (US$ 1.87 billion) between April 2000
and February 2014.
Some of the major investments in the Indian healthcare industry are as follows:
Jaypee Group plans to diversify into healthcare by investing in excess of Rs

2,000 crore (US$ 332.68 million) over the next 3–4 years to set up a hospital
chain with a minimum capacity of 3,000 beds.
Helion Venture Partners has invested Rs 27 crore (US$ 4.49 million) in multi-
specialty dental care chain Denty's, as demand for quality patient care
increases rapidly in India.
Medwell Ventures Pvt Ltd has acquired Bengaluru-based Nightingales Home
Health Services, which has more than 5,000 families subscribing to its annual
care plans. The company expects to establish a network in 10 Indian metro
clusters serving over a million families in the coming years.
Strand Life Sciences has partnered with the Mazumdar-Shaw Medical
Foundation (MSMF) to set up a lab that aims to bring down the cost of
detecting cancer.
GE Healthcare and Cancer Treatment Services International have announced
plans to launch 25 cancer detection and treatment centres all over India with
an investment of Rs 720 crore (US$ 119.77 million) in the next five years.
Chrys Capital has invested around US$ 40 million in Torrent Pharma,
expanding its portfolio of healthcare companies and taking up the total
exposure in the sector to nearly US$ 300 million.
5.2 Government Ventures
The Planning Commission has allocated US$ 55 billion under the 12th Five-Year
Plan to the Ministry of Health and Family Welfare, which is about three times the
actual expenditure under the 11th Five-Year Plan. The 12th Plan focuses on
providing universal healthcare, strengthening healthcare infrastructure, promoting
research and development (R&D) and enacting strong regulations for the
healthcare sector.
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Some of the major initiatives taken by the government to promote the healthcare
sector in India are as follows:
All India Institute of Medical Sciences (AIIMS) spends at least Rs 2 million

(US$ 33,271.51) annually on each faculty member, according to a study by the
institute's hospital administration.
Sikkim has become India's first state with 100 per cent sanitation coverage,
according to a report of the drinking water and sanitation ministry. "The state
has also sensitised people to adopt a holistic approach to improve sanitation
and hygiene for a clean environment while accelerating overall development
in the state," according to the Government of Sikkim.
India and Maldives have signed three agreements after delegation level talks
between Mr Abdulla Yameen Abdul Gayoom, President, Maldives, and Dr
Manmohan Singh, Prime Minister of India, on January 2, 2014. The pacts
include a Memorandum of Understanding (MoU) on health cooperation.
The Union Cabinet has approved the proposal for setting up of National
Cancer Institute (NCI) at a cost of Rs 2,035 crore (US$ 338.51 million). NCI
will be set up in the Jhajjar campus (Haryana) of All India Institute of Medical
Sciences (AIIMS), New Delhi. The project is estimated to be completed in 45
months.
It is observed that telemedicine is a fast emerging sector in India. In 2012, the tele
medicine market in India was valued at US$ 7.5 million, and is expected to grow at a
CAGR of 20 per cent to US$ 18.7 million by 2017. India's competitive advantage also
lies in the increased success rate of Indian companies in getting Abbreviated New
Drug Application (ANDA) approvals. India also offers vast opportunities in R&D as
well as medical tourism.
The Indian medical tourism industry is pegged at US$ 1 billion per annum, growing at
around 18 per cent and is expected to touch US$ 2 billion by 2015. There is a
significant scope for enhancing healthcare services considering that healthcare
spending as a percentage of GDP is rising. Rural India, which accounts for over 70
per cent of the population, is set to emerge as a potential demand source. Only three
per cent of specialist physicians cater to rural demand.
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There are vast opportunities for investment in healthcare infrastructure in both urban
and rural India. About 1.8 million beds are required by the end of 2025. Additionally,
1.54 million doctors and 2.4 million nurses are required to meet the growing demand.
5.3 Healthcare sector growth
By 2017, the Indian healthcare industry size is expected to touch US$ 160 billion.
Total healthcare revenue value wise.
Diagram 6
Total healthcare revenues in the country hospitals account for 71 per cent.
Total healthcare revenue percentage wise.
Diagram 7
Sources: Department of Industrial Policy and Promotion (DIPP), Union Budget 2012-
13, RNCOS Reports, Media Reports, Press Information Bureau (PIB)
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5.4 Per-capita healthcare expenditure
Per capita healthcare expenditure in India is estimated at a CAGR of 15.7 per cent
during 2008–15 to US$ 88.7 by 2015.
Total healthcare expenditure value wise.
Diagram 8
Total healthcare expenditure percentage wise.
Diagram 9
Sources: Department of Industrial Policy and Promotion (DIPP), Union Budget 2012-
13, RNCOS Reports, Media Reports, Press Information Bureau (PIB)
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5.5 Trends in Healthcare Industry in India
According to Dr Akash S Rajpal, Head, Consultancy Services, HOSMAC India Pvt

Ltd, growing population, increasing affordability, comparative cheaper treatment
costs as opposed to the west, medical tourism, increased health insurance penetration
and increased patient awareness will be the key factors to look out for which would
drive the future of healthcare in India.
According to recent studies conducted, the customer's (patient) aspirations are fast
changing. Customers are growing more aware of their health needs; they demand
quick response, less waiting times, and above all demand nearness of the healthcare
unit to them. Customers now demand better quality care and they do not want to
travel much as in earlier days.
It shows that if this is the window to the future of healthcare, then it leaves immense
opportunity for existing hospitals across the country to revamp and re-organize in
order to woo back their immediate local drainage population as the competition would
heat up soon. The patients would have a lot to choose from, now being insured. As
per various studies including a report by IDFC, and Mc Kinsey, Indian Healthcare
industry will be worth $125 billion in the next five years.
Statistics show that India presently has a bed deficit of approximately 30 lakh beds as
per the WHO recommendation of four beds per 1000 population. Considering even a
250 bedded hospital on an average, the country would need 12000 hospitals in the
near future. As almost 80 per cent of this would be fulfilled by the private players.
Recent spurt in Public Private Partnership (PPP) projects and thrust on quality by the
government sector and its demand on NABH and ISO, a lot of consultancy business is
abuzz with the projects in the accreditation field. It is clear that with CGHS making
NABH mandatory for care and hospitalization cost reimbursements, there is hectic
activity seen in hundreds of hospitals waking up to the long due need for quality
healthcare and applying for the coveted quality mark.
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High capital costs:
Studies in healthcare state that depending on the region and real estate costs, an
average hospital requires capital infusion of Rs 40 lakhs to a crore per bed or even
more. Industry estimates suggest that any hospital with capital costs of more than 50
lakhs per bed has high gestation period and even may be unviable. Land and building
together account for almost 40 per cent of the total project cost and affects the
viability depending on the resulting per bed cost.
Human resources:
According to Dr Prathap Reddy "the biggest challenge for him and Apollo Hospitals
is filling the void of human resources". As per ministry of health, there is a shortage
of approximately half a million doctors, a million nurses and the deficit needs to be
filled in the next five years. Such shortage will lead to exponential salary hike
demands, and further lead to high patient care costs. With organised sector being the
preferred choice now, there will be a huge demand even for the skilled and quailed
health administrators to run the show.
5.6 Conventional models of business
Research in the public health sector shows, millions of square feet of space is left
unutilized, expensive equipment ill-maintained and lack of skilled professionals
adding to the woe, still do not find adequate initiatives happening towards outsourcing
or even Public Private Partnerships (PPP). Almost 90 per cent of private sector in
India is run under the unorganized sector. The clinical establishment bill also has
faced immense opposition and a professional healthcare consultancy firm guided
healthcare business is not still seen frequently.The conventional model of healthcare
business would need to change to bring in untapped opportunities, operational
efficiencies and better profitability. This would also attract better private equity which
is now diverted to more lucrative industries.
Referral System
According to Cervantes K, Salgado R, Choi M and Kalter H. (2003) management of

diseases in any healthcare system with different levels essentially depends on a
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referral system. Basically, this is a pyramidal system with multiple primary healthcare
centers at the base, less number of secondary centers in the middle, and a fewer
number of tertiary care centers at the top.
Accordingly, the (STGs) standard treatment guidelines are designed to suit a

particular level of care. While the primary care centers offer the minimum levels of
essential tests and treatments on an outpatient care basis, the secondary level centers
are able to offer most of the diagnostic tests and management facilities, including
hospitalization, interventional procedures, surgery, and rehabilitation programs.
The role of tertiary level centers is restricted for complex interventions and surgical
procedures, prescription of highly advanced and costly tests, and prescriptions of
costly domiciliary devices and life support systems. Both secondary and tertiary level
centers are also important for appropriate training programs and undertaking other
developmental activities.
Pyramidal structure of healthcare in India.
Diagram 10
Source: Indian Journal of Community medicine (2003).
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Population:
Many would consider that the massive population of India would be a bane. But it has
turned out to be an immense business opportunity across industries like telecom,
broadcast and healthcare. The 1.17 billion population of 2009 is projected to reach
1.33 billion in the next 10 years. Of which almost 60 per cent of population is in the
15-64 year age group - which is the active earning population and will primarily drive
the industry, especially the healthcare insurance industry.
Insurance:
It is estimated that the penetration of health insurance in India is only 2 per cent of the
population. However this figure is expected to rise to a penetration of almost 20 per
cent in the next five years keeping in mind the high growth seen in disposable income
of the Indian families. Though this figure is the country's average, the percentage of
insured visiting urban private setups even now is in the range of 20- 60 per cent of the
hospital admissions.
5.7 Comparative low costs and Medical Tourism
As per industry studies, almost five million foreigners had availed treatment in Indian
healthcare setups by 2008. With surgical cost almost one tenth in western worlds, the
estimated 15 billion dollar medical tourism industry will only grow further. This has
led to the creation of health cities and medical tourism hub. Now with immense
support of the Indian tourism ministry and its dedicated medical arm, the medical
tourism industry in India will grow leaps and bounds.
It is evident, Leaders in India have realized, that to emerge as a global economic

superpower, it is imperative to make investments in building the country‟s social
fabric, in particular education and healthcare. More so, as India is expected to become
the world‟s most populous country by 2035, and is already the youngest, its home to
20 per cent of the world‟s under-24-year olds. Without doubt, this realization is a big
step forward. But it is simply not enough. India needs to think of innovative
approaches that will enable leaders across all walks of society, business, government
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and civil society to contribute towards building an educated workforce and a healthy
India.
India is uniquely positioned to tackle its healthcare challenges due to two fundamental
reasons. First, the nation has the privilege to learn from and avoid the costly errors of
the advanced economies. Second, it has the opportunity to create new models that
draw on the best resources from every sector of society. Unquestionably, designing
ways to strengthen the healthcare system will challenge the ingenuity of India‟s
government officials, business executives, academicians, and non-profit leaders. The
task will require leadership skills that can mobilize all Indians behind a Grand
National purpose. An India ready for leadership must design an approach adapted to
its social structures that promotes a combination of three factors: availability of
quality care, access to affordable healthcare services and more importantly creating
awareness of the benefits of preventive measures.
Studies emphasise that concerted efforts in this direction should be the cornerstones of
India‟s healthcare reform. By focusing on these three factors, India can overcome a
significant portion of its enormous health burdens, a high rate of infant mortality, low
overall life-expectancy rate, malnutrition, chronic outbreaks of preventable diseases
such as diarrhoea, pneumonia, cholera, malaria, tuberculosis, diabetes, cardiovascular
disease and cancer.
5.8 Rural India's healthcare
A new study on access to healthcare facilities shows that rural areas remain
significantly underdeveloped in terms of health infrastructure i.e. about half the
people in India and over three-fifths of those who live in rural areas have to travel
beyond 5 km to reach a healthcare centre. Availability of healthcare services is
skewed towards urban centers with these residents, who make up only 28% of the
country's population, enjoying access to 66% of India's available hospital beds, while
the remaining 72%, who live in rural areas, have access to just one-third of the beds.
It is understood through surveys made by researchers that insufficiencies in public

healthcare services have driven people across socio-economic strata to private
healthcare facilities leading to issues of affordability challenges. In 2012, 61% of rural
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patients and 69% of urban patients chose private in-patient service providers, up from
40% reported in a 1986-87 government survey. According to (IMS) Institute for
Healthcare Informatics, the cost of treatment at private healthcare facilities is at least
2 to 9 times higher than at public facilities. Poor patients receiving outpatient care for
chronic conditions at a private facility spent on an average 44% of their monthly
household expenditure per treatment, against 23% for those using a public facility. .
According to the IMS study, the lack of accessible healthcare facilities in rural areas,
the difficulty in accessing transport and the loss of earnings means patients postpone
treatment, or make do with facilities that may be closer but are not cost-effective or
even suited to their needs. Bennett, Coleman & Company Limited Jul 23, (2013), in
their study which was based on a survey of nearly 15,000 households across 12 states,
says that a 40-45% reduction in out-of-pocket expenditures for both outpatient and
inpatient treatments can be achieved by addressing physical accessibility of healthcare
facilities, availability and capacity of needed resources, quality and functionality of
service, and affordability of treatment relative to a patient's income.
Rural healthcare system in India.
Diagram 11 Source: Health and Beyond... Strategies for a Better India: Concept
Paper on Primary Health Care in India. Soumyadeep Bhaumik Senior Research
Scientist, South Asian Cochrane Network and Centre.
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The Primary Healthcare centre in India.
The health care system is India is organized as shown in the above Chart. Staffing at
all these centers is as per the Indian Public Health Services (IPHS) standards. The
sub-center is thus the peripheral most and the first contact point between the primary
health care system and the community. However, the first contact point between the
community and a trained physician is the Primary Health Center, which is supposed to
provide an "integrated curative and preventive health care to the rural population with
emphasis on preventive and promotive aspects of health care." However, specialist
physicians are available only at the point of Community Health Center, which caters
to a population base of 120,000 in the plains and 80,000 in hilly or difficult areas.
5.9 Indian Healthcare Industry

It is observed that over the years, India has made significant strides in the
advancement of healthcare and the quality of life. Recently in India, the life
expectancy of a person is 64.4 years, a notable increase compared to the situation in
the early 1990s. However, the WHO estimated in 1999 that the percentage of the
Indian population having sustainable access to essential drugs was within the 0-49
range, resulting in India being categorized as a country with a low-level access to
healthcare. It is often held that the main obstacles preventing consumer access to
medicine are economic constraints, particularly as a majority of Indians reside in rural
areas.
According to the International Journal of Pharmaceutical and Healthcare, the drug

costs are among the main drivers of the overall healthcare cost inflation along with
more aggressive contract bargaining by doctors, hospitals and new medical
technology. Within this scenario, there is a need to ensure that economically weaker
sections of the population in rural India i.e. the ones who exhibit higher rates of
disease proneness, higher infant mortality, higher malnutrition and lesser life
expectancy, have better access to medicine. One of the remedies in tackling the
problem of the escalating cost of healthcare in general and that of the drugs in
particular has been the use of generic drugs. Generic drugs are expected to play an
important social role in making life-saving drugs available at lower prices.
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It is seen that governments of several countries including the USA are encouraging
generic manufacturing. Recently, the world generics market has grown to a level of
$50 billion. In all countries, generics are far lower priced than their branded
equivalents. Almost 15 percent of the formulation market in India is generics of anti-
invectives, analgesics, anti-diarroheals and cough and cold preparations. Large
portions of these products go to bulk users like hospitals, nursing homes and medical
practitioners.
There are reports from which we can conclude that exports form a vital component
of the growth strategy of most Indian pharmaceutical companies and the growth over
the last five years has been more than 20 percent. The USA is the largest export
market for Indian pharmaceuticals. A major share of Indian pharmaceutical exports is
destined to highly regulated markets such as that of the USA, Germany, UK and The
Netherlands. The Indian generic drug manufacturing has seen a substantial rise over
the last few years and is expected to be the main growth driver in the future.
During the period 2002-2005, the market for generic drugs exceeded US$55 billion.
India with its technology, R&D facilities and trained human resources can capture a
significant part of this market. With new drugs slated to be introduced in the Indian
market, the share of patented drugs is expected to rise. Patent expirations would
contribute to the growth of the generics market. Advanced countries like the USA are
publicising increased consumption of generic drugs especially by the fixed income
older generation. This is expected to further bolster the generic drug production
market in India.
The Indian pharmaceutical industry has shown tremendous progress with reference to
infrastructure development, technology base creation and the development of
production. The pharmaceutical industry produces bulk drugs belonging to major
therapy groups. According to the Department of Chemicals and Petrochemicals
(2008) India ranks fourth world wide accounting for 8 percent of the world‟s
production in terms of volume and 13 in terms of value. The industry has developed
good manufacturing practices facilities for the production of different dosage forms.
The pharmaceutical industry exports drugs and pharmaceuticals worth over $3.8
billion. It ranks 17th in terms of export value of bulk actives and dosage. Indian
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exports cover more than 200 countries including the highly regulated markets of the
USA, Europe, Japan and Australia.
Therefore, the opportunities for the Indian pharmaceutical industries are scope for
generic drug production market, contract research, lean manufacturing, clinical
research and trials, significant export potential and supply of generic drugs to
developed markets. Buoyed by a congenial economic environment and demographic
changes, the Indian healthcare industry has experienced exceptional growth over the
past few years. In 2010, the industry was valued at USD 50 billion. This momentum is
expected to continue and place the sector at the top of the service sector players in
India.
It is seen that globally, the industry is amongst fastest growing sectors, with
approximate revenues of USD 5.5 trillion in 2010. Within this context, India is
viewed as one of the most promising markets among the developing countries and is
projected to reach USD 140 billion by 2017. This report gives a comprehensive
insight into the soaring Indian healthcare industry. It analyses the wide and diverse
spectrum of Indian healthcare, with emphasis on opportunities in the areas of hospital
infrastructure, pharmaceuticals, medical equipment, diagnostic labs and emerging
fields like healthcare tourism, clinical trials & research and telemedicine.
The overall industry scenario is upbeat, propelled by a growing economy, shifting

demographics, rising disposable incomes, high incidence of lifestyle-induced
diseases, new investment avenues and a large pool of talented and cost-effective
human resource. The segments that are reaping the most benefits are hospitals,
pharmaceuticals, medical equipment companies, pathological labs and other service
providers. The Indian government, on its part, is promoting this sector through
positive regulations like the introduction of the Health Bill, which proposes to bring
all independent bodies like the Medical Council of India (MCI), the Dental Council of
India (DCI), the Pharmacy Council of India (PCI) and the Nursing Council of India
(NCI) under a centralized authority. The government is also increasing public
expenditure on healthcare to 2.5 percent of GDP from 1 percent, encouraging public-
private partnerships (PPP) in hospital infrastructure and boosting medical tourism.
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According to Indian Healthcare Industry Gyan Research and Analytics Pvt Limited
(2012), taking advantage of the prevalent optimistic atmosphere, many foreign players
are looking to enter the country, especially in Tier-II and Tier-III cities, which have
huge untapped markets. Meanwhile, the generic drugs market is set to expand, since
most patents are going to expire in the next 5 years. Simultaneously, health cities and
single specialty clinics are gaining prominence in promoting quality healthcare
services at affordable prices. Health insurance portability is expected to increase the
penetration of insurance by not only improving the quality of service levels, but also
by raising competition among insurers to retain customers.
It is a known fact that Health care covers not merely medical care but also all aspects
pro preventive care too. Nor can it be limited to care rendered by or financed out of
public expenditure within the government sector alone but must include incentives
and disincentives for self care and care paid for by private citizens to get over ill
health. In India private out-of-pocket expenditure dominates the cost financing health
care. Health care at its essential core is widely recognized to be a public good. Its
demand and supply cannot therefore, be left to be regulated solely by the invisible
hand of the market.
It is noticed that Specialty clinics are emerging out of the general hospitals as a
universal trend. Globally, niche specialties are being catered to by specialty clinics.
The share of single specialty clinics, though is small, is rapidly growing in India. The
market for specialty clinics is highly fragmented in India, with the presence of many
small and niche players. However, the popularity of these clinics is increasing day-by-
day. In 2013, specialty clinics accounted for approximately 18% - 20% share of the
total Indian healthcare industry.
The ever increasing demand for healthcare services in India has opened up significant
scope for new opportunities in delivering affordable healthcare services to the rural
and semi-urban population of the country. This, coupled with the rising number of
diseases, makes it essential for the healthcare players to strive to increase the ease of
availability of healthcare services. With the GDP growing at close to 6-7%, the
healthcare expenditure is also expected to simultaneously expand in the coming 5
years.
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Specialty clinics would largely help in bridging the gap between the demand and
supply of healthcare services and facilities by providing cost effective and superior
care. There is a great future for the specialty clinics in India in the years to come.
With the increase in the number of players into this sector, there will be an increase in
the level of competition. As single specialty clinics are mainly focused on providing a
comprehensive range of services for a specific therapeutic area, they require lesser
investment than multi-specialty hospitals and hence are easier to operate and provide
facilities. It is expected that this business model of single clinics specialized in
particular domain would lead the growth in the Indian healthcare industry.
Findings indicate that India's healthcare services industry is expected to be very

appreciable in the near future. The Indian healthcare sector is anticipated to be the
future growth driver for the economy. The Indian government expects that the
healthcare industry, which is currently valued at $17 billion and comprises of hospital
service, healthcare equipment, managed care and pharmaceuticals would grow at a
rate of 13 percent annually. The Indian healthcare industry overview indicates it has
the same exponential growth potential as software and pharmaceutical industries in
the country. Till now only 12% of the opportunities in Indian healthcare sector have
been dug. In terms of percentage of GDP, India's expenditure on health is among the
highest of the developing countries. With the gaping difference in health costs
between Indian and western countries, India is now the preferred destination quality
health solutions. Other reasons account to the improved healthcare sector performance
through growth in pharmaceutical market and health insurance market in the country.
5.10 India’s Healthcare Achievements

Our overall achievement in regard to longevity and other key health indicators are
impressive but in many respects uneven across States. In the past five decades life
expectancy has increased from 50 years to over 64 in 2000. Crude birth rates have
dropped to 26.1 and death rates to 8.7. At this stage, a process understanding of
longevity and child health may be useful for understanding progress in future.
Longevity, always a key national goal, is not merely the reduction of deaths as a result
of better medical and rehabilitative care at old age. In fact without reasonable quality
of life in the extended years marked by self-confidence and absence of undue
dependency longevity may mean only a display of technical skills.
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It is understood that reduction in child mortality involves as much attention to
protecting children from infection as in ensuring nutrition and calls for a holistic view
of mother and child health services. The cluster of services consisting of antenatal
services, delivery care and low birth weight and childhood diarrhoea are linked
priorities. Programme of immunization and childhood nutrition seen in better
performing states indicate sustained attention to routine and complex investments into
growing children as a group to make them grow into persons capable of living long
and well. Indeed persistence with improved routines and care for quality in
immunization would also be a path way to reduce the world's highest rate of maternal
mortality.
It is observed that Indian medical tourism is an outcome of extensive primary and

secondary research, and a thorough analysis of various industry trends. According to
the report, India has managed to match-up with the quality of healthcare services that
are being provided in developed countries. The qualified medical staff, adoption of
advance technology and improving healthcare infrastructure has made India an
attractive destination for patients all over the world. The advantage of cost
competitiveness further contributes to the factors responsible for making India a
preferred destination for medical tourists. Extensive research and analysis also
revealed that many private information agencies in India are offering attractive
packages to medical tourists. They offer customized travel and treatment itineraries to
the international patients, which include personalized treatment packages depending
on individual needs and assistance throughout the stay.
It has also been observed that alternative traditional medicine like ayurveda, pranic
healing, aromatherapy, music therapy, meditation and yoga are becoming popular
among the medical tourists. Many tourists come to India to seek the divine peace and
healing power provided by these alternative medical therapies. This provides India an
extra advantage over the other countries.
5.11 Health care expenditure in India

According to a report by Berki (1986), out-of-pocket healthcare payments that are
high enough to endanger a household‟s customary living standards are referred to as
„catastrophic‟ healthcare expenditure. The notion of „high enough‟ expenditure is
arguably relative in nature, as it is plausible that even small health expenditures can
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be financially disastrous for low income households. In fact, such payment prevents
poor households from meeting their basic necessities and compels them to adopt
desperate coping strategies such as sale of productive assets.
It is observed that, the resulting indebtedness due to high treatment expenditure

pushes several of the households into chronic poverty. The welfare - reducing impact
of catastrophic expenditures is increasingly being identified by the development
community as an area requiring urgent policy action. For instance, the World Health
Assembly (2005) has called for interventions to protect individuals seeking care
against catastrophic health - care expenditure and possible impoverishment. A large
number of studies have attempted to quantify the incidence of catastrophic
expenditure using alternative theoretical and empirical definitions. According to
Wagstaff and Van Doorlaer (2003), Xu et al (2003) most of the studies categorise
health expenditures as „catastrophic‟ when it exceeds a certain pre-specified threshold
of medical expenditure to household ability to pay.
It is further noted that although this method corresponds well with the concept of
catastrophic expenditure, in the absence of appropriate data and information on
household‟s ability to pay, it is rather difficult to capture the true incidence of the
problem. For instance, Ghosh (2011) applies this method on the Consumption
Expenditure Survey data for India and finds that, at any given threshold, the incidence
of catastrophic health payments is concentrated among the richer households.
Previously, Van Doorslaer et al. (2007) also arrived at similar conclusions regarding
the pro-rich concentration of catastrophic expenditure in India.
As such, better-off Indian households spend large fractions of total consumption on

health care thus making one question the impact of such expenditures on households.
Ghosh (2011) suggests that the main problem with the method is that it misses a huge
number of households that do not have the financial capacity to utilize healthcare
services. Part of the problem, therefore, is also regarding the accuracy of information
that signifies ability to pay of households. Given such concerns, certain alternatives
are suggested to estimate the incidence of catastrophic expenditure and impoverishing
effects of health expenditure. In their study Flores et al. (2008) utilize the information
on sources of health financing i.e. including own savings, borrowings and sale of
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assets accessed by households to devise a measure of „coping‟ adjusted health
expenditure ratio.
5.12 Healthcare services for the rural and semi -urban segments in
India
The access to high quality, a reliable and affordable basic healthcare service is one of
the key challenges facing the rural and semi-urban population lying at base of the
pyramid (BoP) in India. Realizing this as a social challenge and an economic
opportunity, there has been an emergence of healthcare service providers who have
bundled entrepreneurial attitude and passion with available scarce resources to design
and implement cost-effective, reliable and scalable market solutions for the BoP.
Prahalad and Hammond (2002) have described bottom of pyramid (BoP) as both a
challenge as well as an opportunity for organizations. This is an opportunity to solve
the unique problems profitably and to develop breakthrough business models for
sustainability at BoP.
Since 2006, the developed economies are growing at a rate of 1-2 percent as
compared to developing economies, which are growing at a rate of 6-10 percent. The
declining gross domestic product (GDP) growth rate and market saturation in
developed economies is bringing about a paradigm shift in focus and attention
towards the growing demands and potential business opportunities in developing
economies. The predominant market in these developing economies is characterized
as uncertain, informal, rural and heterogeneous having people lying in the BoP socio-
economic segment.
It is observed that India is one such developing economy, which is emerging as a

promising market having a consistent GDP growth rate of more than 7 percent since
2006 and having a huge population base (1.2 billion as in year 2011). As per UNICEF
(2009), 70 percent of the population in India resides in rural areas. According to Haub
and Sharma (2010) the World Bank estimates, 41.6 percent of India‟s population lives
below $1.25 per day and 75.6 percent live below $2 per day.
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According to Viswanathan et al., (2007) this is characterized as a BoP segment, which
lives and resides in an informal market and differs from mid and high-income context
with respect to increasingly prevalent market imperfections like information
asymmetries, market fragmentation, weak legal institution, weak infrastructure,
resource scarcity and poverty.
The BoP segment lacks access to formal market conditions for the fulfillment of their
basic needs like food, energy, drinking water, healthcare, sanitation, education,
financial infrastructure, insurance etc. This presents a significant business opportunity
for the organizations to enter the BoP market using a differentiated business model
and organizational mind-set. One such area is need for healthcare, where there exists a
significant demand-supply gap at BoP in India. There is a big gap between the pricing
and quality of healthcare services provided by the private hospitals and public
hospitals.
The lack of accessibility and availability of affordable healthcare products, services

and information has created a big barrier in the social and economic development of
the BoP population in India. With the organizations realizing this as a huge
opportunity, there has been an emergence of self-sustainable and profitable business
models aimed at the healthcare related offerings for the BoP population.
These organizations are bundling entrepreneurial attitude and passion, information

and communication technology and innovation to design and implement cost-
effective, reliable and scalable market solutions for the BoP segment. The BoP
segment carries a different mindset and involves the application of a different set of
rules as compared to the middle and upper segments. So, there is a need to undertake
phenomenon driven research based upon analyzing and interpreting the data from
multiple sources.
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Base of Pyramid population comparative
estimates – below pohallenge or/and opportunopulation
Diagram 12
Insurance in India
Findings suggest that the need for medical insurance has increased in recent times
mainly because market-driven healthcare facilities are not at all affordable for many.
According to Review of Management, (2011) Nasiha Munib, the IRDA regulations in
recent years for rural and social sector, has provided much needed impetus to micro
health insurance products of a number of private players which hitherto cared only for
the urban and rich clientele.
While health insurance is gaining popularity in India, the variety and availability of
products is severely limited even for the rich. The situation is worse for the poor who
have only partial access to a limited set of healthcare services. Scenario is alarming in
terms of overall coverage of health insurance. Merely 3.3% of GDP is spent on all
kinds of insurance in India, out of which a very low percentage is spent on non-life
insurance and only marginally on health insurance. Broadly speaking, health
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insurance is grossly under-penetrated: as around 70% Indians live in villages and less
than 2% are insured. In a country where a major share of the total spending on health
(over 98 %) is OOP (out of pocket), there must be an appropriate pooling mechanism
to mobilize this huge sum.
Existing health insurance schemes can be categorized into five broad groups:
mandatory, voluntary, employer-based, government-run schemes for families below
the poverty line (BPL), community and NGO based insurance programmes. The first
three categories of insurance schemes mainly serve the Indian elite, and those
belonging to the organized sector while the last two types of insurance schemes fall
under micro insurance or micro health insurance.
Health Insurance Schemes for BPL Families
Research points out that of late, the government has taken plausible steps to provide
quality healthcare to 300 million poor in the country. Most of these people are
working in the unorganised sector and are devoid of any formal health and social
security policy. For example, the government has launched the Rashtriya Swasthya
Bima Yojana (RSBY) for those living below the poverty line. The scheme provides an
insurance coverage to the tune of Rs. 30,000 per annum. There is a provision of
cashless healthcare facility with the provision of smart card and coverage of pre-
existing diseases. The centre and the states contribute towards payment of the
premium in the ratio of 75:25.
The Universal Health Insurance Scheme (UHIS) was launched by the Government of
India in 2003. The scheme provides for reimbursement of medical expenses in case of
hospitalisation up to Rs.30, 000 coverage for accidental death of the earning head of
the family for Rs.25, 000 and compensation due to his loss of earning at the rate of
Rs. 50 per day up to a maximum of 15 days. In 2004 the scheme was redesigned and
made exclusively for persons and families below the poverty line (BPL). The revised
annual premium was set at Rs. 365 with a subsidy of Rs. 200 for individuals, Rs. 548
with a subsidy of Rs. 300 for a family of five and Rs. 730 with a subsidy of Rs. 400
for a family of seven.
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5.13 Hospital Services Market in India
It is observed that the hospital services market represents one of the most lucrative
segments of the Indian healthcare industry. Various factors such as increasing
prevalence of diseases, improving affordability and rising penetration of health
insurance continue to fuel growth in the Indian hospital industry. According to new
research report "Booming Hospital Services Market in India", the Indian hospital
service industry is projected to grow at more than 9% during 2010-2015. Currently,
the market is dominated by unorganized investors and this is likely to continue in near
future as well. Besides, high private sector investments will contribute significantly to
the development of hospital industry.
It has been found that there is a strong demand for hospital beds in the country and a
major part of this demand comes from rural and sub urban areas. It is anticipated that
most of this demand will be met by private investments as majority of government
investments will be focused on primary healthcare segment. Hospitals play a major
role in the society as they provide healthcare services to patients. Increasing
population and healthcare requirements and the complexity of diseases brought about
by radical changes in the concept of healthcare services in the country. Public
healthcare system alone is unable to do justice in such a scenario. Healthcare services
witnessed a tremendous growth with the entry of private multi-speciality hospitals.
More and more hospitals were built to bridge the gap between demand and supply of
healthcare services in a growing economy. As management of hospitals became a
core issue, the demand for trained and efficient staff increased.
Research indicates that the Hospital industry accounts for half the healthcare sector's
revenues. There is a huge pent up demand for quality healthcare and increase in
healthcare spending in the long-term are fundamentally strong drivers in this market.
An analysis of this sector explains factors contributing to the huge potential based on
healthcare consumption, increasing instances of lifestyle - related diseases, medical
tourism, and growing health insurance. The key challenges identified include
significant capital requirements and a shortage of medical professionals. Major
Private Players in the industry are also identified as well as new domestic and
international entrants in the market.
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The future outlooks cover the nature of private equity investment and buy outs by
large hospital chains, emergence of "health cities" and telemedicine initiatives.
Hospital Market in India 2014 captures the largest segment of the overall domestic
healthcare market. The emerging Indian economy is witnessing rapid expansion of the
hospital market. The growing burden of disease, along with unhealthy lifestyles, aging
population, growing affordability and widespread health insurance penetration
comprise some of the key factors propelling the hospital sector.
The market is clearly segmented into public and private sectors wherein the public
sector caters to a larger population base that is unable to afford the relatively
expensive private hospital services. The private sector is diverting its business
progressively from metro city markets and is focusing on capturing market share in
tier-II and tier-III cities with the introduction of hospital chains and specialty clinics
aimed at attracting the masses towards quality healthcare services.
The Indian government's awareness about the large gap in the delivery of healthcare
services is seeing both direct and indirect initiatives towards raising the level of
service availability. Higher budgetary allocations, financial incentives and public
private partnerships are some of the methodologies being adopted to bridge this gap.
A number of non-healthcare related business houses are also venturing into the
healthcare delivery space due to the immense growth opportunities that exist within
the sector, resulting in greater competitiveness and betterment of service delivery on
the part of the market players.
The hospital service‟s market represents one of the most lucrative segments of the
Indian healthcare industry. Various factors, such as increasing prevalence of diseases,
improving affordability, and rising penetration of health insurance are fuelling the
growth in the Indian hospital industry. Several private players are also entering the
sector with new plans of establishing hospitals and health centers around the country.
On the back of continuously rising demand, the hospital services industry is expected
to be worth US$ 81.2 Billion by 2015.
According to our new research report, “Indian Hospital Services Market Outlook”,
the country needs to cover the cumulative deficit of around 3 Million hospital beds to
match up with the global average of 3 beds per 1000 population. Huge private sector
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investments will significantly contribute to the development of hospital industry,
comprising around 80% of the total market. Big private players including Apollo,
Fortis, and Max Healthcare are making huge investments in metropolitan cities like
Delhi, Mumbai, Pune, Bengaluru, Hyderabad, etc for expanding their operations and
increasing bed capacity. These cities are densely populated and have high proportion
of middle-income earners, and the quality-of-life is better off compared to the other
Tier-II and -III cities.
The demand for good quality healthcare services is high in these areas and thus, they
are attracting private players in order to improve healthcare infrastructure in the
country. The Indian healthcare delivery system consists of varied health institutions
and mixed ownership patterns. Private and public-private partnerships dominate the
tertiary care, while secondary healthcare is a lopsided mix of both, private and public
and government health systems cater mostly to primary care. It is estimated that there
are more than 15,000 hospitals operating in the country, of which 30 per cent are in
public sector. However, number of beds in the public sector is almost four times that
in the private sector.
While 80 per cent of hospitals in the private sector have less than 30 beds, about 10
per cent of hospitals are with beds in the range of 30-100. Only six to seven per cent
of the hospitals are with more than 100 beds. In terms of expenditure on health, the
private and public investment is roughly in the ratio of 80:20 respectively. With
regards to healthcare and services spending, 62 per cent is self-sponsored. The
Government contributes 24 per cent, employer provides for 9 per cent and only 5 per
cent comes through insurance. This is dismal, when we discover that only Rs 250
crore is being collected for health insurance, whereas life insurance gets Rs 25,000
crores and even non-life items get Rs 9,000 crores towards insurance.
5.14 Key Stake Holders of any Health and Hospital setup
Stake holders are those entities in the organizations enviornment that play a role in the
organizations health and performance, or that are affected by an organizational action.
Persons or groups who have vested interest in the clinical decision and the evidence
that supports that decision are also reffered to as stakeholders.
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External Stake Holders : Suppliers of equipment, consumables etc. Vendors who are
interacting with the stores and Pharmacy of a Hospital. Patients who need compassion
as well as skill with clear communication. Medical Insurance companies and media
are all in the category of external stake holders.
Government Authorities, Statutory Bodies like the Medical Council of India (MCI),
the Dental Council of India (DCI), the Pharmacy Council of India (PCI) and the
Nursing Council of India (NCI), which constantly monitor whether there is
compliances of statutes.
Internal stake Holders: They are almost entirely within the organization and its
environment.The top management, i.e. the trustees and owners are the main internal
stake holders as they take strategic decisions and are responsible for the profits of the
organization. They want both to keep their costs down, and to get their employees
back to work quickly.The technical and non technical staff also comes in the category
of internal stake holders. They tend to view quality in a technical sense – accuracy of
diagnosis, appropriateness of therapy, resulting health outcome.
The Key Stake holders of any Health and Hospital set up
Diagram 13
Source: Prof Dr. R Gopal‟s lecture notes on strategic management in Healthcare

Enviornment, (2012).
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5.15 Major Hospitals in India
India is one country which has witnessed a lot of growth in the medical world. Not
only Indian doctors are now leading practitioners in the field of medicine across the
world, but also patients from different parts of the world are coming to India for
treatment.
The 10 best hospitals in India are as follows:
1. All India Institute of Medical Sciences: established in 1956, employs the

best Indian doctors in their respective fields. It is a hospital-cum-learning
institute, where students can learn medicine on undergraduate and post-
graduate levels. With some highly efficient departments in teaching, research
and patient care, AIIMS is a leading name in India today.
2. Apollo Hospitals: Maintaining a path breaking record in the world of
medicine, Apollo is a reliable brand name in India. Its hospitals, diagnostic
clinics, consultancy services and pharmacies are state-of-the-art. Though the
cost of treatment here is on a higher side, the quality of service is real value-
for-money.
3. Fortis Hospitals: A leading name in healthcare, Fortis offers excellence and is
a world class establishment. It has hospitals in around 11 countries, all of
which promise health, hygiene and perfect care. With their brilliant staff,
management, treatments and services, Fortis is one of the leading names in
India's healthcare field.
4. NIMHANS: The National Institute of Mental Health and Neuro Sciences, in
Bangalore is a Deemed University which offers brilliant learning, training and
professional facilities in the field of mental health and neuro-sciences.
Academics and research, both are its fully developed areas, while its
treatments in the field of mental diseases are popular all over the country. It
houses a lunatic asylum as well, with great facilities.
5. Christian Medical College: An excellent name in education, research and
medical aid, CMC is gaining new heights. Adopting all the latest technologies,
cost effective methods and sanitary measures, the hospital is another brilliant
name for medical research as well. The institution offers a wonderful helping
hand to disabled, marginalized, poor and disadvantaged as well through many
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reforms. They work on a solid theological ground, which believes in taking
care of everybody.
6. PGIMER: Post Graduate Institute of Medical Education and Research is one
of the popular names, not just in Chandigarh, but also in India, in the field of
medicine. Offering quality medical services, teaching staff, nursing facilities,
research labs and latest technology, the institution has come a long way since
1960, when it was established.
7. Tata Memorial Hospital: A very popular hospital for cancer treatment in the
country, TMH is a government institute that also offers a lot of research
facilities and options. Founded in 1941, the institute works in collaboration
with the Health ministry and some top medical staff in the country. It also has
a close working relationship with Cancer Research Institute, and that is why
they have an almost spotless cancer treating record.
8. Lilavati Hospital: A product of a charitable trust by Lilavati Kirtilal Mehta,
Lilavati Hospital in Mumbai is one of the most acknowledged names in the
country, when it comes to medical emergencies and requirements. Established
in 1978, the hospital is equipped with best services, staff, technology and all
kind of research aids.
9. Sankara Nethralaya: A charitable, non-profit eye care hospital, Sankara
Nethralaya is an iconic name in the country. Established in 1976, the centre is
an excellent eye hospital and patients come from all over the world for
treatment of eye-related problems.
10. Bombay Hospital: A multi-tasking medical institution, which offers training,
education, research facilities and health care to millions and millions of
patients, Bombay Hospital is one of the best medical institutions in the
country. The various departments work brilliantly in their areas here, and have
brought revolutionary benefits to the medical world. You can get the best
sanitation and nursing also here.
Hospitals and Research

In India, many corporate hospitals and major public hospitals are actively involved in
conducting clinical trials of various drugs. Private corporate hospitals such as Apollo
Care, Narayana Hrudayalaya, Usha Cardiac Institute, Shankar Netralaya,
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Indraprastha, Breach Candy, and Bayer diagnostics as well as public hospitals such as
All India Institute of Medical Sciences, Nizam Institute of Medical Sciences and
many of the Medical colleges and teaching hospitals are actively involved in various
stages of clinical trials. Many of them have state-of-the-art infrastructure facilities for
conducting clinical trials and treating patients. These have not only helped in
improving patient outcomes but also helped in tackling increased volume of patients
suffering from debilitating diseases.
Single Speciality Hospitals

Single speciality hospitals are a small but rapidly growing genre among today‟s
hospitals in India. The growing number of speciality centres and hospitals signals a
move towards maturity of the healthcare industry with an increasing complexity of
business and consumer affordability.tSpeciality hospital formats range from low-risk
speciality including eye care, dermatology, mother and child to high-end speciality
including cardiology, cancer and transplant medicine. The mid-level specialities are
offered in a multi speciality hospital format. The low-risk speciality models require
low capital expenditure and have comparatively low operating costs as in-patient stay
is rarely required for day procedures. This reduces the need for support infrastructure
and offers easy replication. Consumers expect convenience and are not willing to
travel too far for such speciality services.
Potential Benefits
There are several advantages to Single Speciality Hospitals
• Cost efficiency due to higher volumes
• Provide higher quality care due to greater specialization
• Easily attract human resource
• Economies of scale and scope
• Ease of operation
• Increase consumer satisfaction
• Competitive pricing and increased choice for consumer
Ayurvedic and Wellness Care

According to Research on India, Wellness Services Market Report (2010), Ayurvedic
treatments are 5,000 years old in India with the bulk of the ayurvedic treatment
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market concentrated in South India, mostly in Kerala. Firms are also investing in this
space while mergers with ayurveda pharmacies are also taking place. Ayurvedic
market which is a part of the Beauty and Rejuvenation market is estimated at INR 40
Billion in 2009. India is a popular destination for ayurvedic therapies leading to a
large number of foreign tourists visiting local spas and ayurvedic treatment centres.
Surveys state that inbound medical tourism in India is therefore growing at a 12

percent CAGR. The State government of Kerala also has taken certain initiatives to
encourage Ayurvedic spas and resorts as a tourist destination. Spas in Kerala receive
government approval when they are set up. Ayurveda centres which are approved by
the State Department of Tourism are eligible for claiming 10 percent state investment
subsidy or electric tariff concession and considered during publicity and promotional
activities through print and electronic media by the Department. Kerala government
has even collaborated with large private players in order to develop resort spas.
According to Kerala Tourism“Bharat Hotels” (2009), in order to attract tourists into

India, the Government has introduced various schemes and to implement them it has
also tied up with leading wellness centres. Tourism ministry launched a promotional
scheme offering one night free stay at a spa centre in India if a tourist books three
nights at a certain wellness centres. Hospitals are also setting up wellness centres to
cater to the requirements of the medical tourists.
Apollo Hospitals. has an entity called Apollo Wellness Plus which has fitness
and ayurvedic treatment centres.
Manipal Hospitals. provides ayurvedic treatment, fitness solutions through

Manipal Cure and Care.
Kerala Ayurveda Ltd. Ramesh Vangal owned KAL was founded in 1945. It
is listed on Bombay Stock Exchange. It has 30 wellness centres which are
mostly concentrated in the south but it also has its presence in the north. It
owns Kerala Ayurvedegram that is present in Bangalore.
Ananda Spa. It has destination spas in Tehri - Garhwal, Uttaranchal which

provides Treatment based on ayurvedic science via herbal scrubs, wraps and
packs.
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CHAPTER VI
CUSTOMER SATISFACTION
Customer satisfaction is a marketing term that measures how products or services

supplied by a company meet or surpass a customer‟s expectation. Customer
satisfaction is important because it provides marketers and business owners with a
metric that they can use to manage and improve their businesses. In a survey of nearly
200 senior marketing managers, 71 percent responded that they found a customer
satisfaction metric very useful in managing and monitoring their businesses.
6.1 Importance of Customer Satisfaction
1. It’s a leading indicator of consumer repurchase intentions and loyalty.
Customer satisfaction is the best indicator of how likely a customer will make a
purchase in the future. Asking customers to rate their satisfaction on a scale of 1-10 is
a good way to see if they will become repeat customers or even advocates. Any
customers that give you a rating of 7 and above, can be considered satisfied and you
can safely expect them to come back and make repeat purchases. Customers who give
you a rating of 9 or 10 are your potential customer advocates who get you more
business. Scores of 6 and below are warning signs that a customer is unhappy and
might leave. Customers need to be put on a customer watch list and followed up so
you can determine why their satisfaction is low.
2. It’s a point of differentiation
In a competitive marketplace where businesses compete for customers, customer

satisfaction is seen as a key differentiator. Businesses who succeed in these cut-throat
environments are the ones that make customer satisfaction a key element of their
business strategy.
3. It reduces customer churn
An Accenture global customer satisfaction report (2008) found that price is not the
main reason for customer churn; it is actually due to the overall poor quality of
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customer service. Customer satisfaction is the metric you can use to reduce customer
churn. By measuring and tracking customer satisfaction you can put new processes in
place to increase the overall quality of your customer service.
4. It increases customer lifetime value
A study by Info Quest found that a „totally satisfied customer‟ contributes 2.6 times
more revenue than a „somewhat satisfied customer‟. Further, a „totally satisfied
customer‟ contributes 14 times more revenue than a „somewhat dissatisfied
customer‟. Satisfaction plays a significant role in how much revenue a customer
generates for your business. Customer lifetime value is a beneficiary of high customer
satisfaction and retention.
5. It reduces negative word of mouth
McKinsey found that an unhappy customer tells between 9-15 people about their
experience. In fact, 13% of unhappy customers tell over 20 people about their
experience. Customer satisfaction is tightly linked to revenue and repeat purchases.
What often gets forgotten is how customer satisfaction negatively impacts your
business. It‟s one thing to lose a customer because they were unhappy. It‟s another
thing completely to lose 20 customers because of some bad word of mouth. To
eliminate bad word of mouth you need to measure customer satisfaction on an
ongoing basis. Tracking changes will help you identify if customers are actually
happy with your product or service.
6. It’s cheaper to retain customers than acquire new ones
This is probably the most publicized customer satisfaction statistic out there. It costs
six to seven times more to acquire new customers than it does to retain existing
customers. Customers cost a lot of money to acquire. Imagine if you allocated one
sixth of your marketing budget towards customer retention. How do you think that
will help you with improving customer satisfaction and retaining customers?
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Measure satisfaction to see how happy your customers really are
Lee Resource Inc. found that for every customer complaint there are 26 other unhappy
customers who have remained silent. That is an alarming statistic. Most companies
think they are the best and they have no unhappy customers. The reality is, 96% of
unhappy customers don‟t complain. In fact, most simply just leave and never come
back. Customer satisfaction plays an important role within your business. Not only is
it the leading indicator to measure customer loyalty, identify unhappy customers,
reduce churn and increase revenue, it is also a key point of differentiation that helps
you to attract new customers in competitive business environments.
Sometimes companies are misguided by the notion that customers depend on them.
The truth of the matter is that we very much so depend on them. Many researchers
and academia have highlighted the importance of customers in today‟s market. The
level of satisfaction a customer has with a company has profound effects. Studies
have found that the level of customer‟s satisfaction has a positive effect on
profitability:
A totally satisfied customer contributes 2.6 times as much revenue to a

company as a somewhat satisfied customer.
A totally satisfied customer contributes 17 times as much revenue as a
somewhat dissatisfied customer.
A totally dissatisfied customer decreases revenue at a rate equal to 18 times
what a totally satisfied customer contributes to a company.
According to Ryan Nelson, merely focusing solely on customer satisfaction has its
drawbacks in the marketplace as well. For those companies that focus only on
customer satisfaction run a real risk of failing to differentiate their brand from others.
In order to achieve long-term sustainability companies must seek to establish ties of
loyalty with consumers that are strong enough to ward off the advances of
competitors. Creating loyalty among customers can help the company to increase
purchases of existing products, charge premium prices for appreciation of your added-
value services and create positive word-of-mouth promotion for your company, which
is the core marketing objective for companies.
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It is observed that customer loyalty is much harder to obtain than satisfaction. Even
though customers are satisfied with the company there are several factors that could
cause the customer to defect to the competition, such as finding a better value or the
competitor is more convenient. With that said, having high levels of customer
satisfaction does not always lead to customer loyalty. However, a company cannot
achieve customer loyalty without having customer satisfaction. Thus, though
customer satisfaction does not guarantee the repurchase from a company but it does
play a very important role in achieving customer loyalty. Conducting customer
satisfaction research will provide your company with the necessary insight it needs to
make informed decisions in order to retain and increase your customer base and
improve customer relationships.
The most frequently mentioned outcome of the marketing process is a satisfied

customer, with many definitions of marketing incorporating this important marketing
concept. Marketing leads to outcomes other than satisfaction, including awareness,
image perceptions and loyalty. There are also other factors that influence purchasing
where satisfaction does not always play a role, i.e. lack of perceived differentiated
competitors, such as in the banking industry. Thus, satisfaction should not be the only
goal for marketing practitioners.
As per norms, satisfaction is used as a common marketing benchmark of an

organization's performance, almost to the exclusion of other issues. In-Touch Survey
Systems, (2003) a major US market research firm states that customer satisfaction is
the key to success and makes the emphatic statement that a satisfied customer is a
repeat customer. While admirable, it is myopic to focus so intensely on only one of
the factors that influences repeat purchase. Ideally, an organization should include
other key influencers of repeat purchase in their performance.
According to marketing literature, satisfaction leads to attitudinal loyalty. According

to Oliver (1996), it is assumed that high levels of attitudinal loyalty are an outcome of
high levels of satisfaction. Satisfaction is defined as an emotional post-consumption
response that may occur as the result of comparing expected and actual performance,
or it can be an outcome that occurs without comparing expectations.
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6.2 Customer Satisfaction Surveys
Diagram 14
Source: National Research Bureau Ltd (2013)
Successful business owners and managers, quickly realize the importance of keeping
customers costs less than finding new ones. If certain practices drive customers away,
a business repeatedly spends time and money on advertising and other efforts to
recruit customers. These business owners know that weaknesses in the production or
delivery of goods lead to distressed customers. They use online surveys to collect
feedback from customers as tools for improvement using customer satisfaction
surveys. Studies show satisfied clients tend to buy products more often and develop
loyalty to a particular brand.
They often spread the word by recommending products and services to friends and
family as an informal referral process. Customer satisfaction surveys give firms
specific information about positive and negative perceptions, which could improve
marketing or sales efforts. These perceptions are especially important because of the
increased use of social media by people of all ages. One negative comment posted on
a social media site could be seen by thousands of potential customers. Angry
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customers can use unfair criticism and untrue statements to harm a firm's reputation.
Repairing the damage or countering false representations could prove costly.
A customer satisfaction survey might be worthless unless it creates statistical data that
can be scientifically analysed. The first step to developing an online survey examines
intended goals and a process for comparing results. Employees charged with
analysing survey results should have some background in statistics to make the survey
meaningful. When drafting survey questions, as much detail as possible should be
included in the questionnaire, along with an area for independent customer comments.
If survey results lead to a plan to correct weak areas of operation, a follow-up survey
can be used to measure whether changes worked. Information can again be analysed
and compared to earlier feedback.
According to Mo Naser, customer satisfaction surveys also reveal data that can be
used to gauge estimated customer satisfaction rates of competitors. In some firms,
each unhappy customer is personally contacted in an effort to resolve any problem.
Customers who ranked service or goods poorly might be offered discounts in an effort
to retain their business. If comments they made on the survey resulted in action to
their responses on the online questionnaire, then these personal contacts let customers
know their opinions are valuable and taken seriously.
Reasons to survey your customers:
Customer Loyalty: It should be understood what they like about the organization and
what they dislike. Knowing what keeps them coming back over and over again is the
secret to success.
Customer satisfaction: Satisfied customers are those who do not have outstanding
negative issues concerning the organization on their mind. This doesn‟t mean
everything has always been perfect. Sometimes things may not have gone all right.
Sympathetic listening to customers is essential. Online surveys provide a way where
customers get a chance to get their side of the story out without being interrupted. A
second essential is follow-through.
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Spotting Trends: Beyond understanding the drivers behind loyalty and satisfaction of
customers, organizations can benefit from the wisdom of the masses by asking them
for their ideas and spotting patterns in their feedback. Spotting such trends ahead of
competition could offer a significant advantage.
6.3 Customer Satisfaction and Brand Equity
It is observed that though customer satisfaction is a critical component of brand

equity, companies often under deliver on service. To improve the service element can
be costly; often it requires the substantial reorganization of a business. However, if
the benefits of doing so can be quantified, such investment may be justified. And
when high levels of service delivery have been achieved, strong marketing can help to
enhance perceptions of good service. In many large organizations, one team handles
customer satisfaction while another manages brand equity. When these teams don‟t
collaborate or even communicate with one another, opportunities to increase brand
value can be lost. Effective management of the customer experience is key to building
customer commitment, brand equity, and hence sustained financial success. However,
to consistently deliver a quality customer experience in any kind of extended business
operation is easier said than done. Senior management may be unwilling to buy in to
the expense, in terms of both time and money of reorganization and training.
It is no secret that customer satisfaction levels directly affect brand loyalty, but getting
a realistic understanding of your customer‟s sentiment can be tricky, especially when
using antiquated survey methods. Applications from companies can determine how a
company and its competitors are being perceived and whether that perception is
positive, neutral, or negative. They can also determine where a company's brand value
stands and what it can do to enhance it. According to earlier studies, there are certain
tips for assessing customer satisfaction levels by going beyond the standard
satisfaction survey.
Deliver on the brand promise
It is observed in many organizations that efficiency and basic levels of courtesy have
become the benchmark, when measuring customer satisfaction, but times are
changing. To distinguish themselves, companies need to do better. According to
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Schreuer, "One of the problems with the customer satisfaction movement is that it led
to everyone looking alike, because the measurements and feedback were all very
similar. It was measuring minimum standards. If you measure to a minimum standard
you can only manage to a minimum standard."
According to researchers there is a need to examine value drivers other than the usual
courtesy and time to resolution goals. To do this, define value metrics that go beyond
the norm, such as flexibility, or the ability to resolve unexpected difficulties. There
should be procedures that enable you to exceed the usual parameters of service and
measure their effectiveness. Schreuer in his study states that, if you don't, it could be a
hugely expensive customer interaction. Focus should be on behavior and not on
satisfaction.
Save and search
It is a known fact that customers may not tell you when they are happy, but will tell
you when they are unhappy. These red flags provide insight into detecting the
emotional state of the customer. With this information, companies can respond
quickly with targeted offers or communication to keep customers happy.
The media is the message
According to Marshall McLuhan's theory, medium is the message that comes into
play for marketers, but they should pay attention to the media as well. "The world is
moving faster and the amount of information that is available to us grows
exponentially every day," says Cheryle Custer, director of product marketing at
marketing intelligence firm Biz360. Press coverage influences consumer sentiment.
Applications from companies like Biz360 can search the Web for favorable and
unfavorable coverage of companies. According to David Myron these applications
can determine how a company and its competitors are being perceived and whether
that perception is positive, neutral, or negative. They can also determine where a
company's brand value stands and what it can do to enhance it.
Senior consultants are of the view that customer experience as a competitive

differentiator is a goal for many businesses, but many find it‟s easier said than done.
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As proof of this, more than two thirds of business leaders recently surveyed by
Forrester Research stated that their firms have set this as a goal, but more than half
lack a definitive strategy to do so. That‟s because when it comes to improving
customer service operations, many companies lack the right information. In their
attempts to determine the success and ultimate value of their contact centers,
companies have traditionally looked at customer service purely from a financial
vantage point.
6.4 Customer delight
According to Gross, Scott (2004), Rakesh Seth and Kirti (2005), customer delight is
surprising a customer by exceeding his or her expectations and thus creating a
positive emotional reaction. This emotional reaction leads to word of mouth.
Customer Delight directly affects sales and profitability of a company as it helps to
distinguish the company and its products and services from the competition. In the
past customer satisfaction has been seen as an important success indicator. Customer
satisfaction measures the extent to which the expectations of a customer are met i.e.
compared to expectations being exceeded. However, it has been discovered that mere
customer satisfaction does not create brand loyalty nor does it encourage positive
word of mouth.
It is also observed by Peters and Jan Carlzon in their study that customer delight can
be created by the product itself, by accompanied standard services and by interaction
with people at the front line. The interaction is the greatest source of opportunities to
create delight as it can be personalized and tailored to the specific needs and wishes of
the customer. During contacts with touch points in the company, more than just
customer service can be delivered. According to Hsieh, Tony (2010) and Michelli,
Joseph the person at the front line can surprise by showing a sincere personal interest
in the customer, offer small attentions that might please or find a solution specific to
particular needs. Those front line employees are able to develop a relationship
between the customer and the brand. Elements in creating motivated staff are:
recruiting the right people, motivating them continuously and leading them in a clear
way.
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Purpose of customer delight
There are three objectives when implementing Customer Delight.
According to Sewell, Carl, Brown, Paul B. (2002) first, make customers loyal. As
described by Sewell Amazon.com. (2002), that finding new customers costs 4 to 9
times more time and money than reselling to an existing client. It is thus
commercially intelligent to retain as many clients as possible.
A second objective is to have customers that are more profitable. Average delighted
customers spend more with less hassle. When all other elements are correct, clients
accord less importance to price as long as their perception of price remains
reasonable.
In his study Nielsen (2013), has observed that the last objective of Customer Delight is to
have clients talk positively about your product, brand or shop, the so-called Word of
Mouth. In a world of well informed customers, 92% of customers consider word of
mouth as the most reliable source of information. Delighted clients are a valuable
source of advertisement for your company.
According to Arundhati.r (2012), Customer delight is quite different from the

satisfaction. Customer satisfaction is only a stepping stone to customer delight. We
have to provide a service that exceeds the customer expectations, that surprises the
customer in a positive way. There are some methodologies to get the customer delight
in a better way. It's not that easy to delight a customer unless we deliver quality
services to them. Quality in the sense, we determine and adopt a set of standards or
measurements for our service. If we meet these standards, our customers should be
satisfied. However, meeting the "quality“ standards does not necessarily lead to
customer satisfaction even if we produce a "quality" product, or deliver a “quality
service”. It is completely based on the the customer's perception of the service that
will be measured against their expectations. We have to take actions that are
consistent with those expectations combine to produce a declaration of satisfaction.
Therefore it is essential to manage these aspects in a pro-active manner to excel at
Customer Satisfaction.
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Customer Satisfaction.
Diagram 15
Source: How to achieve customer delight in help desk support? (Arundhati July 15,
2012).
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CHAPTER VII
PATIENT SATISFACTION AND LOYALTY
According to the American Marketing Association (AMA), customer satisfaction is

the degree to which a customer‟s expectations are fulfilled or surpassed by a product.
Oliver (1980) argued that customer satisfaction implies a comprehensive mental state
derived from a combination of emotions caused by a customer‟s actual experience and
disconfirmation of expectation and emotions prior to the buying experience.
Numerous researches have been vigorously conducted on customer satisfaction and
developed the expectation-disconfirmation paradigm to explain the variables deciding
customer satisfaction. According to the paradigm, a disconfirmation between prior
expectation and product performance affects customer satisfaction or dissatisfaction
and customer satisfaction is determined based upon a customer‟s internal
determinants and perceived performance.
In recent studies, researchers have been placing a significant emphasis on value as an

important antecedent to the loyalty intention of a patient. Ostrom (1995) argued that a
better value in fact, increases the preference for re-utility and the value of care,
likewise affects the re-visit intention of consumers to hospitals. Woodside et al.
(1989) verified that the satisfaction level serves as a medium between medical
services quality and re-visit.
7.1 Patient Satisfaction

It is observed that usually patient satisfaction is routinely measured at the Hospitals
through patient feedback forms. The data for each Hospital is periodically analyzed to
compare its historic patient satisfaction trends as well as compare the patient
satisfaction levels against a benchmark across all Hospitals. In addition, each Hospital
usually maintains visitor books, which build up a database of customers that provides
for excellent data mining opportunities. These visitor books were used to record the
comments of top corporate executives and other well-known personalities visiting the
clinics.
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It is also noted that these comments are periodically shared across all the staff as a
source of encouragement and feedback. Customer‟s expectations are rationalized
based on the current healthcare standards in India. Given the superior quality
standards that Hospitals have set, feedback results have typically shown higher levels
of satisfaction as compared to the market. In order to ensure that there is no
compromise on service quality levels, Hospitals also conduct periodic service quality
audits with follow-up by the local teams to ensure that deficiencies on clinical and
non-clinical quality are removed. Repeat patient visits are a good indication of the
level of customer satisfaction. Benchmarking is used to analyse visits and repeat visits
during the year.
The healthcare industry in India is unorganized and there are no established standards
and practices. Establishing standards and ensuring that the Hospitals remain
committed to them, especially when competition gets away with lower standards, is a
challenge. There‟s also the challenge of ensuring the availability of affordable
healthcare while still ensuring profitability for the Hospital. Profitability can be
achieved only with higher emphasis on volumes and not necessarily through price
increases. Volume growth also needs to be balanced so that there is no over
dependence on any one revenue stream.
It is seen that a significant factor to ensure the success of a Hospital is that the profile
of the Hospital includes the Hospitals commitment to the success of the business.
Formal research conducted by a leading agency through in-depth interviews with a
number of Hospitals has confirmed this. On the other hand, Hospitals that have relied
excessively on the magic of the brand to carry the burden of success have typically
fallen short. However, prior knowledge of the industry is not necessarily an ingredient
for the success of the Hospital. Past performance records show that doctors who have
taken up small Hospitals are not necessarily more successful than non-doctors.
It is a fact that conventional advertising as a means of creating brand awareness plays

a limited role in the case of healthcare. Healthcare brands cannot be built through
aggressive mass media advertising or conventional promotional tools, normally
employed by FMCG or other service industries. Service quality and word of mouth
are the key drivers for growth in business. Hospitals which have focused on employee
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retention, service quality and community relationships have exhibited sustainable
success patterns.
Earlier studies have shown that Service quality, along with its two critical
determinants of customer and employee satisfaction are as important, or perhaps more
important, in the healthcare context than in other service contexts. With only one
service opportunity being available to the service provider, it is not possible to predict
a repeat visit of a patient in healthcare, unlike in other service environments, it is
critical that customer expectations are consistently exceeded.
It is also seen that to accelerate growth, Hospitals have invested in software that
allows features such as electronic medical records to be shared, with adequate security
measures, across the entire network. Also, a brand-building mass media campaign
using a broad spectrum of vehicles including print, TV, radio and outdoor media high
lighting the nature of services offered is being launched to boost awareness levels and
comprehension of the concept among the vast target audience. Hospitals have also
developed a few product variants, which provide for a limited range of ambulatory
procedures through an expanded model.
7.2 Improving Satisfaction

There is a need to generate change ideas and implement them. Given the staff interest
in the importance of the therapeutic relationship, one area of change is to focus on
providing a range of training activities over a period. The training should be focused
on improving the patient – provider relationship. The literature on training should
indicate that the training to be effective, it needs to be intensive and needs to involve a
combination of education, skill practice and case consultation.
Earlier studies indicate that major training activity involves an intensive training
program in cognitive behavioral therapy with a focus on the importance of the
collaborative relationship between the patient and the provider. Training can also be
provided in the Four Habits communication model which is a model of interpersonal
communication adapted by Kaiser Permanente, to enhance the interpersonal
communication between physicians and patients. This training model involves skill
practice through the use of actors as well as providing coaching experience whereby
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facilitators observed providers consulting with patients and then providing them with
feedback focused on ways to improve communication between patient and provider.
It is usually noticed that given the intensity of this training activity, it can be made
available to those providers who have low patient satisfaction scores. The other set of
change ideas to improve provider – patient relationship involves incorporating patient
satisfaction measurement into the ongoing management processes within the
department. One step could involve giving individual feedback to staff on their patient
satisfaction scores focusing specifically on a question that appeared to be most
relevant to patient – provider relationship i.e., how well doctors and staff understood
patient concerns. On a quarterly basis, they could receive emails summarizing their
performance over the quarter as well as providing feedback on how their performance
compares to that of their colleagues.
The other step involves identifying specific performance targets for the staff, which
could be reviewed on a regular basis with staff and incorporated into their annual
evaluation. Finally, for the health medical staff an incentive system could be
implemented through which providers receive a bonus for achieving a certain
performance level in the patient satisfaction survey questions.
Responsibility for Improving Patient Satisfaction.
Diagram 16
Source: Healthcare Intelligence Network, Patient Experience and Satisfaction Survey,

May (2011).
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The May 2011 Benchmarks in Patient Satisfaction e-survey by the Healthcare
Intelligence Network captured the details of how organizations are working to
improve patients satisfaction with their services.
There were 146 healthcare organizations which provided responses. The survey
indicated that quality of care is the most important aspect of the care delivery
experience and that communication between the provider and the patient is the one
area of the patient experience that needs the most improvement. According to
respondents, healthcare professionals principally responsible for improving the
patient's care experience are:
Other: 39 percent
Physician: 36 percent
Case manager: 19 percent
Nurse practitioner: 6 percent
7.3 The Effects of Patient-Centered Care on Satisfaction

According to Robinson et al. (2008), Wolf et al. (2008), Davis et al. (2005) the over
arching goal of the Patient centered care model is to provide care that is most
conducive to patients preferences, needs, and desires. The Patient centered care
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.
It can be stated that Patient centered care is, therefore intended to transform both the
underlying philosophy of patient care and the organization of work needed to shift
this philosophy. The focus on patient input and voice is one of the characteristics that
makes Patient centered care a unique workplace innovation and distinct from other
sets of practices. For transforming the relationship between the hospital and the
patient requires other important changes, such as the organization of work for direct
care frontline staff.
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According to Davis et al. (2005) and Corrigan et al. (2001), patient centered care is
founded on the notion that information should be shared between physicians and
patients and more importantly, that decision making is based on patient involvement
so that viable treatment or medication options take into account patient preferences
and perspectives. The Patient centric care model also entails a restructuring of
workplace practices in order to facilitate greater levels of interaction between front
line staff primarily nurses and nurse‟s aides and clinicians.
According to a survey done by, Wolf et al. (2008), Lemieux, Charles and McGuire
(2006), the primary mechanism used to deliver patient-centered care is the
organizations of work around inter disciplinary teams. Gittell et al. (2010) are of the
view that patient centric care emphasis on coordination across disciplines and
professions is in fact, similar in many ways to relational coordination practices that
have been linked to a variety of positive organizational outcomes.
It is the combination of staff coordination and patient engagement that is unique to

Patient centered care. Patient centered care also represents a distinct workplace
innovation separate from other traditional Human resource management areas.
Researchers have examined a number of different work arrangements in healthcare.
Patient centered care is designed to enhance employee teamwork, voice and
communication.
It is observed that, the patient-centered care model shares similar dimensions with the
high involvement work practices approach in manufacturing and other service sector
settings. Specifically, the focus on quality through specific “production” processes,
staff engagement, involvement, and coordination on productivity and performance
outcomes is similar to the innovations currently pervading healthcare. Patient
centered care entails the facilitation of input and participation from both frontline staff
and the patients for whom they care. The existing Patient centered care literature has
identified five dimensions of the delivery care model:
(1) Access to care

(2) Patient engagement in care or patient preferences
(3) Patient education or information systems
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(4) Coordination of care across hospital staff
(5) Patient emotional support
It is thus seen, that the combination of these Patient centered care dimensions is
intended to shift fundamental aspects of how healthcare organizations operate and
provide care for patients. As is evident, four of this Patient centered care dimensions
are intended to alter the traditional relationship between hospital patients and those
who provide them with care. For example, the focus on increased patient education is
designed to enhance the patients understanding of their conditions as well as the
advantages and disadvantages of different treatment options. One of the five Patient
centered care dimensions i.e. coordination of care, is specifically related to the
manner in which frontline staff are organized in order to deliver care. According to
Charmel and Frampton (2008) and Wolf et al. (2008) 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.
7.4 Patient Loyalty

In his findings Lee (2003) suggests that patient loyalty measure is basically the
surrogate of the customer satisfaction and service quality measures, as understanding
these processes is the first step in improving patient-provider relationship.
Alternatively, satisfaction is a measure of what people say and loyalty is a measure
what they actually do and as such there is always a strong reason associated with
loyalty and its good type of response, if patient is satisfied. According to Mac Starvic
(1994), patient loyalty is being studied in terms of attitudes, satisfaction, resistance to
changing providers, future intentions, consistent use of same providers, word of
mouth and actual behaviour and as such there is little consensus on the best means of
measuring patient loyalty. The patients in general develop loyalty towards providers
based upon the significant interpersonal experiences they have with the doctors and
nurses and about the operational quality of the hospital.
Therefore it it is seen that, while patients do form overall global impressions of their
experience, they also evaluate the quality of each of their interpersonal experiences
about the administrational operations of the hospitals. Thus, it is important to
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determine the most meaningful way of tracking patient perceptions over time, as well
as diagnosing where care delivery needs to be improved.
According to a survey done by Kotler, Bowen and Makens (2004), the fundamental
aim of today‟s total quality movements has become total customer satisfaction.
Consumer satisfaction is the core concept in service marketing literature. Most studies
on customer satisfaction are based on the confirmation and disconfirmation of
customer‟s expectations. Taylor and Cronin (1994) state that satisfaction is seen as a
function of confirmation or disconfirmation of expectation and is best conceptualized
as an attitude toward service performance. Satisfaction can be defined as an attitude,
like judgment following a purchase act or a series of consumer product interaction. In
a health care setting, the customer is a patient. Patient satisfaction is the dominating
area in health care research, management and marketing.
The findings by Singh (1990) suggest that it will be a wise move on the part of the
medical practitioner to analyze patient satisfaction as well as dissatisfaction in order
to maximize patient satisfaction. Patient‟s satisfaction and dissatisfaction may have an
impact on the financial performance of the healthcare provider. Success in retaining
or attracting patients may result from patient satisfaction with the medical care they
receive. A satisfied customer may or may not become a loyal customer. A loyal
customer is more important than a satisfied customer. 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 enhance the loyalty of
patients in the case of private hospitals.
It is observed that 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 under developed economies. The casual relationship between clinical
quality, patient satisfaction and behavioral intentions may be proved correct if related
to the clinical outcome, i.e. cure, which may be tangible, but it is difficult to
generalize the relationship between process quality, patient satisfaction and behavioral
intentions with heterogeneous socio demographic groups and cross-country hospital
settings, as the process quality outcome is more emotional. The patients and the
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family members do expect a cure as well as the care of a hospital setting. The service
encounter related process quality influences the future decision making.
7.5 Patient satisfaction and its dimensions

In their study Conway and Willcocks (1997) concluded that cure is a fundamental
health service expectation. Specifically, patient satisfaction is defined as an evaluation
of distinct healthcare dimensions. Turner and Pol (1995) too feel that patient
satisfaction may be considered as one of the desired outcomes of care and so patient
satisfaction information should be indispensable to quality assessments for designing
and managing healthcare. Patient satisfaction enhances hospital image, which in turn
translates into increased service use and market share. Satisfied customers are likely
to exhibit favourable behavioural intentions, which are beneficial to the healthcare
provider's long-term success. Customers tend to express intentions in positive ways
such as praising and preferring the company over others, increasing their purchase
volumes or paying a premium.
According to Tucker and Adams (2001) patient satisfaction is predicted by factors

relating to caring, empathy, reliability and responsiveness. Ware et al. (1978)
identified dimensions affecting patient evaluations, including physician conduct,
service availability, continuity, confidence, efficiency and outcomes. Other
dimensions have been introduced to capture patient‟s healthcare evaluations including
core services. Human involvement in the service situation with emotions approaching
love for the patient and positive patient outcomes such as pain relief, life saving and
dealing with anger or disappointment with life after medical interventions are also
included.
Woodside et al. (1989) identified other primary patient satisfaction determinants, i.e.
admissions, discharge, nursing care, food, housekeeping and technical services.
Patient‟s perceptions, notably about physician communication skills are also
significant satisfaction determinants. Two dimensions in Butler et al. (1996) study
explained 66 percent of the variance in patients service quality perceptions i.e. facility
quality and staff performance. Access refers to health service availability i.e. service
is available when it is required and is operationally defined as the number of patient-
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physician contacts, waiting times, convenience and availability associated with
healthcare experiences.
It is known that communication is the degree to which the patient is heard, kept
informed through understandable terms, afforded social interaction and time during
consultation and provided psychological and non-technical information. Outcomes are
defined as the change in physical health status directly attributable to the healthcare
experience and efforts.
It is thus observed that service quality, is the degree to which care was humane and
competent. If the service provider's competence is perceived high then levels of
satisfaction also increase. Competence strongly influences patient‟s service quality
assessments. Staff demeanour also has a significant impact on customer satisfaction.
The manner in which staff interacts with the patient and staff sensitivity to the
patient's personal experience seems to be important.
As per the survey done by Andaleeb (1988), studies show that if hospital costs are
perceived high then patient satisfaction is lower. If physical facilities, including
cleanliness, modern equipment, and the general feeling that the hospital is in a good
physical condition, are well perceived then patient satisfaction increases. In their
research Bitner and Hubbert (1994), Boshoff and Gray (2004) found that satisfaction
with specific service dimensions such as nursing staff, fees and meals were found to
exert positive influence on cumulative patient satisfaction. The strongest being
satisfaction with nursing staff. However, satisfaction with administration, reception
and television services were rejected as things that influence customer satisfaction.
Gilbert et al. (1992) compared patient expectations of three different health provider
options i.e. emergency rooms, private physicians and walk-in clinics. Expectation and
performance questions covered several attributes i.e. time spent with the physician,
the way diagnosis was done, treatment and care were explained, physician and staff
friendliness and amount of information provided. There are also two instrumental
attributes i.e. cost and physician competence. Expectations were not equal for all three
health service providers. For walk-in-clinic patrons, the most important influence on
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expectations is staff friendliness and cost. For private physician patients, they are
friendliness and time spent with the patient, treatment explanations and competence.
The most important influence is physician friendliness, competence, amount of time

spent with the customer and the amount of information provided. Both private
physician and emergency room patrons place walk-in rooms as the referent for their
expectations. Staff friendliness, cost and the amount of time the physician spent with
them are found to be the three most important considerations. With low expectations,
emergency rooms generate higher than expected satisfaction levels. In the case of
private physicians, the performance falls short of expectations, thus generating
dissatisfaction.
According to Pitta and Laric (2004), healthcare delivery value can be described using
elements that precede service delivery. Their study elaborates how links are created
from the simplest, direct physician - patient to more complex and elaborate networks,
which include other players such as employers, insurers, retailers, diagnosis systems
and alternate medical service providers. Healthcare value chains also carry a large
amount of patient information, which patients may feel a perceived risk in disclosing.
The study shows how each of these links and players create positive or negative
patient experiences. All value chain entities are important for service success and any
one can harm image.
In their paper Pitta and Laric (2004) felt that as in all services, the customer tends to
blame the contact organization when there is a problem i.e. the hospital. The hospital
managers can increase perceived value for the customer by handling the bulk of
behind-the-scenes detail, providing clear and appropriate patient information and
showing care and concern. In healthcare a common finding is that physical facilities
are a component of patient healthcare evaluations. Woodside et al. (1989) and Swan
et al. (2003) in a recent study showed that room appearance affects patient perceptions
and satisfaction. Their study compared patient‟s evaluations of rooms that ranged in
quality. Healthcare dimensions affected by room appearance are, physician skill and
expertise, physician and nurse courtesy i.e. answering questions, listening to concerns.
157
It is observed that on all these dimensions, patients staying in appealing rooms gave
more positive evaluations than those in typical rooms. However, regarding nurse
behaviour i.e. answering calls, explaining illness, treatment and home care, no
significant differences were found between room types. Screened patients ratings
were slightly lower than diagnosed patient‟s evaluations, which reflected the
diagnosed patients heightened sensitivity to service levels.
Tucker (2002) states that unclear, contradictory and inconclusive relationships exist
between, satisfaction and gender, race, marital status, and social class. Individual
factors positively associated with patient satisfaction are health status and education.
Younger, less educated, lower ranking, married, poorer health and high-service use
were associated with lower satisfaction. Another study found that the patient's health
quality assessment appeared to change with the introduction of patient's socio-
demographic characteristics.
Butler et al. (1996) found gender and age significantly predicted patients quality
perceptions, but on only one dimension i.e. facilities. Females valued this dimension
more than males. Perceived facility - related quality was found to be better for older
than younger respondents. Earlier studies showed satisfaction differences between
health service users and observers. However, Butler et al. (1996) found no significant
differences in health quality perceptions between users and observers i.e. friends and
families of patient. A significant difference, on the other hand was found on facility
quality dimension where users criticised the hospital's tangible characteristics more
than observers.
Earlier work done by Eiriz and Figueiredu (2005) also suggests that patient's
expectations and priorities vary among countries and are highly related to cultural
background and to the healthcare system. According to Mummalaneni and
Gopalakrishna (1995), Income was the only socio-demographic characteristic found
to have an influence on patient satisfaction. This study included socio-demographic
characteristics such as age, gender, occupation, employment status, education and
income. It revealed that only income influenced patient satisfaction i.e. upper income
customers appeared more concerned with personal health delivery such as answers
they receive to medical queries, waiting time for appointments and medical care.
158
Lower income consumers, on the other hand, were more concerned with costs and
overall physical facilities, indicating value orientation.
It is known that quality is positively correlated with satisfaction, however the

direction and strength of the predictive relationship between quality and satisfaction
remains unclear. Some authors believe that complex healthcare services and the
patient's lack of technical knowledge to assess them should incorporate broader
healthcare quality measures, including financial performance, logistics, professional
and technical competence. Quality is a judgmental concept and operational quality
definitions, as we have seen are based on values, perceptions and attitudes.
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CHAPTER VIII
MAJOR FINDINGS AND CONCLUSIONS PART- I
The findings of the survey conducted, in Private and Public Hospitals are as follows.
8.1 Demographic Factors
Type of Hospital: Information collected through questionnaire is about type of

hospital where medical services are provided. These medical service providers are
classified into two types. First is „Private hospital‟ and second is „Public hospital‟.
A Private hospital is one which is owned and governed by a person or many people
who are managing the whole finances on their own. Not just finances, even the whole
funds process, administration, staff and doctors is under the control of that private
body.
Public hospitals, on the other hand, are completely and entirely run on the
governments funding and money. Everything from the construction, the fees of the
doctors, the equipments, medicines, each and every single thing is being taken care of
by the local government body.
Type of Hospital Frequency Percent
Private hospital 284 81.1

Public hospital 66 18.9
Total 350 100.0
Table 3
As per the survey, the above table indicates that there were a total of 350 respondents,
of which 284 (81.1%) respondents availed medical services from private hospitals.
Remaining 66 (18.9%) respondents availed medical services from public hospitals.
160
This information is presented using pie-diagram as shown below.
Diagram of respondents according to type of hospital
19%
Private hospital
Public hospital
81%
Diagram 17
City of Respondent: Information is collected from Hospitals in various cities.

Respondents are classified into five cities. These cities are as follows: Mumbai, Navi
Mumbai, Pune, Surat and Thane.
City Frequency Percent
Mumbai 152 43.4

Navi Mumbai 50 14.3
Pune 54 15.4
Surat 56 16.0
Thane 38 10.9
Total 350 100.0
Table 4
Above table indicate that out of 350 respondents 152 (43.4%) are from Mumbai, 50
(14.3%) respondents are from Navi Mumbai, 54 (15.4%) are from Pune, 56 (16.0%)
are from Surat and remaining 38 (10.9%) are from Thane.
161
Diagram of respondents according to city
11%
Mumbai
16% 44% Navi Mumbai
Pune
Surat
15%
Thane
14%
Diagram 18
1. Age group: For the survey the patients were divided into three categories, age
wise. All respondents below 30 years were put in the young category, the
respondents between 30 to 45 years were put in the middle age category and all
the respondents above 45 years were put in the Elderly category.
Age group Frequency Percent
Young 127 36.3
Middle 109 31.1
Elderly 114 32.6
Total 350 100.0
Table 5
As per the survey, the above table indicates that out of 350 respondents 127 (36.3%)
were young, 109 (31.1%) were middle aged and 114 (32.6%) were elderly.
162
The information is presented using a pie- diagram as shown below.
Diagram of respondents according to age group
33%
36%
Elderly
Middle
Young
31%
Diagram 19
2. Gender: The survey was done of both male and female respondents.
Gender Frequency Percent
Female 142 40.6
Male 208 59.4

Total 350 100.0
Table 6
As per the survey the above table indicates that out of 350 respondents 142 (40.6%)
were female and 208 (59.4%) were male respondents.
163
The information is presented using a pie- diagram as shown below.
Diagram of respondents according to gender
41% Female
59% Male
Diagram 20
3. Frequency of visit to hospital: The frequency of the patients visiting the hospital
was divided into three categories. i.e. first time, two to four times and more than
four times.
Frequency of visit Frequency Percent
First time 132 37.7
Two to four times 128 36.6

More than four times 90 25.7
Total 350 100.0
Table 7
As per the survey the above table indicates that the number of respondents visiting a
Hospital for the first time is 132 (37.7%), the number of respondents visiting a
Hospital two to four times are 128 (36.6%) and the numbers of respondents visiting a
Hospital more than four times are 90 (25.7%).
164
The information is presented using a pie-diagram as shown below.
Diagram of respondents according to frequency of visit to

hospital
36% 38% First time

More than four times
Two to four times
26%
Diagram 21
5. Monthly Income: The respondents who participated in the survey, their monthly
income was divided into three categories. In the low category the monthly income is
below Rs 20,000, in the medium category the monthly income is between Rs 20,000
and Rs 50,000 and in the High category the monthly income is above Rs 50,000.
As per the table below 52 respondents i.e. (14.9%) fall in the low monthly income
category, 103 (29.4%) fall in the medium monthly income category and 195 (55.7%)
respondents fall in the High monthly income category.
Monthly Income Frequency Percent
LOW 52 14.9
MEDIUM 103 29.4
HIGH 195 55.7
Total 350 100.0
Table 8
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The information is presented using a pie-diagram shown below.
Diagram of respondents according to monthly income of

respondent
29%
HIGH
LOW
56%
MEDIUM
15%
Diagram 22
8.2 Variables of Study
The 5 Dimensions Defined
After extensive research, Zeithaml, Parasuraman and Berry found five dimensions
customers use when evaluating service quality. They named their survey instrument
SERVQUAL.
In other words, if providers get these dimensions right, customers will hand over the
keys to their loyalty, because they‟ll have received service excellence, according to
what‟s important to them.
The five SERVQUAL dimensions are:
TANGIBLES - Appearance of physical facilities, equipment, personnel, and

communication materials
RELIABILITY - Ability to perform the promised service dependably and
accurately
RESPONSIVENESS - Willingness to help customers and provide prompt
service
166
ASSURANCE - Knowledge and courtesy of employees and their ability to
convey trust and confidence
EMPATHY - Caring, individualized attention the firm provides its customers
Tangibles
Que Question Strongly Disagree Neither Agree Strongly

no Disagree agree nor Agree
Disagree
The hospital has all
9 6 7 17 187 133
latest equipments
Physical facilities are
10 4 7 13 190 136
visually appealing.
The location of
11 supplementary 8 13 27 178 124
services is convenient
Table 9
Response given to above mentioned questions asked in the survey is rated as follows.
Strongly disagree : 1
Disagree : 2
Neither agree nor Disagree : 3
Agree : 4
Strongly agree : 5
Using rating of these questions, score of satisfaction is calculated for each respondent
using formula given below.
Mean score of Commitment = Sum of scores of all four questions * 100

Maximum score of all questions
167
Descriptive Statistics
Tangible_score N Minimum Maximum Mean Std. Deviation
Tangible_score 350 26.67 100.00 84.34 13.89

Valid N (listwise) 350
Table 10
The above table indicates that mean score of „tangibles‟ is 84.34. Which is very high
and therefore it is an overall indication that most of the equipments are available at
the hospitals.
Respondents are classified in to three groups according to their score of „tangibles‟.

Respondents of score below 70.45 are classified as “low satisfaction‟, respondents of
score between 70.45 and 98.24 is classified as „medium satisfaction‟ and respondents
of score 98.24 and above is classified as „high satisfaction‟.
Classified information is presented in the following table.
Tangible level Frequency Percent
Low 35 10.0
Medium 220 62.9
High 95 27.1
Total 350 100.0
Table 11
Above table indicate that out of 350 respondents, 35 (10.0%) respondents are having
low satisfaction, 220 (62.9%) respondents are of medium satisfaction and 95 (27.1%)
respondents are highly satisfied for „tangibles‟.
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Diagram of respondents according to satisfaction for 'tangible'
27%
High
Low
Medium
63% 10%
Diagram 23
Reliability
Que Question Strongly Disagree Neither Agree Strongly

no Disagree agree nor Agree
Disagree
12 Doctors and medical 5 14 15 181 135
staff are intelligent.

staff spend enough
time with patients to
evaluate the disease.

staff take efforts to
maintain accurate
records.
15 Your expectations 1 15 13 224 97

are fully met with
regard to services.
Table 12
169
Disagree : 2
Agree : 4
Strongly agree : 5
by using the formula given below.

Reliability_score N Minimum Maximum Mean Std. Deviation
Reliability_score 350 20.00 100.00 82.6571 12.33822
Table 13
The above table indicates the mean score of Reliability as 82.6571, which is very high
and thus overall, indicates that the reliability is very high i.e. the ability to perform the
services is high.
The respondents are classified into three groups according to the score of “reliability”.
Respondents of score below 70.32 are classified as “low satisfaction”, Respondents of
score between 70.32 and 95.08 are classified as “medium satisfaction” and
respondents with score of 95.08 and above are classified as “high satisfaction”.
170
Classified information is presented in the following table.
Reliability level Frequency Percent
Low 39 11.1
Medium 263 75.1
High 48 13.7
Total 350 100.0
Table 14
The above table indicates that out of 350 respondents 39 (11.1%) of respondents are
of low satisfaction, 263 (75.1%) of respondents are of medium satisfaction and 48
(13.7%) of respondents are highly satisfied with the reliability of services.
This information is presented in a pie-diagram shown below.
Diagram of respondents according to satisfaction for 'reliable'
14%
11% High
Low
Medium
75%
Diagram 24
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Responsiveness
Neither Strongly
Que Strongly agree
Question Disagree Agree Agree
no Disagree nor
Disagree
Doctors and medical
16 staff respond to 5 15 16 240 74
patients quickly.
Doctors and medical
staff are approachable
17 to the patients 2 12 29 242 65
personal problems.
Front office staff is

cooperative and
18 5 13 25 231 76
helpful.
Table 15
Disagree : 2
Agree : 4
Strongly agree : 5
by using the formula given below.

172
Response_score N Minimum Maximum Mean Std. Deviation
Response_score 350 20.00 100.00 80.5524 11.36692
Table 16
The above table indicates the mean score of Responsiveness is 80.5524, which is very
high and that means the overall responsiveness is high i.e. the willingness to help
patients and promptness is very high.
The respondents are classified into three groups according to the score of
responsiveness. Respondents of score below 69.19 are classified as “ low
satisfaction”, respondents of score between 69.19 and 91.92 are classified as medium
satisfaction and respondents with score of 91.92 and above are classified as “high
satisfaction”. Classified information is presented in the table below.
The table below indicates that out of 350 respondents, 39 (11.1%) are having low
satisfaction, 275 (78.6%) are having medium satisfaction and 36 (10.3%) are highly
satisfied with the responsiveness factor.
Response level Frequency Percent
Low 39 11.1
Medium 275 78.6
High 36 10.3
Total 350 100.0
Table 17
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The information is provided in a pie- diagram given below.
Diagram of respondents according to satisfaction for 'response'
10%
11%
High
Low
Medium
79%
Diagram 25
Assurance
Neither Strongly
Que Strongly
Question Disagree agree nor Agree Agree
no Disagree
Disagree
Patients feel relaxed and
19 assured while services are 1 8 18 248 75
being provided.
Doctors and medical staff
sincerely reassure
20 4 8 18 255 65
patients.
Behaviour of Doctors and

medical staff instills
21 6 10 29 239 66
confidence in patients.
Table 18
Response given to above mentioned question is rated as follows.
Disagree : 2
174
Agree : 4
Strongly agree : 5

Assurance_score N Minimum Maximum Mean Std. Deviation
Assurance_score 350 20.00 100.00 81.0667 10.80663
Table 19
The above table indicates the mean score of Assurance as 81.0667, which is very high
and that means the overall assurance is high i.e. the ability to convey trust and
confidence is high. The respondents are classified into three groups according to the
score of assurance.
Respondents of score below 70.26 are classified as “low satisfaction”, respondents of

score between 70.26 and 91.87 are classified as medium satisfaction and respondents
with score of 91.87 and above are classified as “high satisfaction”.
175
Classified information is presented in the table below.
Assurance level Frequency Percent
Low 34 9.7
Medium 256 73.1
High 60 17.1
Total 350 100.0
Table 20
The above table indicates that out of 350 respondents 34 (9.7%) are having low
satisfaction, 256 (73.1%) are having medium satisfaction and 60 (17.1%) respondents
are highly satisfied with assurance level.
The information is provided in a pie-diagram below.
Diagram of respondents according to satisfaction for 'assurance'
17%
10% High
Low
Medium
73%
Diagram 26
176
Empathy
Neither Strongly
Que Strongly
Question Disagree agree nor Agree Agree
no Disagree
Disagree
Doctors and medical
staff have priority for
22 4 13 36 238 59
patient‟s problems.
Doctors and medical

staff treat patients with
23 7 14 37 230 62
love and affection.
Doctors and medical

staff show concern to
24 6 6 41 223 74
patient and his family.
Table 21
Disagree : 2
Agree : 4
Strongly agree : 5

177
Empathy_score N Minimum Maximum Mean Std. Deviation
Empathy_score 350 20.00 100.00 79.3143 12.70886
Table 22
The above table indicates the mean score of Empathy as 79.3143, which is high, i.e.
the overall empathy level is high, which means that the level of caring the Hospital
provides its patients is high.The respondents are classified into three groups according
to the score of empathy.
Respondents of score below 66.61 are classified as “low satisfaction”, respondents of

score between 66.61 and 92.02 are classified as medium satisfaction and respondents
with score of 92.02 and above are classified as “high satisfaction”.
Classified information is presented in the table below.
Empathy level Frequency Percent
Low 38 10.9
Medium 247 70.6
High 65 18.6
Total 350 100.0
Table 23
The above table indicates that out of 350 respondents 38 (10.9%) are having low
satisfaction, 247 (70.6%) are having medium satisfaction and 65 (18.6%) are highly
satisfied with empathy.
178
The information is provided in a pie-diagram below.
Diagram of respondents according to satisfaction for 'empathy'
19%
High
11% Low
Medium
70%
Diagram 27
179
CHAPTER IX
MAJOR FINDINGS AND CONCLUSIONS PART-II
The Hypothesis which were formulated in the study were tested and the respective
conclusions were obtained as follows.
9.1 Hypothesis Testing
Null hypothesis H01: There is no significant difference in all five parameters in

public and private hospitals.
Alternate hypothesis H11: There is significant difference in all five parameters in

public and private hospitals.
For testing of above null hypothesis first chi-square test is applied to study association
between type of hospital and each of five parameters.
1. Association between type of hospital and ‘tangibles’:
To test this association bivariate frequency table between type of hospital and
satisfaction level of tangibles is obtained and presented in the following table.
Crosstab
Count
Type_of_Hospital Tangible_level Total
Low Medium High
Private hospital 27 205 52 284
Public hospital 8 15 43 66
Total 35 220 95 350
Table 24
Out of 35 respondents of low satisfaction level for tangibles, 27 patients are of private
hospitals and remaining 8 patients are of public hospitals.
Out of 220 respondents of medium satisfaction level for tangibles, 205 patients are of
private hospitals and remaining 15 are patients are of public hospitals.
180
Out of 95 respondents of high satisfaction level for tangibles, 52 are patients of
private hospitals and remaining 43 patients are of public hospitals.
This information is presented using bar diagram as shown below.
Diagram of respondents according to type of hospital and level

of satisfaction of tangible Private hospital
250 Public hospital
205
Number of respondents
200
150
100
52 43
50 27
8 15
0
High Low Medium
Level of satisfaction
Diagram 28
To test above hypothesis Chi-square test is applied. Results of test are as follows.
Chi square calculated value = 64.496

Degrees of freedom = 2
Chi square tabulated value = 5.99
Result of test = Rejected
Above results indicate that calculated Chi-square value (64.496) is greater than table
chi-square value (5.99). Therefore test is rejected.
Conclusion there is association between type of hospital and ‘tangibles’.
181
2. Association between type of hospital and ‘reliability’:
Count
Type_of_Hosp Reliability level Total
Low Medium High
Total 39 263 48 350
Table 25
Out of 39 respondents of low satisfaction level for reliability, 34 patients belong to

private hospitals and remaining 5 patients are of public hospital.
Out of 263 respondents of medium satisfaction level for reliability, 242 patients
belongs to private hospitals and remaining 21 are patients of public hospital.
Out of 48 respondents of high satisfaction level for reliability, 8 are patients of private
Diagram of respondents according to type of hospital and level Private hospital

of satisfaction of reliability Public hospital
300
242
250
200
150
100
40 34
50 21
8 5
0
High Low Medium
Level of satisfaction
Diagram 29
182

Conclusion there is association between type of hospital and ‘reliability’.
3. Association between type of hospital and ‘response’:
Crosstab
Count
Response_level
Type_of_Hosp Total
Low Medium High
Total 39 275 36 350
Table 26
Out of 39 respondents of low satisfaction level for response, 34 patients belong to

Out of 275 respondents of medium satisfaction level for response, 234 patients belong
to private hospitals and remaining 41 are patients of public hospital.
Out of 36 respondents of high satisfaction level for response, 16 are patients of private
183
Diagram of respondents according to type of hospital and

250 level of satisfaction of response 234
Private hospital
200
Public hospital
150
100
34 41
50 20
16 5
0
High Low Medium
Diagram 30

Conclusion there is association between type of hospital and ‘response’.
4. Association between type of hospital and ‘assurance’:
Crosstab
Count
Assurance_level
Type_of_Hosp Total
Low Medium High
Total 34 256 60 350
Table 27
184
Out of 34 respondents of low satisfaction level for assurance, 27 patients belong to
Out of 256 respondents of medium satisfaction level for assurance, 221 patients
belong to private hospitals and remaining 35 patients are of public hospitals.
Out of 60 respondents of high satisfaction level for assurance, 36 are patients of


of satisfaction of assurance
250 221
Private hospital
Num,ber of resopondents
200 Public hospital
150
100
50 36 27 35
24
7
0
High Low Medium
Diagram 31

Conclusion there is association between type of hospital and ‘assurance’.
185
5. Association between type of hospital and ‘empathy’.
Crosstab
Count
Empathy_level Total
Type_of_Hosp
Low Medium High
Total 38 247 65 350
Table 28
Out of 38 respondents of low satisfaction level for empathy, 22 patients belong to

private hospitals and remaining16 patients are of public hospitals.
Out of 247 respondents of medium satisfaction level for empathy, 224 patients belong
to private hospitals and remaining 23 are patients of public hospitals.
Out of 65 respondents of high satisfaction level for empathy, 38 are patients of private

250
of satisfaction of empathy
224
Private
200 hospital
150
100
50 38
27 22 23
16
0
High Low Medium
Diagram 32
186

Conclusion there is association between type of hospital and ‘empathy’.
All above results indicate that there is association between type of hospital and each
of five parameters. To verify difference in mean scores of satisfaction for private and
public hospitals, ANOVA is obtained and F-test is applied.
ANOVA for Type of Hospital
Sum of Mean P
df F Result
Squares Square value
Between Groups 2988.192 1 2988.192 16.156 .000
Tangible
Within Groups 64366.221 348 184.960 Significant
score
Total 67354.413 349
Between Groups 6713.831 1 6713.831 50.337 .000
Reliability
score
Total 53128.857 349
Between Groups 2843.161 1 2843.161 23.418 .000
Response
score
Total 45093.206 349
Between Groups 1101.996 1 1101.996 9.671 .002
Assurance
score
Total 40757.333 349
Between Groups 64.100 1 64.100 .396 .529
Empathy Non
Within Groups 56304.662 348 161.795
score Significant
Total 56368.762 349
Table 29
187
Above table indicate results as given below:
1. For tangible, calculated p-value (0.000) is less than standard p-value (0.05).
Therefore difference is significant. Conclusion is there is significant difference
in mean satisfaction scores of tangibles for private and public hospitals.
2. For Reliability, calculated p-value (0.000) is less than standard p-value (0.05).
in mean satisfaction scores of reliability for private and public hospitals.
3. For Response, calculated p-value (0.000) is less than standard p-value (0.05).
in mean satisfaction scores of response for private and public hospitals.
4. For Assurance, calculated p-value (0.002) is less than standard p-value (0.05).
in mean satisfaction scores of assurance for private and public hospitals.
5. For Empathy, calculated p-value (0.529) is more than standard p-value (0.05).
Therefore difference is not significant. Conclusion is there is no significant
difference in mean satisfaction scores of empathy for private and public
hospitals.
Mean
Type of Tangible Reliability Response Assurance Empathy

Hospital score score score score score
Private
82.93 80.54 79.17 80.21 79.10
hospital
Public
90.40 91.74 86.46 84.74 80.20
hospital
Total 84.34 82.65 80.55 81.06 79.31
Table 30
188
Diagram of scores of satisfaction according to type of hospitals
94
91.74 Private
92 90.4
hospital
90
88
Score of satisfaction
86.46
86 84.74
84 82.93
82 80.54 80.21 80.2
80 79.17 79.1
78
76
74
72
Tangible score Reliability score Response score Assurance score Empathy score
Diagram 33
1. Out of five parameters for first four parameters (tangible, reliability,

response and assurance) null hypothesis is rejected. Alternate hypothesis is
accepted. For fifth parameter null hypothesis is accepted.
2. Patients of public hospitals are more satisfied as compare to private
hospitals for tangibles.
hospitals for reliability.
hospitals for assurance.
5. Patients of public hospitals are equally satisfied to private hospitals for
empathy.
189
different cities.

different cities.
between different cities and each of five parameters.
1. Association between different cities and ‘tangibles’:
To test this association bivariate frequency table between cities and satisfaction level
of tangibles is obtained and presented in the following table.
Crosstab
Count
Tangible_level
Cities Total
Low Medium High
Mumbai 18 105 29 152
Navi Mumbai 6 33 11 50
Pune 2 42 10 54
Surat 6 24 26 56
Thane 3 16 19 38
Total 35 220 95 350
Table 31
Out of 35 respondents of low satisfaction level for tangibles, 18 respondents are from
Mumbai, 6 from New Mumbai, 2 from Pune, 6 from Surat and 3 from Thane.
Out of 220 respondents of medium satisfaction level for tangibles, 105 respondents
are from Mumbai, 33 from Navi Mumbai, 42 from Pune, 24 from Surat and 16 from
Thane.
Above table indicate that out of 95 respondents of high satisfaction level for tangibles
29 respondents are from Mumbai, 11 from New Mumbai, 10 from Pune, 26 from
Surat and 19 from Thane.
190

120
105
Low
100
Medium
80 High
60
42
40 29 33
24 26
18 16 19
20 11 10
6 2 6 3
0
Mumbai Navi Mumbai Pune Surat Thane
Diagram 34

Conclusion there is association between different cities and ‘tangibles’.
2. Association between different cities and ‘reliability’
of reliability is obtained and presented in the following table.
191
Crosstab
Count
Reliability_level
Cities Total
Low Medium High
Mumbai 22 108 22 152
Navi
6 38 6 50
Mumbai
Pune 3 51 0 54
Surat 6 50 0 56
Thane 2 16 20 38
Total 39 263 48 350
Table 32
Out of 39 respondents of low satisfaction level for reliability, 22 respondents are from
Mumbai, 6 from Navi Mumbai, 3 from Pune, 6 from Surat and 2 from Thane.
Out of 263 respondents of medium satisfaction level for reliability, 108 respondents
Thane.
Out of 48 respondents of high level of satisfaction for reliability 22 respondents are

from Mumbai, 6 from Navi Mumbai, nill from Pune, nill from Surat and 20 from
Thane.

120 108 Low
100 Medium
High
Number of city
80
60 51 50
38
40
22 22
16 20
20 6 6 6
3 0 0 2
0
Diagram 35
192

Conclusion there is association between different cities and ‘reliability’.
3. Association between different cities and ‘response’
of response is obtained and presented in the following table.
Crosstab
Count
Response_level
Cities Total
Low Medium High
Mumbai 28 109 15 152
Pune 1 53 0 54
Surat 5 50 1 56
Thane 2 29 7 38
Total 39 275 36 350
Table 33
Out of 39 respondents of low satisfaction level for response, 28 respondents are from
193
Out of 275 respondents of medium satisfaction level for response, 109 respondents
Thane.
Out of 36 respondents of high level of satisfaction for response, 15 respondents are

from Mumbai, 13 from Navi Mumbai; nill from Pune, 1 from Surat and 7 from Thane.
120
109
Low
100 Medium
80 High
60 53 50
40 34 29
28
15 13
20 5 7
3 1 0 1 2
0
Diagram 36

Conclusion there is association between different cities and ‘response’.
194
4. Association between different cities and ‘Assurance’
of response is obtained and presented in the following table.
Crosstab
Count
Assurance level
Cities Total
Low Medium High
Mumbai 19 110 23 152
Pune 0 52 2 54
Surat 7 49 0 56
Thane 4 19 15 38
Total 34 256 60 350
Table 34
Out of 34 respondents of low satisfaction level for assurance, 19 respondents are from
Mumbai, 4 from Navi Mumbai; nill from Pune, 7 from Surat and 4 from Thane.
Out of 256 respondents of medium satisfaction level for Assurance, 110 respondents
Thane.
Out of 60 respondents of high level of satisfaction for Assurance, 23 respondents are

from Mumbai, 20 from Navi Mumbai, 2 from Pune, nill from Surat and 15 from
Thane.
195

Low
120
Medium
100 High
80
60
40
20
0
Diagram 37

Conclusion there is association between different cities and ‘assurance’.
5 Association between different cities and ‘empathy’
of empathy is obtained and presented in the following table.
196
Crosstab
Count
Empathy_level
Cities Total
Low Medium High
Mumbai 12 117 23 152
Pune 1 51 2 54
Surat 3 52 1 56
Thane 18 13 7 38
Total 38 247 65 350
Table 35
Out of 38 respondents of low satisfaction level for Empathy, 12 respondents are from
Out of 247 respondents of medium satisfaction level for Empathy, 117 respondents
Thane.
Out of 65 respondents of high level of satisfaction for Empathy, 23 respondents are

from Mumbai, 32 from Navi Mumbai, 2 from Pune, 1 from Surat and 7 from Thane.
140
Low
Number of respomdetns
120
Medium
100 High
80
60
40
20
0
Diagram 38
197
Conclusion there is association between different cities and ‘empathy’.

All above results indicate that there is association between the different cities and
each of five parameters. To verify difference in mean scores of satisfaction for
different cities, ANOVA is obtained and F-test is applied.
ANOVA
Sum of Squares df Mean Square F Sig. Result
Between
2530.482 4 632.620 3.367 .010 Significant
Tangible Groups
score Within Groups 64823.931 345 187.895
Total 67354.413 349
Between
4460.869 4 1115.217 7.906 .000 Significant
Reliability Groups
Total 53128.857 349
Between
4493.333 4 1123.333 9.546 .000 Significant
Response Groups
Total 45093.206 349
Between
3029.361 4 757.340 6.925 .000 Significant
Assurance Groups
Total 40757.333 349
Between
6811.215 4 1702.804 11.854 .000 Significant
Empathy Groups
Total 56368.762 349
Table 36
198
Therefore difference is significant. Conclusion is there is significant difference in
mean satisfaction scores of tangibles for different cities.
mean satisfaction scores of reliability for different cities.
mean satisfaction scores of response for different cities.
mean satisfaction scores of assurance for different cities.
5. For Empathy, calculated p-value (0.000) is less than standard p-value (0.05).
Therefore difference is not significant. Conclusion is there is significant difference
in mean satisfaction scores of empathy for different cities.
Mean
Region Tangible Reliability Response Assurance Empathy

score score score score score
Mumbai 82.0175 80.9868 78.3772 80.3070 78.9912
Navi
86.5333 85.7000 88.4000 86.0000 88.0000
Mumbai
Pune 83.0864 79.9074 79.8765 80.3704 79.6296
Surat 86.0714 81.0714 78.0952 76.6667 78.0952
Thane 90.0000 91.5789 83.5088 85.0877 70.5263
Total 84.3429 82.6571 80.5524 81.0667 79.3143
Table 37
199
199
For tangibles, highest satisfaction score is (90.00) for thane city and lowest (82.01) for
Mumbai.
For Reliability highest satisfaction score is for Thane (91.5789) and lowest for Pune
(79.9074).
For Response highest satisfaction score is (83.5088) for Thane city and lowest is
(78.0952) for Surat.
For Assurance highest satisfaction score is (86.00) for Navi Mumbai and lowest for
(76.6667) for Surat.
For Empathy highest satisfaction score is (88.00) for Navi Mumbai and lowest
(70.5263) for Thane.

Mean
91.58
90.00
100.00
86.07
85.09
83.51
83.09
82.02
81.07
80.99
80.37
80.31
79.91
79.88
79.63
78.99
86.53
78.38
78.10
78.10
76.67
90.00
70.53
80.00
70.00
Scores in per cent
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Tangible_score Reliability_score Response_score Assurance_score Empathy_score
Diagram 39
200
H03 There is no significant difference in satisfaction of male and female patients
for all five parameters.
H13: There is significant difference in satisfaction of male and female patients for
between male and female respondents and each of five parameters.
1. Association between male and female respondents and ‘tangibles’
To test this association bivariate frequency table between male and

female respondents and satisfaction level of tangibles is obtained and
presented in the following table.
Crosstab
Count
Gender Tangible_level Total
Low Medium High
Female 10 93 39 142
Male 25 127 56 208
Total 35 220 95 350
Table 38
Out of 35 respondents of low level of satisfaction for Tangibles, 10 respondents are

females and 25 respondents are male.
Out of 220 respondents of medium level of satisfaction for Tangibles, 93 respondents

are females and 127 respondents are male.
Out of 95 respondents of high level of satisfaction for Tangibles, 39 respondents are

201
Diagram of respondents according gender

Low Medium High
140 127
120
100 93
80
56
60
39
40 25
20 10
0
Female Male
Diagram 40

Result of test = Accepted
Above results indicate that calculated Chi-square value (2.364) is less than Chi-square
table value (5.99). Chi-square test is accepted.
Conclusion is that, there is no association between satisfaction level for tangibles

for male and female patients.
2. Association between male and female respondents and ‘Reliability’
To test this association bivariate frequency table between male and female
respondents and satisfaction level of reliability is obtained and presented in the
following table.
202
Crosstab
Count
Reliability_level
Gender Total
Low Medium High
Female 13 108 21 142
Male 26 155 27 208
Total 39 263 48 350
Table 39
Out of 39 respondents of low level of satisfaction for Reliability, 13 respondents are

Out of 263 respondents of medium level of satisfaction for Reliability,108

respondents are females and 155 respondents are male.
Out of 48 respondents of high level of satisfaction for Relibility, 21 respondents are


Low Medium High
180
155
160
140
120 108
100
80
60
40 21 26 27
20 13
0
Female Male
Diagram 41
203
Crosstab
Count
Assurance_level
Gender Total
Low Medium High
Female 13 99 30 142
Male 21 157 30 208
Total 34 256 60 350
Table 41
Out of 34 respondents of low level of satisfaction for Assurance, 13 respondents are

Out of 256 respondents of medium level of satisfaction for Assurance, 99 respondents



180 Low
157
160 Medium
140
High
120
99
100
80
60
40 30 30
21
20 13
0
Female Male
Diagram 43
206

Conclusion is that, there is no association between satisfaction level for reliability

3. Association between male and female respondents and ‘Response’
respondents and satisfaction level of response is obtained and presented in the
following table.
Crosstab
Count
Response_level
Gender Total
Low Medium High
Female 20 103 19 142
Male 19 172 17 208
Total 39 275 36 350
Table 40
Out of 39 respondents of low level of satisfaction for Response, 20 respondents are

Out of 275 respondents of medium level of satisfaction for Response, 103 respondents
Out of 36 respondents of high level of satisfaction for Response, 19 respondents are

204
Low
Medium
200
180 172 High
160
140
120 103
100
80
60
40 20 19 19 17
20
0
Female Male
Diagram 42

Conclusion is that, there is no association between satisfaction level for response

4. Association between male and female respondents and ‘Assurance’
respondents and satisfaction level of assurance is obtained and presented in the
following table.
205

Conclusion is that, there is no association between satisfaction level for assurance

5. Association between male and female respondents and ‘Empathy’
respondents and satisfaction level of empathy is obtained and presented in the
following table.
Crosstab
Count
Empathy_level
Gender Total
Low Medium High
Female 20 97 25 142
Male 18 150 40 208
Total 38 247 65 350
Table 42
Out of 38 respondents of low level of satisfaction for Empathy, 20 respondents are

Out of 247 respondents of medium level of satisfaction for Empathy, 97 respondents

207
Low
Diagram of respondents according to gender Medium
160 150
High
140
120
97
100
80
60
40
40 25
20 18
20
0
Female Male
Diagram 44

Conclusion is that, there is no association between satisfaction level for empathy

All above results indicate that there is no association between the male and female
groups and each of five parameters. To verify difference in mean scores of
satisfaction for male and females, ANOVA is obtained and F-test is applied.
208
ANOVA
Sum of df Mean F Sig. Result

Squares Square
Between Non
398.207 1 398.207 2.070 .151
Groups significant
Tangible
Within
score 66956.206 348 192.403
Groups
Total 67354.413 349
Between Non
193.197 1 193.197 1.270 .261
Groups significant
Reliability
Within
score 52935.660 348 152.114
Groups
Total 53128.857 349
Between Non
24.108 1 24.108 .186 .666
Groups significant
Response
Within
score 45069.098 348 129.509
Groups
Total 45093.206 349
Between Non
139.586 1 139.586 1.196 .275
Groups significant
Assurance
Within
score 40617.747 348 116.718
Groups
Total 40757.333 349
Between Non
80.905 1 80.905 .500 .480
Groups significant
Empathy
Within
score 56287.857 348 161.747
Groups
Total 56368.762 349
Table 43
1. For tangible, calculated p-value (0.151) is more than standard p-value (0.05).
difference in mean satisfaction scores of tangibles for male and female.
209
2. For Reliability, calculated p-value (0.261) is more than standard p-value
(0.05). Therefore difference is not significant. Conclusion is there is no
significant difference in mean satisfaction scores of reliability for male and
female.
3. For Response, calculated p-value (0.666) is more than standard p-value (0.05).
difference in mean satisfaction scores of response for male and female.
4. For Assurance, calculated p-value (0.275) is more than standard p-value

significant difference in mean satisfaction scores of assurance formale and
female.
difference in mean satisfaction scores of empathy formale and female.
Report
Mean
Gender Tangible Reliability Response Assurance Empathy

Female 85.6338 83.5563 80.2347 81.8310 78.7324

Male 83.4615 82.0433 80.7692 80.5449 79.7115
Total 84.3429 82.6571 80.5524 81.0667 79.3143
Table 44
For tangibles, the total score is (84.3429) out of which the female score is (85.6338)
and the male score is (83.4615).
210
For Reliability the total score is (82.6571) out of which the female score is (83.5563)
For Response the total score is (80.5524) out of which the female score is (80.2347)
For Assurance the total score is (81.0667) out of which the female score is (81.8310)
For Empathy the total score is (79.3143) out of which the female score is (78.7324)

Mean
Diagram of respondents of scores according to gender
88.00
85.63 Femal
86.00
e
84.00 83.46 83.56
Score in per cent
82.04 81.83
82.00
80.77 80.54
80.23
79.71
80.00
78.73
78.00
76.00
74.00
Diagram 45
and empathy) null hypothesis is accepted and the Alternate hypothesis is rejected.
211
H14: There is significant difference in satisfaction of patients of different age

between different age groups for all five parameters.
1. Association between different age groups and ‘tangibles’:
To test this association bivariate frequency table between different age groups and
Crosstab
Count
Tangible_level
Age Groups Total
Low Medium High
Elderly 5 73 36 114
Middle 5 61 43 109
Young 25 86 16 127
Total 35 220 95 350
Table 45

elderly, 5 respondents are middle age and 25 respondents are young.

are elderly, 61 respondents are middle age and 86 respondents are young.

Elderly, 43 respondents are middle age and 16 respondents are young.
212
Diagram of respondents according to age group Low

100 Medium
90 86
High
80 73
70
61
60
50 43
40 36
30 25
20 16
10 5 5
0
Elderly Middle Young
Diagram 46

Above results indicate that calculated Chi-square value (36.832) is more than Chi-
square table value (9.49). Chi-square test is rejected.
Conclusion is that there is association between satisfaction level for Tangibles for
elderly, middle age and young patients.
2. Association between different age groups and ‘Reliability’
satisfaction level of reliability is obtained and presented in the following table.
213
Crosstab
Count
Reliability_level
Age groups Total
Low Medium High
Elderly 8 88 18 114
Middle 6 87 16 109
Young 25 88 14 127
Total 39 263 48 350
Table 46
Out of 39 respondents of low level of satisfaction for Reliability, 8 respondents are

Out of 263 respondents of medium level of satisfaction for Reliability, 88 respondents

Out of 48 respondents of high level of satisfaction for Reliability, 18 respondents are

Low
Medium
100
88 87 88 High
90
80
70
60
50
40
30 25
18 16
20 14
8 6
10
0
Diagram 47
214

Conclusion is that, there is association between satisfaction level for Reliability

for elderly, middle age and young patients.
3. Association between different age groups and ‘Response’
satisfaction level of response is obtained and presented in the following table.
Crosstab
Count
Response_level
Age Groups Total
Low Medium High
Elderly 8 94 12 114
Middle 6 91 12 109
Young 25 90 12 127
Total 39 275 36 350
Table 47


215
Low
Diagram of respondents according to age group Medium
100 94 91 High
90
90
80
70
60
50
40
30 25
20 12 12 12
8 6
10
0
Diagram 48

Conclusion is that there is association between satisfaction level for Response for
4. Association between different age groups and ‘Assurance’
satisfaction level of Assurance is obtained and presented in the following table.
216
Crosstab
Count
Assurance_level
Age Groups Total
Low Medium High
Elderly 6 88 20 114
Middle 6 84 19 109
Young 22 84 21 127
Total 34 256 60 350
Table 48



Diagram of respondents according to age group Low

100 Medium
88
84 84
High
80
60
40
20 19 22 21
20
6 6
0
Diagram 49
217

Conclusion is that there is association between satisfaction level for Assurance

for elderly, middle age and young patients.
5. Association between different age groups and ‘Empathy’
satisfaction level of Empathy is obtained and presented in the following table.
Crosstab
Count
Empathy_level
Age Groups Total
Low Medium High
Elderly 12 78 24 114
Middle 4 90 15 109
Young 22 79 26 127
Total 38 247 65 350
Table 49


218
Low
Medium
100 90 High
90
78 79
80
70
60
50
40
30 24 26
22
20 12 15
10 4
0
Diagram 50

Conclusion is that there is association between satisfaction level for Empathy for
All above results indicate that there is association between the elderly, middle aged
and young groups and each of five parameters. To verify difference in mean scores of
satisfaction for elderly, middle aged and young, ANOVA is obtained and F-test is
applied.
219
ANOVA
Sum of Mean
df F Sig. Result
Squares Square
Between
3584.949 2 1792.474 9.754 .000 Significant
Groups
Tangible
Within
score 63769.464 347 183.774
Groups
Total 67354.413 349
Between
1714.597 2 857.299 5.786 .003 Significant
Groups
Reliability
Within
score 51414.260 347 148.168
Groups
Total 53128.857 349
Between
658.120 2 329.060 2.570 .078 Significant
Groups
Response
Within
score 44435.087 347 128.055
Groups
Total 45093.206 349
Between
298.720 2 149.360 1.281 .279 Significant
Groups
Assurance
Within
score 40458.613 347 116.595
Groups
Total 40757.333 349
Between
744.583 2 372.291 2.322 .100 Significant
Groups
Empathy
Within
score 55624.179 347 160.300
Groups
Total 56368.762 349
Table 50
in mean satisfaction scores of tangibles for elderly, middle age and young.
220
in mean satisfaction scores of reliability for elderly, middle aged and young.
in mean satisfaction scores of response for elderly, middle age and young.
in mean satisfaction scores of assurance for elderly, middle age and young.
in mean satisfaction scores of empathy for elderly, middle age and young.
Mean
Age_of_ Tangible Reliability Response Assurance Empathy

respondent score score score score score
Elderly 86.6082 84.2982 81.4620 81.7544 80.0000
Middle 86.9113 84.3578 81.7125 81.7737 80.7951
Young 80.1050 79.7244 78.7402 79.8425 77.4278
Total 84.3429 82.6571 80.5524 81.0667 79.3143
Table 51
For tangibles, highest satisfaction score is (86.9113) for middle aged and lowest score
is (80.1050) for young age.
For Reliability highest satisfaction score is (84.3578)for middle age and lowest score
is (79.7244) for young.
221
For Response highest satisfaction score is (81.7125) for middle age and lowest is
(78.7402) for young.
For Assurance highest satisfaction score is (81.7737) for middle age and the lowest
score is (79.8425) for young group.
For Empathy highest satisfaction score is (80.7951) for middle age and lowest score is
(77.4278) for young age.

Mean
Diagram of scores of respondents according to age Elderly
group
86.91
Middle
86.61
88.00
Young
84.36
84.30
86.00
81.77
81.75
81.71
81.46
84.00
80.80
Score in per cent
80.11
80.00
79.84
79.72
82.00
78.74
77.43
80.00
78.00
76.00
74.00
72.00
Diagram 51
222
H05: There is no significant difference in satisfaction of patients of different
income groups for all five parameters.

For testing of above null hypothesis first chi-square test is applied to study
association between different income groups for all five parameters.
1. Association between different income groups and ‘tangibles’:
To test this association bivariate frequency table between different income groups
And satisfaction level of tangibles is obtained and presented in the following table.
Crosstab
Count
Tangible_level
Monthly income group Total
Low Medium High
LOW 7 27 18 52
MEDIUM 12 61 30 103
HIGH 16 132 47 195
Total
35 220 95 350
Table 52

from low income group and 12 respondents are from medium income group,16
respondents are from high income group.

are low income group and 61 respondents are from medium income group,132
223
from low income group and 30 respondents are from medium income group, 47
Diagram of respondents according to income group
140 132
Low
120
Medium
100
High
80
61
60 47
40 27 30
18 16
20 12
7
0
Low Income Medium Income High Income
Diagram 52

Conclusion is that there is no association between satisfaction level for Tangibles

for high, low and medium level of monthly income group.
224
2. Association between different income groups and ‘Reliability’
and satisfaction level of reliability is obtained and presented in the following table.
Crosstab
Count
Reliability_level
Low Medium High
LOW 8 26 18 52
MEDIUM 15 65 23 103
HIGH 16 172 7 195
Total 39 263 48 350
Table 53
Out of 39 respondents of low level of satisfaction for Relibility, 8 respondents are

from low income group, 15 respondents are from medium income group and 16
Out of 263 respondents of medium level of satisfaction for Relibility, 26 respondents

are low income group, 65 respondents are from medium income group and 172
Out of 48 respondents of high level of satisfaction for Reliability, 18 respondents are

225

200
180 172
Low
160
140 Medium
120 High
100
80 65
60
40 26 23
18 15 16
20 8 7
0
Diagram 53

Conclusion is that there is association between satisfaction level for Reliability

3. Association between different income groups and ‘Response’
and satisfaction level of response is obtained and presented in the following table.
226
Crosstab
Count
Response_level
Low Medium High
LOW 10 36 6 52
MEDIUM 12 69 22 103
HIGH 17 170 8 195
Total 39 275 36 350
Table 54

Out of 275 respondents of medium level of satisfaction for Reponse, 36 respondents


from low income group, 22 respondents are from medium income group and8

200 Low 170
Medium
150
High
100
69
50 36
22 17
10 6 12 8
0
Diagram 54
227

high, low and medium level of monthly income group.
4 . Association between different income groups and ‘Assurance’
Crosstab
Count
Assurance_level
Low Medium High
LOW 7 31 14 52
MEDIUM 14 58 31 103
HIGH 13 167 15 195
Total 34 256 60 350
Table 55

228


200
167
Low
150 Medium
High
100
58
50 31 31
7 14 14 13 15
0
Diagram 55


229
4. Association between different income groups and ‘Empathy’
Crosstab
Count
Empathy_level
Monthly income Total
Low Medium High
LOW 13 26 13 52
MEDIUM 9 56 38 103
HIGH 16 165 14 195
Total 38 247 65 350
Table 56



230

180 165
160 Low
140 Medium
120
High
100
80
56
60
38
40 26
13 13 16 14
20 9
0
Diagram 56

Conclusion is that there is association between satisfaction level for Empathy for
high, low and medium level of monthly income group.
All above results indicate that there is no association between the high, low and
medium income groups and Tangibles, but there is association between the high,
medium and low income groups and Reliability, Response, Assurance and Empathy.
To verify difference in mean scores of satisfaction for elderly, middle aged and
young, ANOVA is obtained and F-test is applied.
231
ANOVA

Squares Square
Between Non
267.690 2 133.845 .692 .501
Groups significant
Tangible
Within
score 67086.723 347 193.333
Groups
Total 67354.413 349
Between Significant
1218.998 2 609.499 4.074 .018
Groups
Reliability
Within
score 51909.859 347 149.596
Groups
Total 53128.857 349
Between Significant
1060.600 2 530.300 4.179 .016
Groups
Response
Within
score 44032.606 347 126.895
Groups
Total 45093.206 349
Between Non
674.798 2 337.399 2.921 .055
Groups Significant
Assurance
Within
score 40082.535 347 115.512
Groups
Total 40757.333 349
Between Significant
1531.507 2 765.754 4.846 .008
Groups
Empathy
Within
score 54837.254 347 158.032
Groups
Total 56368.762 349
Table 57
1. For tangible, calculated p-value (0.501) is more than standard p-value (0.05).
Therefore difference is not significant. Conclusion is there is not significant
difference in mean satisfaction scores of tangibles for high, middle and low
income groups.
232
in mean satisfaction scores of reliability for high, medium and low income
groups.
in mean satisfaction scores of response for high, medium and low income
groups.
4. For Assurance, calculated p-value (0.279) is more than standard p-value

significant difference in mean satisfaction scores of assurance for high,
medium and low income groups.
in mean satisfaction scores of empathy for high, medium and low income
groups.
Report
Mean
Monthly Tangible Reliability Response Assurance Empathy
Income score score score score score
HIGH 83.5897 81.0000 79.1453 79.8291 78.4274
LOW 85.7692 85.0962 80.7692 82.6923 76.5385
MEDIUM 85.0485 84.5631 83.1068 82.5890 82.3948
Total 84.3429 82.6571 80.5524 81.0667 79.3143
Table 58
For tangibles, highest satisfaction score is (85.0485) for medium income level and
lowest score is (83.5897) for high income group.
For Reliability highest satisfaction score is (85.0962)for low income group and lowest
score is (81.0000) for high income group.
For Response highest satisfaction score is (83.1068) for medium income group and
lowest is (79.1453) for high income group.
233
For Assurance highest satisfaction score is (82.6923) for low income group and the
lowest score is (79.8291) for high income group.
For Empathy highest satisfaction score is (82.3948) for medium income group and
lowest score is (76.5385) for low income group.
Mean
Diagram of scores of respondents according LOW
85.77
88.00 income group

85.10
85.05
84.56
MEDIU
83.59
86.00
83.11
M
82.69
82.59
82.39
84.00
81.00
80.77
79.83
Scores in per cent
82.00
79.15
78.43
80.00
76.54
78.00
76.00
74.00
72.00
70.00
Diagram 57
Out of five parameters tangible and assurance null hypothesis is accepted. And
alternative hypothesis is rejected. Reliability, Response and empathy null hypothesis
is rejected and Alternate hypothesis is accepted.
234
H06: There is no significant difference in satisfaction of patient’s frequency of
visit for all five parameters
H16: There is significant difference in satisfaction of patient’s frequency of visit

For testing of above null hypothesis first chi-square test is applied to study
association between patients frequency of visit for all five parameters.
1. Association between patients frequency of visits and ‘tangibles’:
To test this association bivariate frequency table between patients frequency of visits
Crosstab
Count
Tangible_level
Frequency of hospital visits Total
Low Medium High
First time 15 101 16 132
Two to four times

13 73 42 128
More than four

7 46 37 90
times
Total 35 220 95 350
Table 59
Out of 35 respondents of low level of satisfaction for Tangibles, 15 respondents have

visited for the first time,13 respondents have visited two to four times and 7
respondents have visited for more than four times.
Out of 220 respondents of medium level of satisfaction for Tangibles, 101

respondents have visited the hospital for the first time, 73 respondents have visited
two to four times and 46 respondents have visited the hospital for more than four
times.
235
Out of 95 respondents of high level of satisfaction for Tangibles, 16 respondents have
visited for the first time, 42 respondents have visited the hospital two to four times
and 37 respondents have visited for more than four times.
Diagram of respondents according to frequency of visit
120 Low
101
Medium
100
73 High
80
60
42 46
37
40
15 16 13
20 7
0
First time Two to four times More than four times
Diagram 58

Conclusion is that there is association between satisfaction level for Tangibles for
frequency of visits of patients.
236
2. Association between patients frequency of visits and ‘Reliability’:
and satisfaction level of Reliability is obtained and presented in the following table.
Crosstab
Count
Reliability_level
Frequency_of_Hospital Visits Total
Low Medium High
First time 17 110 5 132
Two to four
times 17 101 10 128
More than four 5 52 33 90

times
Total 39 263 48 350
Table 60
Out of 39 respondents of low level of satisfaction for Reliability, 17 respondents

have visited for the first time, 17 respondents have visited two to four times and 5
Out of 263 respondents of medium level of satisfaction for Reliability, 110

times.
Out of 48 respondents of high level of satisfaction for Reliability, 5 respondents have

237

Low
120 110
101 Medium
100
High
80
60 52
40 33
17 17
20 10
5 5
0
Diagram 59

Conclusion is that there is association between satisfaction level for Reliability

for frequency of visits of patients.
3 . Association between patients frequency of visits and ‘Response’
and satisfaction level of Response is obtained and presented in the following table.
238
Crosstab
Count
Response level
Low Medium High
First time 15 112 5 132
Two to four
times 17 97 14 128

times
Total 39 275 36 350
Table 61
Outof 39 respondents of low level of satisfaction for Response, 15 respondents have

have visited the hospital for the first time, 97 respondents have visited two to four
times and 66 respondents have visited the hospital for more than four times.
Out of 36 respondents of high level of satisfaction for Response, 5 respondents have

and17 respondents have visited for more than four times.

120 112
97 Low
100 Medium
80 High
66
60
40
15 17 14 17
20 5 7
0
Diagram 60
239

4 .Association between patients frequency of visits and ‘Assurance’
and satisfaction level of Assurance is obtained and presented in the following table.
Crosstab
Count
Assurance_level
Low Medium High
First time 16 104 12 132
Two to four
times 10 87 31 128

times
Total 34 256 60 350
Table 62
Out of 34 respondents of low level of satisfaction for Assurance, 16 respondents

have visited for the first time, 10 respondents have visited two to four times and 8
240
Out of 256 respondents of medium level of satisfaction for Assurance, 104
times.
Out of 60 respondents of high level of satisfaction for Assurance, 12 respondents have


120 112
Low
97
100 Medium
80 High
66
60
40
15 17 14 17
20 7
5
0
Diagram 61


and frequency of visits of patients.
241
6. Association between patients frequency of visits and ‘Empathy’
and satisfaction level of Empathy is obtained and presented in the following table.
Crosstab
Count
Empathy_level
Low Medium High
First time 12 103 17 132
Two to four
times 9 91 28 128

times
Total 38 247 65 350
Table 63
Out of 38 respondents of low level of satisfaction for Empathy, 12 respondents have

have visited the hospital for the first time, 91 respondents have visited two to four
times and53 respondents have visited the hospital for more than four times.
Out of 65 respondents of high level of satisfaction for Empathy, 17 respondents have

242
Diagram of respondents according to frequency of

visit
120
103 Low
100 91
Medium
80 High
60 53
40 28
17 17 20
20 12 9
0
Diagram 62

Conclusion is that there is association between satisfaction level for Empathy and
All above results indicate that there is association between the frequency of hospital
visits and all the parameters To verify difference in mean scores of satisfaction for the
frequency of visits, ANOVA is obtained and F-test is applied.
243
ANOVA

ANOVA
Squares Square
Between Significant
2828.307 2 1414.154 7.605 .001
Groups
Tangible
Within
score 64526.105 347 185.954
Groups
Total 67354.413 349
Between 10.97 Significant
3159.393 2 1579.697 .000
Groups 0
Reliability
Within
score 49969.464 347 144.004
Groups
Total 53128.857 349
Between Non
501.186 2 250.593 1.950 .144
Groups Significant
Response
Within
score 44592.020 347 128.507
Groups
Total 45093.206 349
Between Significant
766.660 2 383.330 3.326 .037
Groups
Assurance
Within
score 39990.673 347 115.247
Groups
Total 40757.333 349
Between Non
366.402 2 183.201 1.135 .323
Groups Significant
Empathy
Within
score 56002.360 347 161.390
Groups
Total 56368.762 349
Table 64
1. For tangible, calculated p-value (0.001) is less more than standard p-value
(0.05). Therefore difference is significant. Conclusion is there is significant
difference in mean satisfaction scores of tangibles for frequency of visits to the
hospital.
244
Therefore difference is significant. Conclusion is there is significant
difference in mean satisfaction scores of reliability for frequency of visits to
the hospital.
3. For Response, calculated p-value (0.144) is more than standard p-value (0.05).
Therefore difference is not significant. Conclusion is there is not significant
difference in mean satisfaction scores of response for frequency of visits to the
hospital.
Therefore difference is significant. Conclusion is there is significant
difference in mean satisfaction scores of assurance for the frequency of visits
to the hospital.
difference in mean satisfaction scores of empathy for frequency of visits to
hospital.
Report
Mean
Frequency of Tangible Reliability Response Assurance Empathy
Hosp score score score score score
First time 80.7071 79.6591 79.0909 79.2929 79.0909
Two to four 86.2500 82.4609 81.0417 82.7083 80.5208

times
More than four 86.9630 87.3333 82.0000 81.3333 77.9259

times
Total 84.3429 82.6571 80.5524 81.0667 79.3143
Table 65
245
For tangibles, highest satisfaction score is (86.9630) for more than four visits and
lowest score is (80.7071) for first time visit.
For Reliability highest satisfaction score is (87.333) for more than four times visits
and the lowest score is (79.6591) for first time visits.
For Response the highest satisfaction score is (82.000) for more than four times visits
and (79.0909) is the lowest score for first time visits.
For Assurance the highest satisfaction score is (82.7083) for two to four times visits
and the lowest score is (79.2929) for first time visits.
For Empathy the highest satisfaction score is (80.5208) for two to four times visits
and the lowest score is (77.9259) for more than four times visit.

Mean
First time
Diagram of scores of respondents
according to frequency of visit Two to four times
87.33
90.00
86.96
86.25
88.00
86.00
82.71
82.46
82.00
Scores in per cent
81.33
84.00
81.04
80.71
80.52
79.66
79.29
82.00
79.09
79.09
77.93
80.00
78.00
76.00
74.00
72.00
Diagram 63
Finding of Hypothesis:Out of five parameters response and empathy null hypothesis

is accepted. And alternative hypothesis is rejected. For Tangibles, Reliability, and
assurance null hypothesis is rejected and Alternate hypothesis is accepted.
246
H07: There is no association between type of hospital and monthly income of
patients.
H17: There is association between type of hospital and monthly income of

patients.
between type of hospital and monthly income of patients
1. Association between type of hospitals and the monthly income of patients.
To test this association bivariate frequency table between type of hospitals and the
monthly income of patients is obtained and presented in the following table.
Type_of_Hosp * Monthly_Income Crosstabulation
Count
Monthly_Income
Type of hospitals Total
LOW MEDIUM HIGH
Private
27 73 184 284
hospital
Public
25 30 11 66
hospital
Total 52 103 195 350
Table 66
Out of 52 respondents of low monthly income, 27 go to Private hospitals and 25 go to

Public hospitals.
Out of 103 respondents of medium monthly income 73 go to Private hospitals and 30

go to Public hospitals.
Above table indicate that out of 195 respondents of high monthly income, 184 go to
Private Hospitals and 11 go to Public hospitals.
247

and type of hospital
200 184
180
160 Low
140 Medium
120
High
100
80 73
60
40 27 25 30
20 11
0
Private hospital Public hospital
Diagram 64

From this hypothesis conclusion is, that there is association between type of hospital
and monthly income of patients. This indicates that patients of high income prefer
private hospital for medical treatment. Patients of low income prefer public hospitals.
248
H08: There is no correlation between the five parameters of study.
H18: There is correlation between the five parameters of study.
Correlations
Tangible Reliability Response Assuranc Empathy
score score score escore score
Pearson Correlation 1 .737 ** .576 ** .615 ** .400 **
Tangible
Sig. (2-tailed) .000 .000 .000 .000
score
N 350 350 350 350 350
Pearson Correlation 1 .718** .774** .557**
Reliability
Sig. (2-tailed) .000 .000 .000
score
N 350 350 350
Pearson Correlation 1 .713** .675**
Response
Sig. (2-tailed) .000 .000
score
N 350 350
Pearson Correlation 1 .624**
Assurance
Sig. (2-tailed) .000
score
N 350
Pearson Correlation 1
Empathy_
Sig. (2-tailed)
score
N 350
Table 67
** Correlation is significant at the 0.01 level (2-tailed).
The above table shows that there is significant correlation between the five parameters
of study.
249
CHAPTER X
SCOPE FOR IMPROVEMENT AND RECOMMENDATIONS
The hardworking competitive scenario and mushrooming growth of service

organizations has invigorated the need to look beyond customer satisfaction i.e.
towards customer retention and loyalty. Thus, it is important to determine the exact
way of tracking patient perception over a period of time, as well as diagnosing where
healthcare services need to be improved. 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
more efforts in patient relationship management is still to be taken. 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.
Hospital. Various studies of outpatient services have highlighted problematic areas
like delay in getting appointments, delay in consultations, attitude of staff and doctors.
Hence it can be concluded that OPD services are extremely important in a Hospital
and immediate remedial measures must be taken on patient feedbacks. Good Hospital
facilities and reliable services have a positive effect on patient satisfaction.Satisfied
patients revisit the Hospital for same and different treatments. The satisfied patients
also refer the Hospital to other patients.
Today, our planet is taken by storm of globalization and technology and to sustain in
this type of scenario, quality of interpersonal experiences with hospital staff, are to be
understood in depth in both public as well as private organizations. The concept of
service quality has led to growing research on various concepts such as total quality
management, customer loyalty and relationship management.The outcomes of service
quality i.e. customer relationship management and loyalty, are most significant
250
performance measurement tools in the present competitive market. The study was an
effort in this regard, i.e. to identify the factors in sustaining customer longevity after
analyzing both private and public hospitals.
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 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
gaining an understanding of user‟s needs and their perception of the service received.
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.

hospital. More than a decade ago, two landmark reports: 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.
251
It is clearly evident form our findings that almost most of the hospitals should bring in
changes to improve the out patient services. Throughout this study we have analyzed
service quality over the five services parameters of SERVAQUAL and have noticed a
gap between expected and perceived services.
Recommendations and scope for Improvement
It is felt that the following points will help private and public hospitals to minimize its
service gap.
Hospital staff at all interaction point should provide efficient and prompt
service. Hospitals must improve guidance of patients and facilitate easy
understanding of Hospital procedures.
Hospital staff should always be ready to help patients.There should be proper
signage system, name boards, direction signs of various service areas.
Efficient reception services and proper procedural instructions should be
printed and kept at help desks.
Reduce overcrowding and minimize patient waiting time. Hospital staff
should always find time to respond to patients requests. Hospitals should have
special clinics at different timings, e.g. in the afternoon well baby clinics and
diabetes clinics.
Hospitals should synchronize functioning of ancillary facilities with OPD
workload. Departments like Pharmacy, radiology and laboratory should be
adequately staffed even at peak times, so that patients are serviced efficiently
when they arrive from OPD for their respective tests.
The behavior of staff should instill confidence among the patients and their
relatives.
Full attention should be given to the patient‟s health and it should be
monitored regularly. Patients should feel that they are the most important and
their health and well being is the top most priority of the Hospital.
Doctors should improve their soft skills and be friendly with their patients. A
patient is always expecting his Doctor to be understanding and friendly.
Hospitals should look into all the amenities. The internal and external
environment should be clean (toilet, cabin, and wards). There should be
proper seating accommodation, good transport facilities and effective security
systems.
There should be an ongoing process of interacting and meeting visiting
Doctors to get their views on how to improve the Hospital services.
252
Hospital authorities should resolve internal Human resource problems eg
union disputes etc, so that they do not affect the day to day functioning of the
Hospital.
Salary should be according to the job and position and there should be
fairness and equality. Besides it should be determined after considering the
living cost and purchasing power of money.
Participative management among the staff from various departments should
be encouraged, for high morale and job satisfaction.
Since the doctors perceive lack of promotional opportunities as one of the
most important cause of their job dissatisfaction, so it is strongly
recommended that there must be a sound and fair promotional policy, which
would be acceptable to all concerned.
Policy regarding the promotion must be on the basis of merit, seniority,
sincerity and performance.
Reducing job stress of doctors through better shifting system. Moreover
sufficient doctors and staff should be ensured.
Senior doctors should be regular in their office and co-operative with the
junior colleagues.
If all these recommendations are followed properly, it is expected that the job
satisfaction of the doctors as well as their services to the patients will be increased
significantly.
The hospital facility amongst the medical services qualities is an expected factor in
Public and Private Hospitals and thus dissatisfying this requirement of patients will
lead to patient dissatisfaction, but achieving this requirement will lead to limited
patient satisfaction. Hospitals must design registration procedures and examination
processes as patient-oriented. Specifically, patients visiting a particular hospital for
the first time easily waste time and commit mistakes due to insufficient information
on the formalities connected with the visit or admission to the hospital. Thus,
hospitals must establish schemes to simplify appointment, payment, and examination
processes.
Further, an expansion of manpower at information desks and the operation of a

complete charge helper system may be considered in preparation for an aging society.
Secondly, patients generally consider large-sized hospitals more reliable than smaller-
sized hospitals and thus relevant schemes must be established. In particular, large-
253
sized hospitals support the organic cooperation of medical services provided by
specialised medical doctors and the hospitals must amplify a concrete and organic
mutual-assistance system of care rather than a simple transfer of care permedical
specialisation. Thirdly, after care and follow-up services for patients must be
enhanced. Most of the outpatients in a large-sized hospital are long-term outpatients,
and they are likely to forget or neglect specific appointments, usage of internal
remedies or health regulations when the hospital visits are at intervals of more than
six months. In such cases, information calls through specialised medical services call
centres or mobile message dispatch systems may be actively utilised in order to
prevent the neglect and promote the reliability of the hospital. Finally, comforting and
professionally stable medical services personnel, who are easily reachable by patients,
must be promoted.
Limitations of the study
This study does not suggest the attributes of a research hospital, such as regional
background, patient attributes, and medical services attributes per hospital and thus
additional researches are necessary in the future. Secondly, this study is a cross-study
aimed at a specific sample in a short period and thus changes in the importance of
medical services may occur in the future. Thus, continuous research in developing
services of a hospital may be necessary for further improvement in our Public and
Private Hospitals.
254
ANNEXURE I
BIBLIOGRAPHY
1. Abelson, R. (2010). Bills Stalled, Hospitals Fear Rising Unpaid Care.

Retrieved February 9, 2010,
2. Adamy, J. (2010). Health Insurers Plan Hikes. Retrieved September 7,

2010, from Flier, J. (2009). Health 'Reform' Gets a Failing Grade.
Retrieved November 17, 2010, from
www.wsj.com/…/SB1000142405274870443
3. AIHW (2005). Australian hospital statistics 2003-2004. Canberra:

Australian Institute of Health and Welfare.
4. Aiken, Linda H., Sean P. Clarke, and Douglas M. Sloane. 2002(a).

“Hospital Staffing, Organization, and Quality of Care: Cross-National
Findings.” International Journal for Quality in Health Care, Vol. 14, No.
1, pp. 5–14.
5. Alrubaiee, L., and Alnazer, N. (2010). Investigate the Impact of

Relationship Marketing Orientation on Customer Loyalty: The Customer's
Perspective. International Journal of Marketing Studies, Vol. 2, No. 1;
(May), 155-174.
6. Andaleeb, S.S. (1998), “Determinants of customer satisfaction with

hospitals: a managerial model”, International Journal of Health Care
Quality Assurance, Vol. 11 No. 6, pp. 181-7.
7. Andaleeb, S.S., Siddiqui, N. and Khandakar, S. (2007), “Patient

satisfaction with health services in Bangladesh”, Health Policy and
Planning, Vol. 22 No. 4, pp. 263-73.
255
8. Anderson, R.T., Camacho, F.T. and Balkrishnan, R. (2007), “Willing to
wait? The influence of patient wait time on satisfaction with primary care”,
BMC Health Services Research, Vol. 7 No. 31.
9. Arasli, H., Mehtap-Smadi, S., and Katircioglu, S.T. (2005). Customer

service quality in the GreekCypriot banking industry. Managing Service
Quality, Vol. 15 No. 1, pp. 41-56.
10. Ariffin, A. A. M. and Aziz, N. A. (2008), „Determining the Service

Quality Dimensions and Zone of Tolerance for Hospital Services in
Malaysia‟, The Business Review, Cambridge, Vol. 10, No. 2, pp. 164–169.
11. Armistead, C & S. Machin (1997). Implications of business process

management foroperations management. International Journal of
Operations & Production Management, 17(9), 886–898.
12. Arundhati.r July 15, 2012 How to achieve customer delight in help desk
support
13. Ash, Michael, and Jean A. Seago. 2004. “The Effect of Registered Nurses‟
Unions on Heart Attack Mortality.” Industrial and Labor Relations
Review, Vol. 57, No. 3, pp. 422–42.
14. Avis, M., Bond, M. and Arthur, A. (1997), “Questioning patient

satisfaction: an empirical investigation in two outpatient clinics”, Social
Science & Medicine, Vol. 44 No. 1, pp. 85-92.
15. Babakus, E., & Mangold, W.G. (1992). Adapting the SERVQUAL scale to
hospital services: An empirical investigation. Health Services Research,
26(6), 767–78
16. Babakus, E., &Boller, G. W. ( 1992). An empirical assessment of the

SERVQUAL scale. J. Bus. Res. 24 , 253 - 268 .
17. Badri, M., Attia, S., and Ustadi, A. (2008). Testing the not so obvious
models in healthcare quality. International Journal for Quality in
Healthcare, Vol. 21 No. 2, pp. 159-74.
256
18. Badri, M., Attia, S., and Ustadi, A. (2009). Healthcare quality and
moderators of patient satisfaction: testing for causality. International
Journal of Health Care Quality Assurance, Vol. 22 No. 4, pp. 382-410.
19. Baker, W.E. and Sinkula, J.M. (1999), "The synergistic effect of market
orientation and learning orientation on organizational performance",
Journal of the Academy of Marketing Science, Vol. 27, pp. 411-27.
20. Baron, R. M., and D. A. Kenny. 1986. „The Moderator-Mediator Variable

Distinction in Social Psychological Research: Conceptual, Strategic, and
Statistical Considerations.‟ Journal of Personality and Social Psychology
51 (1): 1173–1182.
21. Baron-Epel, O., Dushenat, M. and Friedman, N. (2001), “Evaluation of

the consumer model: relationship between patients‟ expectations,
perceptions and satisfaction with care”, International Journal for Quality in
Health Care, Vol. 13 No. 4, pp. 317-23.
22. Basak, S.C. (2005), “Changes in India‟s patent regime and access to
medicine”, available
23. Batra, R., & Ahtola, O.T. (1991). Measuring the hedonic and utilitarian
sources of consumer attitudes. Educational Psychologist, 28(2), 117–148.
24. Batt, R. (2000). Strategic segmentation in front line services: Matching

customers, employees and human resource systems. International journal
of Human Resource Management, 11(3), 540-561,.
25. Batt, Rosemary. 1999. “Work Organization, Technology, and Performance

in Customer Service and Sales.” Industrial and Labor Relations Review,
Vol. 52, No. 4, pp. 539–64.
26. Behara, R. S., Fisher, W. W. and Lemmink, J. G. A. M. (2002),

„Modelling and evaluating service # 2012 The Braybrooke Press Ltd.
Journal of General Management Vol. 37 No. 2 Winter 2011/12.
257
27. Belkin, N.J. (1978). Information concepts for information science. Journal
of 34, 55–85.
28. Bennett S, Dakpallah G, Garner P et al. 1994. Carrot and stick: state
mechanisms to influence private provider behaviour. HealthPolicy and
Planning 9: 1–13.
29. Bennett S, McPake B, Mills A (eds). 1997. Private health provider in

developing countries: serving the public interest? London: Zed Books.
30. Beresford, P., & Branfield, F. (2006). Developing inclusive partnerships:

User-defined outcomes, networking and knowledge: A case study. Health
and Social Care in the Community, 14(5), 436–444.
31. Bergeson, Steven C., and John D. Dean. 2006. “A Systems Approach to
Patient-Centered Care.” The Journal of the American Medical Association,
Vol. 296, No. 23, pp. 2848–51.
32. Bhandari, L., & Dutta, S. (2009). Health infrastructure in rural India,
accessed on January 11, 2009 through http:// www.iitk.
ac.in/3inetwork/html/reports/IIR2007/ll Health.pdf,
33. Boaden, R., Marchington, M.P., Hyde, P., Harris, C, Sparrow, P., Pass, S.,
Carroll, M., & Cortvriend, P. (2008). The process of engagement and
alignment: Improving health through human resource management.
London: Chartered Institute of Personnel and Development..
34. Bonshoff C. and Gray B., The relationships between service quality,
customer satisfaction and buying intentions in the private hospital
industry'. South African Busi. Manager, 35 (4) (2004)
35. Bopp, K.D. (1990). How patients evaluate the quality of ambulatory
medical encounters: A marketing perspective. Journal of Health Care
Marketing, 10(1), 6–16.
258
36. Borrill, Carol, Michael West, David Shapiro, and Anne Rees. 2000. “Team
Working and Effectiveness in Health Care.” British Journal of Health
Care Management, Vol. 6, No. 8, pp. 364–71.
37. Boshoff, C., and B. Gray. 2004. „The Relationship between Service
Quality, Customer Satisfaction and Buying Intentions in the Private
Hospital Industry.‟ South Africa Journal of Business Management 35 (4):
27–37.
38. Bowers, M.R., Swan, J.E., and Koehler, W.F. (1994). What attributes
determine quality and satisfaction with healthcare delivery? Health Care
Management Review, Vol. 19 No. 4, pp. 49-55.
39. Brady, M. K., and J. J. Cronin Jr. 2001. „Some New Thoughts on
Conceptualizing Perceived Service Quality: A Hierarchical Approach.‟
Journal of Marketing 65 (3): 34–49.
40. Brito, E. P. Z., Aguilar, R. L. B. and Brito, L A. L. (2007), „Customer

choice of a car maintenance service provider: A model to identify the
service attributes that determine choice‟, International Journal of
Operations & Production Management, Vol. 27, No. 5, pp. 464–481.
41. Brook, R.H., & Williams, K.N. (1975). Quality of health care for the
disadvantaged. Journal of Community Health, 1(2), 32–156.
42. Brown, S.W. and Swartz, T.W (1989), "A gap analysis of professional
service quality", Journal of Marketing, Vol. 53 No. 4, pp. 92-8. Calnan, M.
(1988), "Towards a conceptual framework of lay evaluation of health
care", Social Science and Medicine, Vol. 27 No. 9, pp. 927-33.
43. Brown, T.J., Churchill, G.A. Jr., and Peter, J.P. (1993). Improving the
measurement of service quality. Journal of Retailing, Vol. 69 No. 1, pp.
127-39.
44. Buckland, M.K. (1991). Information as thing. Journal of the American

Society for Information Science and Technology, 42, 351–360.
259
45. Butler, D., Oswald, S. and Turner, D. (1996), "The effects of
demographics on determinants of perceived health care service quality",
Journal of Management in Medicine, Vol. 10 No. 5, pp. 8-20.
46. Buttle, F. (1996), "SERVQUAL: review, critique and research agenda",

European Journal of Marketing, Vol. 30 No. 1, pp. 8-32.
47. Buzzell, R. and Gale, B. (1987) The PIMS Principles, New York, The Free
Press.
48. Caemmerer, B. and Wilson, A. (2009), „Customer feedback mechanisms

and organizational learning in service operations‟, International Journal of
Operations & Production Management, Vol. 30, No. 3, pp. 288–311.
49. Camacho, F., Anderson, R., Safrit, A., Jones, A.S. and Hoffmann, P.
(2006), “The relationship between patients‟ perceived waiting time and
office-based practice satisfaction”, North Carolina Medical Journal, Vol.
67 No. 6, pp. 409-13.
50. Campbell, S.M., Roland, M.O. and Buetow, S.A. (2000), “Defining quality
of care”, Social Science & Medicine, Vol. 51 No. 11, pp. 1611-25.
51. Carman, J.M. (1990). Consumer perceptions of service quality: an

assessment of the SERVQUAL dimensions. Journal of Retailing, Vol. 66,
Spring, pp. 33-55.
52. Carrillat F. A., F. Jaramillo, and J. P. Mulki. 2009. „Examining the Impact
of Service Quality: A Meta-Analysis of Empirical Evidence.‟ Journal of
Marketing Theory and Practice 17 (2): 95–110.
53. Caruana, A. (2002). Service loyalty - the effects of service quality and the
mediating role of customer satisfaction. European Journal of Marketing,
Vol. 36 Nos 7/8, pp. 811-27.
54. Cervantes K, Salgado R, Choi M, Kalter H. Rapid assessment of Referral

Care Systems: A guide for Program Managers 2003. Available from:
http://www.jsi.com/Managed/Docs/Publications. [Last accessed on 2003].
260
55. Charmel, Patrick A., and Susan B. Frampton. 2008. “Building the Business
Case for Patient-Centered Care.” Healthcare Financial Management, Vol.
62, No. 3, pp. 80–85.
56. Chaudhury, N; Hammer, J; Knemer, M; Muralidharan, K and Rogers, F H

(2006). “Missing in Action: Teacher and Health Worker Absence in
Developing Countries,” Journal of Economic Perspectives, 20(1), 91-
116
57. Chen and Ravallion (2011); Prahalad and Hammond (2012); Prahalad and
Hart (2012); Hammond et.al (2007); London (2008). Bottom of Pyramid.
58. Chengbo Wang, Tong Yang, Zhaofang Mao, Lixin Zhang, John Vaughan
and John Mercer Lam, S. S. K. (1997), „SERVQUAL: A tool for
measuring patients‟ opinion of hospital service quality in Hong Kong‟,
Total Quality Management, Vol. 8, No. 4, pp. 145–152.
59. Cho, W.H., Lee, H., Kim, C., Lee, S. and Choi, K.S. (2004), “The impact
of visit frequency on the relationship between service quality and
outpatient satisfaction: a South Korean study”, Health Services Research,
Vol. 39 No. 1, pp. 13-33.
60. Choi, K., Cho, W., Lee, S., Lee, H., and Kim, C. (2004). The relationship
among quality, value, satisfaction and behavioral intention in health care
provider choice: a South Korean study. Journal of Business Research, Vol.
57, pp. 913-21.
61. Choi, K.S. (1999). Structural modelling of quality, satisfaction, value and
purchase intention in health care service. Seoul: Yonsei University.
62. Chow, G. C. 1960. „Tests of Equality between Sets of Coefficients in Two

Linear Regressions.‟ Econometrica 28 (1): 591–605.
63. Clark, Paul F., Darlene A. Clark, David V. Day, and Dennis G. Shea.
2001. “Healthcare Reform and the Workplace Experience of Nurses:
Implications for Patient Care and Union Organizing.” Industrial and Labor
Relations Review, Vol. 55, No. 1, pp. 133–48
261
64. CNN Money/Fortune Konrad W. Employers make a push for „medical
tourism‟May 15, 2007.
65. Cohen, G., Forbes, J. and Garraway, M. (1996), “Can different patient
satisfaction survey methods yield consistent results? Comparison of three
surveys”, British Medical Journal, Vol. 313 No. 7061, pp. 841-4.
66. Conway, T. and Willcocks, S. (1997), "The role of expectations in the

perceptions of health care quality: developing a conceptual model",
International Journal of Health Care Quality Assurance, Vol. 10 No. 3, pp.
131
67. Corrigan, Janet. M., Molla S. Donaldson, Linda T. Kohn, Shari K.

Maguire, and Kelly C. Pike. 2001. Crossing the Quality Chasm: A New
Health System for the 21st Century. Institute of Medicine Report on
Medical Errors. Washington, DC: National Academy Press.
68. Cronin, J. J. Jr and Taylor, S. A. (1992), „Measuring service quality: a re-

examination and extension‟, Journal of Marketing, Vol. 56, No. 3, pp. 55–
68.
69. Cronin, J. J., Jr., M. K. Brady, G. Tomas, and M. Hult. 2000. „Assessing
the Effects of Quality, Value and Customer Satisfaction on Consumer
Behavioral Intentions in Service Environments.‟ Journal of Retailing 76
(2): 193–218.
70. Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, &Thomas H.

(2002). The measurement of satisfaction with healthcare: implications for
practice from a systematic review of the literature. Health Technol Assess,
6:1-244.
71. Daily Express Beat waiting lists with overseas op. (UK) July 3, 2005.
72. Dallas Morning Breen K. Patients heading abroad for hope. May 29, 2007.
73. Davenport, T.H. (1993). Process Innovation. Reengineering Work through

Information Technology. Boston: Harvard Business School Press.
262
Davenport, T.H. (1998). Putting the enterprise into the enterprise system.
Harvard Business Review, July-August, 121–131
74. Davenport, T.H. (1998). Putting the enterprise into the enterprise system.
Harvard Business Review, July-August, 121–131
75. Davis, Karen, Stephen C. Schoenbaum, and Anne M. Audet. 2005. “A

2020 Vision of Patient-Centered Primary Care.” Journal of General
Internal Medicine, Vol. 20, No. 10, pp. 953–57.
76. Davis-Sramek, B, Droge, C., & Mentzer, J. T., &. Myers, M. B. (2009).
Creating commitment and loyalty behavior among retailers: what are the
roles of service quality and satisfaction? J. of the Acad. Mark. Sci. 37:440-
454.
77. De Brentani, U., & Ragot, E. (1996). Developing new business-to-business

professional services: What factors impact performance? Industrial
Marketing Management, 25(6), 517–530.
78. Dean, A.M. (1999). The applicability of SERVQUAL in different health

care environments. Health Marketing Quarterly, Vol. 16 No. 3, pp. 1-15.
79. Department of Chemicals and Petrochemicals (2008), “Pharmaceuticals”,

available at: http:// chemicals.nic.in/pharma1.htm (accessed 16 September
2010).
80. Department of Industrial Policy and Promotion (DIPP), Union Budget

2012-13, RNCOS Reports, Media Reports, Press Information Bureau
(PIB)
81. Derbaix, C., & Vanhamme, J. (2003). Inducing word-of-mouth by eliciting

surprise – A pilot investigation. Journal of Economic Psychology, 24, 99–
116.
82. Dervin, B. (1990). Communication: Society‟s glue, for better, for worse.
Finnish Communication Conference, Tampere, Finland, University of
Tampere.
263
83. Devlin, S.J. and Dong, H.K. (1994), "Service quality from customer's
perspective", Marketing Research, Vol. 30 March 2014 Page 81 of 119
ProQuest 6 No. 1, pp. 5-13.
84. Dickson, P.R. (1996), "The static and dynamic mechanics of competition:
a comment on Hunt and Morgan's comparative advantage theory", Journal
of Marketing, Vol. 60, pp. 102-6.
85. Donabedian, A. (1985), “Twenty years of research on the quality of

medical care: 1964-1984”, Evaluation & the Health Professions, Vol. 8
No. 3, pp. 243-65.
86. Donabedian, A. (1988), “Monitoring: the eyes and ears of health care”,
Health Programme, Vol. 69 No. 9, pp. 38-43.
87. Donabedian, A. (1988). The quality of care: how can it be assessed?.

Journal of the American Medical Association, Vol. 260, pp. 1743-8.
88. Donabedian, A. (1989), “Institutional and professional responsibilities in

quality assurance”, Quality Assurance in Health Care, Vol. 1 No. 1, pp. 3-
11.
89. Dr Akash S Rajpal, Head, Consultancy Services, HOSMAC India Pvt Ltd,
90. Dr Prathap Reddy, Apollo Hospitals, (Human Resources ), Future Trends

in Healthcare Industry in India.
91. Dr. R Gopal‟s lecture notes on strategic management in Healthcare

Enviornment, (2012).The Key Stake holders of any Health and Hospital
set up.
92. Drain, M. (2001). Quality improvement in primary care and the

importance of patient perceptions. Journal of Ambulatory Care
Management, Vol. 14 No. 2, pp. 30-46.
93. Duncan, A.K., & Breslin, M.A. (2009). Innovating health care delivery:
The design of health service. Journal of Business Strategy, 30(2/3), 13–20.
264
94. Eiriz, V. and Figueiredo, J.A. (2005), "Quality evaluation in health care
services based customer- provider relationships", International Journal of
95. Ekrem, C., & Fazil, K. (2007). Customer perceived value: The
development of a multiple item scale in hospitals. Business Publications.
Malvern, PA.
96. Emanuel, EJ. and Dubler, N.N. (1995), "Preserving the physician-patient
relationship in the era of managed care", Journal of American Medical
Association, Vol. 273 No. 4, pp. 323-9.
97. Entwistle, V., and Quick, O. (2006). Trust in the context of patient safety
problems. Journal of Health Organization and Management, Vol. 20 No. 5,
pp. 397-416.
98. Epstein, Ronald M., Peter Franks, Kevin Fiscella, Cleveland G. Shields,
Sean C. Meldrum, Richard L. Kravitz, and Paul R. Duberstein.
99. Evans, R.G. (1984). Strained mercy: The economics of Canadian health
care. Toronto, Canada: Butterworths.
100. Evason, E. and Whittington, D. (1997), „Patients‟ perceptions of quality in

a Northern Ireland hospital trust: a focus group study‟, International
Journal of Health Care Quality Assurance, Vol. 10, No. 1, pp. 7–19.
101. File, K. M. Judd, B. B. and Prince, R. A. (1992) „Interactive Marketing:

The Influence of Participation Positive Word-of-Mouth and Referrals‟,
The Journal of Service Marketing,6: 4, 5-14.
102. Fisk, T.A., Brown, C.J., Cannizzaro, K., & Naftal, B. (1990). Creating
patient satisfaction and loyalty.Journal of Health Care Marketing, 10(2),
5–15.
103. Fitzpatrick, R. (1991). Surveys of patient satisfaction: important

considerations. British Medicine Journal, Vol. 302, p. 887.
265
104. Flach, Stephen D., Kimberly D. McCoy, Thomas E. Vaughn, Marcia M.
Ward, Bonnie J. Boots Miller, and Bradley N. Doebbeling. 2004. “Does
Patient-Centered Care Improve Provision of Preventive Services?” Journal
of General Internal Medicine, Vol. 19, No. 10, pp. 1019–26.
105. Fletcher, R.H., O'Malley, M., Earp, J.A., Littleton, T.A., Fletcher, S.W.,
Greganti, M.A., Davison, R.A. and Taylor, J. (1983), "Patients' priorities
for medical care", Medical Care, Vol. 21 No. 2, pp. 234-42.
106. Ford Motor Company (1990) Memorandum to Dealers, October 3.
107. Fred David R., Strategic Management, Concept & Cases, 10* Edition,
Prentice Hall of India Pvt. Ltd., New Delhi (2006)
108. Freidson, E. (1984). The changing nature of professional control. Annual

Review of Sociology, 10, 1-20.
109. Fuentes, C. M. (1999), „Measuring hospital service quality: a

methodological study‟, Managing Service Quality, Vol. 9, No. 4, pp. 230–
239.
110. Furrer, O., Liu, B.S.C., and Sudharshan, D. (2000). The relationships
between culture and service quality perceptions. Journal of Service
Research, Vol. 2 No. 4, pp. 355-71.
111. Gabott, M., and Hogg, G. (1994). Uninformed choice. Journal of Health
Care Marketing, Vol. 14 No. 3, pp. 28-34.
112. Garner C. Alan, "Offshoring in the Service Sector: Economic Impact and
Policy Issues", Economic Review, Federal Reserve Bank of Kansas City,
89 (3), 5-3 7 (2004)
113. Garner P, Thaver I. 1993. Urban slums and primary health care: the private
doctor‟s role. British Medical Journal 306: 667–8.
114. Germano, C. (1992) The Bottom Line of Quality, Memphis, TN, Federal
Express Corporation.
266
115. Gilbert, F.W., Lumpkin, J.R. and Dant, R.P. (1992), "Adaptation and
customer expectations of health care options", Journal of Health Care
Management, Vol. 12 No. 3, pp. 46-55.
116. Gilmore Audrey, Service Marketing and Management, Rresponse Books,

New Delhi (2006)
117. Gittell, Jody H. 2002. “Coordination Mechanisms in Care Provider

Groups: Relational Coordination as a Mediator and Input Uncertainty as a
Moderator of Performance Effects.” Management Science, Vol. 48, No.
11, pp. 1408–26.
118. Global Healthcare Providers: Market line (2013). Global Healthcare

Providers sector category segmentation: % share, by value, Global
Healthcare providers sector geography segmentation: % share, by value,
2013.
119. Goldhill, D. (2009). How American Health Care Killed My Father.

Retrieved January 20, 2010, from
www.theatlantic.com/doc/print…/health-care
120. Goldstein, S. M. and Naor, M. (2005), „Linking publicness to operations

management practices: a study of quality management practices in
hospitals‟, Journal of Operations Management, Vol. 23, pp. 209–228.
121. Goltieb, J.B., Grewal, D. and Brown, S.W. (1994), "Consumer satisfaction
and perceived quality: complementary or divergent constructs?", Journal
of Applied Psychology, Vol. 79 No. 6, pp. 875-85.
122. Gombeski, W.R., Jr., Carroll, P.A., & Lester, J.A. (1990). Minicase:
Influencing decision-making of referring physicians. Journal of Health
Care Marketing, 10(4), 56–60.
123. Gooding, S.K. (1995). An assessment of the relationship between service

quality and customer satisfaction in the formation of consumers purchase
intention. Journal of Retailing, 70(2), 163–178.
267
124. Gooding, S.K.S. (1995), "Quality, sacrifice, and value in hospital choice",
Journal of Health Care Marketing, Vol. 15 No. 4, pp. 24-31.
125. Goodman Bill and Reid Steadman, "Services: Business Demand Rivals
Consumer Demand in Driving Job Growth", Monthly Labor Review, April
(2002)
126. Gotlieb, J.B., Grewal, D., and Brown, S.W. (1994). Consumer satisfaction
and perceived quality: complementary or divergent constructs? Journal of
Applied Psychology, Vol. 79 No. 6, pp. 875-85.
127. Gowen III, C.R., K.L. Mcfadden, K.L., Hoobler, J.M W.J., & Tallon, W.J.
(2006). Exploring the efficacy of healthcare quality practices, employee
commitment, and employee control. Journal of Operations Management,
24 , 765-778
128. Gronroos, C. (2000). Service Management and Marketing: A Customer

Relationship Management Approach. Wiley, New York, NY. Hall, M.A.
(2005). The importance of trust for ethics, law and public policy.
Cambridge Quarterly of Healthcare
129. Gross, Scott (2004). Positively Outrageous Service. How to delight and
astound your customers and win them for life. USA: Dear Born Trade
Publishing. p. 8
130. Gu, X. (2010), Reform of Chinese medical system: current status and
challenge, online at: http:/www.sociology.cass.cnshxwshgz.pdf, [accessed
July].
131. Gulledge, T. R. & R. A. Sommer (2002). Business process management:

public sector implications. Business Process Management Journal,
8(4):364– 376.
132. Haddad, S and Fournier, P (1995). “Quality, Cost and Utilization of Health
Services in Developing Countries: A Longitudinal Study in Zaire,” Social
Science and Medicine, 40, 743-753.
268
133. Haddad, S; Fournier, P and Potvin, L (1998). “Measuring Lay People‟s
Perceptions of the Quality of Primary Health Care Services in Developing
Countries: Validation of a 20-item Scale, International Journal of Quality
Health Care, 10, 93-104.
134. Hall, M.A. (2005). The importance of trust for ethics, law and public
policy. Cambridge Quarterly of Healthcare 30 March 2014 Page 30 of 119
ProQuest Ethics, Vol. 14 No. 2, pp. 156-67.
135. Ham, C., & Alberti, K. (2002). The medical profession, the public and the
government. British Medical Journal, 324, 838–842.
136. Hammer, M. (2007a). The 7 deadly sins of performance measurement.

MIT Sloan Management Review, spring, 19–28.
137. Hammer, M. (2007b). The process audit. Harvard Business Review, April,
111–123.
138. Hancock D. The Complete Medical Tourist – Your Guide to Inexpensive

Cosmetic, Medical and Dental Surgery Abroad. London, UK: John Blake
Publishing; 2006.
139. Hargraves JL, Wilson IB, Zaslavsky A, James C, Walker JD, Rogers G,
&Cleary PD. (2001). Adjusting for patient characteristics when analyzing
reports from patients about hospital care. Med Care. 39:635-641.
140. Harmon, P. (2003). Business Process Change. San Francisco: Morgan

Kaufmann Publishers. 38 AHCMJ, Volume 4, Number 2 2008
141. Harris, K.M. (2003). How do patients choose physicians? Evidence from a
national survey of enrollees in employment-related health plans. Health
Services Research, 38(2), 711–732.
142. Hart, M. (1996), “Improving the quality of outpatient services in NHS

hospitals: some policy considerations”, International Journal of Health
Care Quality Assurance, Vol. 9 No. 7, pp. 28-38.
269
143. Hauser, J. and Clausing, D. (1988) „The house of quality‟, Harvard
Business Review, 66:3, 63-73.
144. Health Resources and services administration, (2011). The Future of

Nursing: Focus on Education.
145. Healthcare Intelligence Network, Patient Experience and Satisfaction

Survey, May (2011). Responsibility for Improving Patient Satisfaction.
146. Hendriks, A., Oort, F., Vrielink, M. and Smets, E. (2002), "Reliability and
validity of the satisfaction with hospital care questionnaire", International
Journal for Quality in Health Care, Vol. 14 No. 6, pp. 471-82.
147. Hensen, P., Schiler, M, Metze, D. and Luger, T. (2008), „Evaluating

hospital service quality from a doctor viewpoint‟, International Journal of
Health Care Quality Assurance, Vol. 21, No, 1, pp. 75–86.
148. Herzlinger, R.E. (1997). Market-driven health care: Who wins, who loses
in the transformation of America’s largest service industry. New York:
Addison-Wesley.
149. Heskett, J. L., Sasser, W. E. & Schlesinger, L. A. (1997). Sewice Profit

Chain. New York: The Free Press.
150. Heskett, J.L., Jones, T.O., Loveman, G.W., Sasser, W.E., Jr.,
&Schlesinger, L.A. (1994). Putting the service–profit chain to work.
Harvard Business Review, 72(2), 164–174.
151. Heskett, J.L., Sasser, W.E. Jr., & Schlesinger, L.A. (1997). The service
profit chain. New York: The Free Press.
152. Hibbard, J.H. and Jewett, J.J. (1996), “What type of quality information do
consumers want in a health care report card?”, Medical Research and
Review, Vol. 53 No. 1, pp. 28-47.
153. Hiidenhovi H., Nojonen K., & Laippala P. (2002). Measurement of

outpatients' views of service quality in a Finnish university hospital.
Journal of Advanced Nursing, 38(1), 59-67.
270
154. Hoerger, T.J., & Howard, L. (1995). Search behavior and choice of
physician in the market for parental care. Medical Care, 33(4), 332–349.
155. Hogg, G., Laing, A., & Newholm, T. (2004). Talking together: Consumer
communities and health care. Advances in Consumer Research, 31, 67–73.
156. Holbrook, M. (1994). The nature of customer value. Newbury Park, CA:
Sage.
157. Howcroft, B. (1993), „Staff Perceptions of Service Quality in a UK

Clearing Bank: Some Empirical Findings‟, International Journal of
Service Industry Management, 4:4, 5-24.
158. Hsieh, Tony (2010). Delivering happiness: a path to profits, passion, and
purpose (1st ed.). New York: Business Plus. pp. 144, 145
159. Hyde, P., Harris, C, Boaden, R., & Cortviend, P. (2009). Human relations
management, expectations and healthcare: A qualitative study. Human
Relations, 62(5), 701-725
160. Indian Journal of Community medicine (2003). Pyramidal structure of

healthcare in India.
161. Isken, M.W. et al. (2005). Collection and preparation of sensor network
data to support modeling and analysis of outpatient clinics. Health Care
Management Science, 8, 87–99.
162. Jabnoun, N., and Khalifa, A. (2005). A customized measure of service

quality in the UAE. Managing Service Quality, Vol. 15 No. 4, pp. 374-88.
163. Jackson, J., Chamberlin, J., & Kroenke, K. (2001). Predictors of patient
satisfaction. Social Science and Medicine, 52: 609-620.
164. Jadad, A. (1998). Promoting partnerships: Challenges for the Internet age.
British Medical Journal, 319, 761–764.
165. Jaipaul CK & Rosenthal GE. (2003). Are older patients more satisfied with
hospital care than younger patients? J Gen Intern Med, 18:23-30.
271
166. Jennings, K. & F. Westfall (1994). A survey-based benchmarking
approach for health care using the baldrige quality criteria. Joint
Commission Journal on Quality Improvement, 20(9), 500–509.
167. John, J. (1991). Improving quality through patient-provider

communication. Journal of Health Care Marketing, 11(4), 51–60.
168. Johnson, L., M. D, and Dunlap, B. (1988) „Service quality determinants

and effectiveness in the real estate brokerage industry‟, Journal of Real
Estate Research, 3:2, 21-36.
169. Johnson, W., and Sirikit, A. (2002). Service quality in the Thai
telecommunication industry: a tool for achieving a sustainable competitive
advantage. Management Decision, Vol. 40 No. 7, pp. 693-701.
170. Journal of Marketing Management, Volume 27 Treacy, M., & Wiersema,

F. (1993). Customer intimacy and other value disciplines. Harvard
Business Review, 71(1), 84–93.
171. Journal of Services Research, Special Issue (February 2008) ©2008 by

Institute for International Management and Technology. All Rights
Reserved.
172. Jun, M., Peterson, R., & Zsidisin, G. A. (1998). The identification and
measurement of quality dimensions in health care: focus group interview
results. Health Care Management Review, 23, pp. 81-96.
173. Kaissi, A., Kralewski, J., Curoe, A., Dowd, B. and Silversmith, J. (2004),
"How does the culture of medical group practices influence the types of
programs used to assure quality of care?", Health Care Management
Review, Vol. 29 No. 2, pp. 129-38.
174. Kamble S.S., 'An Exploratory Study on Service Quality Themes

Determining Patient satisfaction With Health Care delivery In India'
(2007).
272
175. Kane, R. L., Maciejewski, M., & Finch, M. (1997). The relationship of
patient satisfaction with care and clinical outcomes. Med. Care, 35, 714-
730.
176. Kang, G.-D., and James, J. (2004). Service quality dimensions: an

examination of Gronroos's service quality model. Managing Service
Quality, Vol. 12 No. 4, pp. 266-77.
177. Kanousi, A. (2005). An empirical investigation of the role of culture on

service recovery expectations. Managing Service Quality, Vol. 15 No. 1,
pp. 57-69.
178. Kassim, N.M., and Bojei, J. (2002). Service quality: gaps in the Malaysian
telemarketing industry. Journal of Business Research, Vol. 55, pp. 845-52.
179. Kattara H. S., D. Weheba, and O. A. El-Said. 2008. „The Impact of

Employee Behavior on Customer‟s Service Quality Perceptions and
Overall Satisfaction.‟ Tourism and Hospitality Research 8 (1): 309– 323.
180. Kavilanz, P. (2009). Underinsured Americans: Cost to You.

CNNMoney.com. Retrieved January 31, 2010.
181. Kearns, D. and Nadler, D. (1992) Prophets in the Dark: How Xerox
Reinvented Itself and Beat Back Japanese, New York, Harper Collins.
182. Kettinger, W. and Lee, C. (1995) „Perceived service quality and user
satisfaction with the information services function‟, Decision Sciences,
25:5/6, 737-766.
183. Kher U. Outsourcing your heart. Time. :44–47. May 29, 2006.
184. Kilbourne, W.E., Duffy, J.A., Duffy, M., and Giarchi, G. (2004). The
applicability of SERVQUAL in cross-national measurements of health
care quality. Journal of Services Marketing, Vol. 18 No. 7, pp. 524-33.
185. Kim, H. W. and Kim, Y. G. (2001) „Rationalizing the Customer service

process‟, Business Process Management Journal, 7:2, 139-165.
273
186. Kim, Y.K., Chung, K.T., & Ahn, Y.S. (2003). The influence of dental
service qualities on the patient satisfaction and loyalty in dental clinics and
hospitals. Korean Journal of Hospital Management, 8(3), 49–71.
187. Klopfer, W.G., Hillson, J.S., and Wylie, A.A. (1956). Attitudes toward
mental hospitals. Journal of Clinical Psychology, Vol. 12 No. 4, pp. 361-5.
188. Kohli, R., Kerns, B. and Forgionne, G. A. (1995), „The application of

TQM in a hospital‟s casualty and pathology departments‟, International
Journal of Quality & Reliability Management, Vol. 12 No. 9, pp. 57–75.
189. Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson. 2000. To Err
is Human: Building a Safer Health System. Institute of Medicine Report on
Medical Errors. Washington, DC: National Academy Press.
190. Korczynski, M. (2002). HRM in services work. New York: Palgrave

Publishing.
191. Kotler, P., & Clarke, R.N. (1992). Marketing for health care organization.
New Jersey: Prentice-Hall Kim, H. W. and Kim, Y. G. (2001)
„Rationalizing the Customer service process‟, Business Process
Management Journal, 7:2, 139-165.
192. Kueh, Karen and Ho Voon, Boo. (2007). Culture and service quality
Expectations Evidence from Generation Y consumers in Malaysia.
Managing Service Quality, Vol. 17 No. 6, pp. 656-680.
193. Kutty VR. 2000. Historical analysis of the development of health care
facilities in Kerala India. Health Policy and Planning 15:103–9.
194. Labarere, J., Francois, P., Auquier, P., Robert, C., and Fourny, M. (2001).
Development of a French inpatient satisfaction questionnaire. International
Journal for Quality in Health Care, 13 (2): 99-108.
195. Ladhari, Riadh. (2009). A review of twenty years of SERVQUAL

research. International Journal of Quality and Service Sciences, Vol. 1 No.
2, 2009 pp. 172-198.
274
196. Laing, A., & Hogg, G. (2002). Political exhortation, patient expectation
and professional execution: Perspectives on consumerization of health
care. British Journal of Management, 13(2), 173–188.
197. Lam, S. K. S. (1997). SERVQUAL: a tool for measuring patients' opinions

of hospital service quality in Hong Kong. Total Quality Management, 8,
pp. 145-152.
198. Lancaster J. Surgeries, side trips for medical tourists. p. A1. Washington
Post. October 21, 2004.
199. Laroche, M., Ueltschy, L.C., Abe, S., Cleveland, M., and Yannopoulos,
P.P. (2004). Service quality perceptions and customer satisfaction:
evaluating the role of culture. Journal of International Marketing, Vol. 12
No. 3, pp. 58-85.
200. Laschober,M.,Maxfield,M.,Felt,Lisk,S.andMiranda,D.J.(2007),„HospitalR
esponseto Public Reporting of Quality Criteria‟, Health Care Financing
Review, Vol. 28, No. 3, pp. 62–76.
201. Lebas, M.J. (1995). Performance measurement and performance

management. International Journal of Production Economics, 41, 23–35.
202. Lee, M., & Ulgado, F.M. (1997). Consumer evaluation of fast food
service: A cross-national comparison. The Journal of Service Marketing,
11(1), 39–52.
203. Lehtinen, U., and J. R. Lehtinen. 1991. „Two Approaches to Service

Quality Dimensions.‟ The Service Industries Journal 11 (3): 287–303.
204. Lemieux-Charles, Louise, and Wendy L. McGuire. 2006. “What Do We

Know About Health Care Team Effectiveness: A Review of Literature.”
Medical Care Research and Review, Vol. 63, No. 3, pp. 1–38.
205. Licata, J. W., Mowen , J. C., & Chakraborty, G. (1995). Diagnosing

perceived quality in the medical service channel. J. Health Care Market, 15
(4), 42 - 49.
275
206. Likert, R. (1932), „A Technique for the Measurement of Attitudes‟,
Archives of Psychology, New York.
207. Lim, P. C., and Tang, N. K. (2000). A study of patients' expectations and
satisfaction in Singapore hospitals. International Journal of Health Care
Quality Assurance, 13/7, 290-299. 30 March 2014 Page 31 of 119
ProQuest.
208. Lim, P. C., Tang, N. K., and Jackson,P., M. (1999). An innovative

framework for health care performance measurement. Managing Service
Quality, Volume 9. Number 6, pp. 423-433.
209. Lin, B. Kelly, E. (1995). Methodological issues in patient satisfaction

surveys. International Journal of Health Care Quality Assurance, Vol. 5
No. 6, pp. 25-31.
210. Lin, B., and Schneider, H. (1992). A framework for measuring quality in
health care. International Journal of Health Care Quality Assurance, Vol. 5
No. 6, pp. 25-31.
211. Liu, R.R., and McClure, P. (2001). Recognizing cross-cultural differences

in consumer complaint behavior and intentions: an empirical examination.
Journal of Consumer Marketing, Vol. 18 No. 6, pp. 32-37.
212. Lovelock, C. and Wright, L. (1999) Principle of Service Marketing and

Management, New Jersey, Prentice Hall.
213. Lupton, D., Donaldson, C., & Lloyd, P. (1991). Caveat emptor or blissful
ignorance? Patients and the consumerist ethos. Social Science and
Medicine 33(5), 559–568.
214. Lytle, R.S., & Mokva, M.P. (1992). Evaluating health care quality: The
moderating role of outcomes. Journal of Health Care Marketing, 12(1),
460–469.
215. Macready N. Developing countries court medical tourists. Lancet. 2007;

369:1849–1850.
276
216. Maddern, H., Maull, R., Smart, A. and Baker, P. (2007), „Customer
satisfaction and service quality in UK financial services‟, International
Journal of Operations & Production Management, Vol. 27, No. 9, pp.
998–1019.
217. Maheshwari, S., Bhat, R., & Dhiman, A. (2007). Implications of human
resource practices and other structural factors on commitment of public
medical professionals in India. Working Paper Series, 2007-08-04, IIM
Ahmedabad.
218. Malhotra, N.K., Ulgado, F.M., Agarwal, J., and Baalbaki, I.B. (1994). A
comparative evaluation of the dimensions of service quality between
developed and developing countries. International Marketing Review, Vol.
11 No. 2, pp. 5-15.
219. Malhotra, N.K., Ulgado, F.M., Agarwal, J., Shainesh, G., and Wu, L.
(2005). Dimensions of service quality in developed and developing
countries: multi-country cross-cultural comparisons. International
Marketing Review, Vol. 22 No. 3, pp. 256-78.
220. Manjunath, U., Metri, B. A. and Ramachandran, S. (2007), „Quality

management in a healthcare organisation: a case of South Indian hospital‟,
The TQM Magazine, Vol. 19, No. 2, pp. 129–139.
221. Margolis, S., Al-Marzouqi, S., Revel, T., and Reed, R. (2003). Patient
satisfaction with primary health care services in the United Arab Emirates.
International Journal for Quality in Health Care, Vol. 15 No. 3, pp. 241-9.
Marketing 12:6-13.
222. Marley, K. A., D. A. Collier, and S. M. Goldstein. 2004. „The Role of

Clinical and Process Quality in Achieving Patient Satisfaction in
Hospitals.‟ Decision Sciences 35 (3): 349–369.
223. Mattila, A. &Wirtz, J. (2002). The impact of knowledge types on the

consumer search process – an investigation in the context of credence
services. International Journal of Service Industry Management. 13(3).
277
224. Mattila, A., & Wirtz, J. (2001). The moderating role of expertise in
consumer evaluations of credence goods. International Quarterly Journal
of Marketing 1(4), 281–292.
225. Mattila, A.S. (1999). The role of culture and purchase motivation in
service encounter evaluations. Journal of Services Marketing, Vol. 13 Nos
4/5, pp. 376-89.
226. Mayer K. J., Bowen J. T. and Moulton M. R. (2003)„A proposed model of

the descriptors of service process‟, Journal of Services Marketing 17:6,
621-639.
227. Mazor, K., Clauster, B., Field, T., Yood, R., and Gurwitz, J. (2002). A
demonstration of the impact of response bias on the results of patient
satisfaction surveys. Health Services Research, Vol. 37 No. 5, pp. 1404-
17.
228. McKee, L., Ferlie, E., & Hyde, P. (2008). Organizing and reorganizing:
Power and change in health care organizations. London: Palgrave
Macmillan.
229. Melan, E.H. (1989). Process management: A unifying framework for

improvement. National Productivity Review, 8(4), 395–406.
230. Mendoza, A.J., Piechulek, H. and Al-Sabir, A. (2001), “Client satisfaction

and quality of health care in rural Bangladesh”, Bulletin of the World
Health Organization, Vol. 79 No. 6, pp. 512-7.
231. Messina, D. J., Dennis J., Jersey; Caney, R., and Pinto Zipp, C. (2009).
The Relationship between Patient Satisfaction and Inpatient Admissions
across Teaching and nonteaching hospitals. Journal of Healthcare
Management, 54: 3 MAY/JUNE, pp 177-190.
232. Michelli, Joseph. The Zappos experience: 5 principles to inspire, engage,

and wow. New York: McGraw-Hill. p. 136.
278
233. Mowen, J. C., J. W. Licata, and J. McPhail. 1993. „Waiting in the
Emergency Room: How to Improve Patient Satisfaction.‟ Journal of
Health Care Marketing 13 (2): 26–33.
234. Mummalaneni, V., and P. Gopalakrishna. 1995. „Mediators vs. Moderators

of Patient Satisfaction.‟ Journal of Health Care Marketing 15 (4): 16–22.
235. Murray, K.B. (1992). Health care service decision influences: An

exploratory investigation of search and nonsearch criteria for professionals
and patients. Journal of Health Care Marketing, 12(1), 24–38.
236. Naidu, Aditi. (2009). Factors affecting patient satisfaction and healthcare
Quality. International Journal of Health Care Quality Assurance, Vol. 22
No. 4, pp. 366-381.
237. Narver, J.C. and Slater, S.F. (1990), "The effect of a market orientation on
business profitability", Journal of Marketing, Vol. 54 No. 4, pp. 20-35.
238. Nathorst-boos, J., Munck, I.M.E., Eckerlund, I. and Ekfeldt-Sandberg, C.

(2001), “An evaluation of the QSP and the QPP: two methods for
measuring patient satisfaction”, International Journal for Quality in Health
Care, Vol. 13 No. 3, pp. 257-64.
239. National Research Bureau Ltd (2013) Customer Satisfaction Surveys.
240. Ndede-Amadi, A.A. (2004). What strategic alignment, process redesign,

enterprise resource planning, and e-commerce have in common:
enterprise-wide computing.BusinessProcess Management Journal, 10(2),
184–199.
241. Ndubisi, N., Malhotra, N., and Wah, C. (2009). Relationship marketing,
Customer Satisfaction and loyalty: a Theoretical and Empirical Analysis
From an Asian Perspective. Journal of International Consumer marketing,
21:5-16.
242. Neuberger, J. (2000). The educated patient: New challenges for the
medical profession. Journal of Internal Medicine, 247, 6–10.
279
243. New Jersey Hospital Association. (2010). FAST Reports. Princeton, NJ.
New Jersey Hospital Association. (2010). Memorandum to Chief Executive
Officers. Princeton, NJ.
244. Nguyen Thi, Briancon, Empereur and Guillemin. (2002). Factors

determining inpatient satisfaction with care. Social Science &Medicine,
54, pp. 493-504.
245. Nordgren, L. (2009). Value creation in health care services – Developing

service productivity: Experience from Sweden. International Journal of
Public Sector Management, 22(2), 114–127.
246. O' Connor, S. J., Shewchuk, R. M., &Carney, L. W. (1994). The great gap.
Physicians' perceptions of patient service quality expectations fall short of
reality. J. Health Care Market, 14 (2), 32 - 39.
247. O' Connor, S., Shewchuk, R., &Bowers, M. R. (1991). A model of service
quality perceptions and health care consumer behavior. J. Hospital Market,
6 (1), 69 - 92.
248. OECD Health Data 2010. Healthcare spending of seven countries, as a

percentage of their GDP, for the years 2005 to 2008.
249. Okotie, O.T., Patel, N. and Gonzalez, C.M. (2008), “The effect of patient
arrival time on overall wait time and utilization of physician and
examination room resources in the outpatient urology clinic”, Advances in
Urology, available at: http://downloads.hindawi.com/journals/
au/2008/507436.pdf.
250. Oliver, R.L. (1980). A cognitive model of antecedents and consequences

of satisfaction decisions. Journal of Marketing Research, 17(November),
460.
251. Oliver, R.L. (1997). Satisfaction - A Behavioral Perspective on the

Consumer. Irwin/McGraw-Hill, Boston, MA.
280
252. Ostrom, I. (1995). Customer trade-offs and the evaluation of service.
Journal of Marketing, 59(1), 17–28.
253. Ovretveit, J (1992). Health Service Quality. Introduction to Quality

Methods for Health Services, Oxford: Blackwell Scientific Press.
254. Pakdil, F., &Harwood, T. (2005). Patient Satisfaction in a Preoperative

Assessment Clinic: An Analysis Using SERVQUAL Dimensions. Total
Quality Management, Vol. 16, No. 1, 15-30.
255. Parasuraman, A. (2000). Superior customer service and marketing

excellence: two sides of the same success coin. Vikalpa, Vol. 25 No. 3, pp.
3-13.
256. Parasuraman, A. (2004), „Assessing and improving service performance

for maximum impact: insights from a two-decade-long research journey‟,
Performance Measurement and Metrics, Vol. 5, No. 2, pp. 45–52.
257. Parasuraman, A., Berry, L.L., and Zeithaml, V.A. (1991). Refinement and
reassessment of the SERVQUAL scale. Journal of Retailing, Vol. 67 No.
4, pp. 420-50.
258. Parasuraman, A., Berry, L.L., and Zeithaml, V.A. (1993). More on
improving service quality measurement. Journal of Retailing, Vol. 69 No.
1, pp. 140-7.
259. Parasuraman, A., Zeithaml, V. A. and Berry, L. L. (1988), „SERVQUAL:

A Multiple Item Scale for Measuring Consumer Perceptions of Service
Quality‟, Journal of Retailing, Vol. 64, No. 1, pp. 12–40.
260. Parasuraman, A., Zeithaml, V., and Berry, L. (1985). A conceptual model
of service quality and its implications for future research. Journal of
Marketing, Vol. 49, pp. 41-50. 30 March 2014 Page 32 of 119 Pro Quest.
261. Parasuraman, A., Zeithaml, V.A., and Berry, L.L. (1994). Alternative
scales for measuring service quality: a comparative assessment based on
281
psychometric and diagnostic criteria. Journal of Retailing, Vol. 70 No. 3,
pp. 201-30.
262. Peabody, J; Rahman, M; Gertler, P J; Mann, J; Farley, D O and Carter, G

M (1999). Policy and Health: Implications for Development in Asia.
Cambridge, UK: Cambridge University.
263. Peters, Jan Carlzon; [foreword by Tom (1989). Moments of truth (Repr.
Ed.). New York: Perennial Library. p. 2.
264. Peyrot, M., Cooper, P., and Schnapf, D. (1993). Consumer satisfaction and
perceived quality of outpatient health services. Journal of Health Care
Marketing, Vol. 13 No. 1, pp. 24-33.
265. Phillips, L., Chang, D. and Buzzell, R. (1983) „Product quality, cost
position and business performance: A test of some key hypotheses‟,
Journal of Marketing, 47:2, 26- 43.
266. Pollack, Birgit Leisen. (2008). the nature of the service quality and
satisfaction relationship. Managing Service Quality, Vol. 18 No. 6, pp.
537-558.
267. Poon, P.S., Hui, M.K., and Au, K. (2004). Attributions on dissatisfying
service encounters: a cross-cultural comparison between Canadian and
PRC consumers. European Journal of Marketing, Vol. 38 Nos 11/12, pp.
1527-40.
268. Porter Michael E. and Elizabeth O. Teisberg. 2006. Redefining Health

Care. Boston: Harvard Business School Press.
269. Powers, T., and D. Bendall-Lyon. (2003). the satisfaction score. Marketing
Health Services, 23:28-32.
270. Preuss, Gil A. 2003. “High Performance Work Systems and

Organizational Outcomes: The Mediating Role of Information Quality.”
Industrial and Labor Relations Review, Vol. 56, No. 4, pp. 590–605.
282
271. Priporas, C., Laspa , C., and Kamenidou, I. (2008). Patient satisfaction
measurement for in-hospital services: A pilot study in Greece. Journal of
Medical Marketing, Vol. 8, 4 325-340.
272. Quinn J. B., Baruch J. J. and Paquette P. C. (1987) „Technology in

services‟, Scientific American, 257:6, 50-58.
273. Quintana, J., González1, N., Bilbao, A., and Aizpuru, F. (2006). Predictors
of patient satisfaction with hospital health care. BMC Health Services
Research, 6:102.
274. Rahmqvist, M. (2001). Patient satisfaction in relation to age, health status

and other background factors: a model for comparisons of care units.
International Journal for Quality in Health Care, Vol. 13 No. 5, pp. 385-90.
275. Ramachandran, A., and Cram, N. (2005). Standards and customer

satisfaction in the healthcare industry. Journal of Clinical Engineering,
Vol. 10 No. 11, pp. 219-28.
276. Ramsaran-Fowdar, Rooma R. (2008). The relative importance of service

dimensions in a healthcare setting. International Journal of Health Care
Quality Assurance, Vol. 21 No. 1, 2008 pp. 104-124.
277. Rao, K.D., Peters, D.H. and Bandeen-Roche, K. (2006), “Towards patient-
centered health services in India – a scale to measure patient perceptions of
quality”, International Journal for Quality in Health Care, Vol. 18 No. 6,
pp. 414-21.
278. Rathert, Cheryl, and Douglas R. May. 2007. “Health Care Work
Environments, Employee Satisfaction, and Patient Safety: Care Provider
Perspective.” Health Care Management Review, Vol. 32, No. 1, pp. 2–11.
279. Ravald, A., & Gronroos, C. (1996). The value concept and relationship
marketing. European Journal of Marketing, 30(2), 19–30.
283
280. Reidenbach, R.E. and Sandifer-Smallwood, B. (1990), "Exploring
perceptions of hospital operations by a modified SERVQUAL approach",
Journal of Health Care Marketing, Vol. 10 No. 4, pp. 47-55.
281. Reijers, H.A. (2006). Implementing BPM systems: the role of process
orientation. Business Process Management Journal, 12(4):389–409.
282. Richardson, M.L., & Gurtner, W.H. (1999). Contemporary organizational

strategies for enhancing value in health care. International Journal of
Health Care Quality Assurance, 12(5), 183–189.
283. Robinson, Janice H., Lynn C. Callister, Judith A. Berry, and Karen A.
Dearing. 2008. “Patient-Centered Care and Adherence: Definitions and
Applications to Improve Outcomes.” Journal of the American Academy of
Nurse Practitioners, Vol. 20, No. 12, pp. 600–07.
284. Rose, R. C., Uli, J., Abdul, M. and Ng, K. L. (2004), „Hospital service
quality: a managerial challenge‟, International Journal of Health Care
Quality Assurance, Vol. 17, No. 3, pp. 146–159.
285. Rosenheck, R., Wilson, A., and Meterko, M. (1997). Influence of patient
and hospital factors on consumer satisfaction with inpatient health
treatment. Psychiatric Services, Vol. 48, pp. 1553-61.
286. Roter, D.L., Hall, J.A. and Katz, N.R. (1987), "Relations between
physicians, behaviors and analogue patients' satisfaction, recall, and
impressions", Medical Care, Vol. 25 No. 5, pp. 437-51.
287. Saha, U. R. and Bartlema, J. (1998) User free introduction and quality of
care: some empirical indicators from Bangladesh and Comilla. Dhaka:
Ministry of Health and Family Welfare; Thana Functional Improvement
Pilot Project.
288. Sanzo, M.J., Santos, M.L., Vazquez, R., and Alvarez, L. (2003). The Role
Market Orientation In Business Dynamic Relationships: Testing an
Integrator Model. Journal of marketing Management, 19, 73-107.
284
289. Scardina, S. A. (1994). SERVQUAL: a tool for evaluating patient
satisfaction with nursing care. Journal of Nursing Care Quality, 8, pp. 38-
46.
290. Schantin, D. (2004). Makromodellierung von Geschäftsprozessen.

Wiesbaden: Deutscher Universitätsverlag.
291. Schlesinger, L.L., & Heskett, J.L. (1991). Breaking the cycle of failure in
services. Sloan Management Review, spring: 17- 28.
292. Schneider, B. (1994). Human resource management - A service

perspective: Towards a customer focused HRM. International Journal of
Service Industry Management, 5(1), 64-76.
293. Schneider, B., Ashforth, S., Higgs, A.C. and Carr, L. (1996), "Design,
validity and use of strategically focused employee attitude surveys",
Personnel Psychology, Vol. 49, pp. 695-705.
294. Schneider, B., White, S.S. and Paul, M.C. (1998), "Linking service climate
and customer perceptions of service quality: test of a causal model",
Journal of Applied Psychology, Vol. 83 No. 2, pp. 150-63. 36.
295. Schult J. Beauty from Afar – A Medical Tourist's Guide to Affordable and
Quality Cosmetic Care Outside the U.S. New York, NY: Stewart, Tabori
& Chang; 2006.
296. Scotti, D. J., J. Harmon, and S. J. Behson. (2007). Links among High-
Performance Work Environment, Service Quality, and Customer
Satisfaction: An Extension to the Healthcare Sector. Journal of Healthcare
Management, 52 (3): 109-25.
297. Scotti, Dennis, Joel Harmon, and Scott J. Behson. 2007. “Links Among
High–Performance Work Environment, Service Quality, and Customer
Satisfaction: An Extension to the Healthcare Sector.” Journal of
Healthcare Management, Vol. 52, No. 2, pp. 109–24.
285
298. Senarath, U., Fernando, D., and Ishani Rodrigo, I. (2006). Factors
determining client satisfaction with hospitalbased perinatal care in Sri
Lanka. Tropical Medicine and International Health, volume 11 no 9
september, pp 1442-1451.
299. Seth, Rakesh Seth, Kirti (2005). Creating customer delight : the how and
why of CRM. New Delhi: Response Books. p. 19.
300. Sewell, Carl; Brown, Paul B. (2002). Customers for life : how to turn that
onetime buyer into a lifetime customer (Rev. ed.). New York: Doubleday.
p. 13.
301. Shaller, Dale. 2007. Patient-Centered Care: What Does It Take? New
York: The commonwealth Fund.
302. Shemwell D. J. and U. Yavas. 1999. „Measuring Service Quality in

Hospitals: Scale Development and Managerial Applications.‟ Journal of
Marketing Theory and Practice 7 (3): 65–78.
303. Sheth, J.N., Newman, B.I., & Gross, B.L. (1991). Why we buy what we
buy: A theory of consumption values. Journal of Business Research,
22(2), 159–170.
304. Shostack, G.L. (1984) „Designing Services that Deliver‟, Harvard Business
Review, 61:1,13-39.
305. Singh, J. 1990. „A Multifaceted Typology of Patient Satisfaction with a

Hospital Stay.‟ Journal of Health Care Marketing 10 (4): 8–12.
306. Sinkula, J.M., Baker, W. and Noordewier, T. (1997), "A framework for
market-based organizational learning: linking values, knowledge, and
behaviour", Journal of the Academy of Marketing Science, Vol. 25, pp.
305-18.
307. Sitzia, J. (1999). How valid and reliable are patient satisfaction data? An
analysis of 195 studies. International Journal for Quality in Health Care,
Vol. 11, pp. 319-28.
286
308. Sitzia, J. and Wood, N. (1997), “Patient satisfaction: a review of issues and
concepts”, Social Science & Medicine, Vol. 45 No. 12, pp. 1829-43.
309. Slater, S.F. and Narver, J.C. (1995), "Market orientation and the learning
organization", Journal of Marketing, Vol. 59, pp. 63-74.
310. Smith, H. & P. Fingar (2003). Business Process Management: The Third
Wave. Tampa, Florida: Meghan-Kiffer Press.
311. Souelem, O. (1955). Mental patients' attitudes toward mental hospitals.

Journal of Clinical Psychology, Vol. 11 No. 2, pp. 181-5.
312. Soumyadeep Bhaumik Senior Research Scientist, South Asian Cochrane

Network and Centre. Health and Beyond... Strategies for a Better India:
Concept Paper on Primary Health Care in India. Rural healthcare system in
India.
313. Spreng, R.A., and Singh, A.K. (1993). An empirical assessment of the
SERVQUAL Scale and the relationship between service quality and
satisfaction, in Cravens, D.W. and Dickson, P. (Eds), Enhancing
Knowledge Development in Marketing, Vol. 4, pp. 1-6.
314. Srinivasan R., "Strategic Management, the Indian Context. Prentice Hall of
India Pvt. Ltd., New Delhi (2005).
315. Stefanou, C.J. & A. Revanoglou (2006). ERP integration in a healthcare

environment: a case study. Journal of Enterprise Information
Management, 19(1), 115–130.
316. Strasser, S., Schweikhart, S., Welch, G.E. and Burge, J.C. (1995),
"Satisfaction with medical care", Journal of Health Care Marketing, Vol.
15 No. 3, pp. 34-43.
317. Susie, L.P. (1982), “Towards a theory of patient satisfaction”, Social

287
318. Svensson, G. (2006). New aspects of research into service encounters and
service quality. International Journal of Service Industry Management,
Vol. 17 No. 3, pp. 245-57. 30 March 2014 Page 33 of 119 Pro Quest.
319. Taylor, S.A. (1994). Distinguishing service quality from patient

satisfaction in developing health care marketing strategies. Hospital and
Health Services Administration, Vol. 39 No. 2, pp. 221-36.
320. Teas, R.K. (1993a). Consumer expectations and the measurement of

perceived service quality. Journal of Professional Services Marketing, Vol.
57 No. 4, pp. 18-24.
321. Teas, R.K. (1993b). Expectations, performance, evaluation and consumers'

perceptions of quality. Journal of Marketing, Vol. 57, pp. 18-34.
322. The Economic Times Great Indian hospitality can be biz too (India) July
29, 2005.
323. Thi, P., Briancon, S., Empereur, F., and Guillemin, F. (2002). Factors
determining inpatient satisfaction with care. Social Science and Medicine,
Vol. 54, pp. 493-504.
324. Ting, D.H. (2004). Service quality and satisfaction perceptions: curvilinear
and interaction effect. International Journal of Bank Marketing, Vol. 22
No. 6, pp. 407-20.
325. Tomes, A. E. and Ng, S. C. P. (1995), „Service quality in hospital care: the
development of an inpatient questionnaire‟, International Journal of
Health Care Quality Assurance, Vol. 8, No. 3, pp. 25–33.
326. Torres, J.E. & K.L. Guo (2004). Quality improvement techniques to
improve patient.
327. Townsend, K., & Wilkinson, A. (2010). Managing under pressure: HRM
in hospitals. Human Resource Management Journal, 20(4), 332-333.
288
328. Tso, I.F., Ng, S.M. and Chan, C.L. (2006), “The development and
validation of the concise outpatient department user satisfaction scale”,
International Journal for Quality in HealthCare, Vol. 18 No. 4, pp. 275-80.
329. Tsoukatos, E., and Rand, G.K. (2007). Cultural influences on service
quality and customer satisfaction: evidence from Greek insurance.
Managing Service Quality, Vol. 17 No. 4, pp. 467-85.
330. Tucker, J. (2002). The moderators of patient satisfaction. Journal of

Management in Medicine, Vol. 16 No. 1, pp. 48-66.
331. Uplekar MW, Rangan S. 1993. Private Doctors and tuberculosis control in
India. Tuberculosis and Lung Disease 74: 332–7.
332. Van Dusen A. Outsourcing your health. Forbes Web site. May 22, 2007.
333. Venugopal Vasanti and Raglu U.N., "Service Marketing". Himalaya

Publishing House, Mumbai (2004).
334. Vera, A. & L. Kuntz (2007). Process-based organization design and

hospital efficiency. Health Care Management Review, 32(1), 55–65.
335. Vinagre, M., & Neves, J. (2008). The influence of service quality and
patients' emotions on satisfaction. International Journal of Health Care
Quality Assurance, Vol. 21 No. 1, 2008 pp. 87-103.
336. Voon, B.H. (2006). Linking a service-driven market orientation to service

quality. Managing Service Quality, Vol. 16 No. 6, pp. 595-619.
337. Vuori, H. (1987), “Patient satisfaction – an attribute or indicator of the

quality of care?” QRB Quality Review Bulletin, Vol. 13 No. 3, pp. 106-8.
338. Vuori, H. (1991). Patient satisfaction - does it matter?. Quality Assurance

Health Care, Vol. 3, 1991, p. 183.
339. Walbridge, S. W., &Delene, L. M. (1993). Measuring physician's attitudes

of service quality. J. Health Care Market, 13 (1), 7 - 15.
289
340. Ware, J.E., & Hays, R.D. (1988). Methods for measuring patient
satisfaction with specific medical encounters. Medical Care, 26(4), 393–
402.
341. Ware, J.E., & Synder, M.K. (1975). Dimensions of patient attitude
regarding doctors and medical care services. Medical Care, 13(8), 669.
342. Ware, J.E., Davis-Avery, A., & Stewart, A.L. (1978). The measurement
and meaning of patient satisfaction. Health & Medical Care Services
Review, 1(1), 1–15.
343. Weiss, B., and Senf, H. (1990). Patient satisfaction survey instrument for
use in health.
344. Westway, M., Rheeder, P., Van Zyl, D., and Seager, J. (2003).
Interpersonal and organizational dimensions of patient satisfaction: the
moderating effects of health status. International Journal for Quality in
345. Wifcks, D. (1998). Doctors and nurses at work: Rethinking professional

boundaries. Buckingham: Open University Press. Buckingham.
346. Williams, B. (1994), “Patient satisfaction: a valid concept?”, Social

347. Williams, S J. and Calnan, M. (1991), "Convergence and divergence:

assessing criteria of consumer satisfaction across general practice, dental
and hospital care settings", Social Science Medicine, Vol. 33 No. 6, pp.
707-16.
348. Wisniewski M and Wisniewski H.,'Measuring service quality in a hospital

colposcopy clinic'. International Journal of health Care Quality
assurance, 18 (3) (2005).
349. Wolf, Debra M., Lisa Lehman, Robert Quinlin, Thomas Zullo, and Leslie
Hoffman. 2008. “Effect of Patient- Centered Care on Patient Satisfaction
290
and Quality of Care.” Journal of Nursing Care Quality, Vol. 23, No. 4, pp.
316–21.
350. Woodside, A.G. and Shinn, R. (1988), "Consumer awareness and

preference toward competing hospital services", Journal of Health Care
Marketing, Vol. 8 No. 1, pp. 39-47.
351. Woodside, A.G., Frey, L., & Daly, R.T. (1989). Linking service quality,
customer satisfaction, and behavioral intension. Journal of Health Care
Marketing, 9(4), 5–17.
352. World Health Organization. World health report 2003: shaping the
future.Geneva: World Health Organization, 2003.
353. Xavier M.J., Strategic Marketing, Response Books, New Delhi (2006).
354. Yesudian CA.1994. Behavior of the private sector in the health market of
Bombay. Health Policy and Planning 9: 72–80.
355. Ygge, B., and Arnetz, J. (2001). Quality of paediatric care: application and
validation of an instrument for measuring parent satisfaction with hospital
care. International Journal for Quality in Health Care, Vol. 13 No. 1, pp.
33-43.
356. Yoon, S.J., Choi, D.C. and Park, J.W. (2007), "Service orientation: its
impact on business performance in the medical service industry", The
Service Industries Journal, Vol. 27 No. 4, pp. 371-88.
357. Young, F., & Stanton, P. (Eds.), Workplace reform in the healthcare
industry: The Australian experience, Basingstoke: Palgrave Macmillan.
358. Zang, G. (2006), Quality management standards and working procedures

handbook for hospitals, Journal of Services Research, Volume 9, Number
1 (April-September 2009).
359. Zaslavsky, A.M., Beaulieu, N.D., Landon, B.E. and Cleary, P.D. (2000),
“Dimensions of consumer-assessed quality of medicare managed-care
health plans”, Medical Care, Vol. 38 No. 2, pp. 162-74.
291
360. Zeithaml, V. (1981), "How consumer evaluation processes differ between
goods and services", in Lovelock, C.H. (Ed.), Services Marketing, 2nd ed.,
Prentice-Hall, Englewood Cliffs, NJ.
361. Zeithaml, V. A. and Bitner, M. J. (2003) Services Marketing: Integrating

Customer Focus Across the Firm (3rd edn), New York, Irwin McGraw-
Hill.
362. Zeithaml, V. A., M. J. Bitner, D. D. Gremler, and A. Pandit. 2008.

Services Marketing: Integrating Customer Focus Across the Firm. New
York: McGraw-Hill.
363. Zeithaml, V. A., Parasuraman, A. and Berry, L. L. (1990) Delivering

Quality Service: Balancing Customer Perceptions and Expectations, New
York, The Free Press.
364. Zeithaml, V.A. (1988). Consumer perceptions of price, quality, and value:
A means-end model and synthesis of evidence. Journal of Marketing,
52(3), 2–22Total Quality Management 117
365. Zeithaml, V.A., Berry, L.L. and Parasuraman, A. (1996) „The behavioral
consequences of service quality‟, Journal of Marketing, 60(2), 31-46.
292
Annexure II
Questionnaire
Note:
 The information is collected only for academic purpose.
 The information given shall be strictly held in confidence.
 Giving the name is optional.
 Tick in the appropriate box.
1. Name of respondent (Patient) :- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
2. Name of Hospital :- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
3. Type of Hospital:-
Public hospital Private hospital
4. Location of the Hospital
Maharashtra Gujarat ---------
5. Age of the respondent:-
Below 30 30 to 45
Above 45
6. Gender of the respondent: - Male Female
7. visits to this hospital:-
First time two to five
More than five
8. Monthly Income of family:-
Below 20,000 20,000 to 50,000
Above 50,000
293
(I) Tangibles:
9. The hospital has all advanced and latest equipments.
Strongly Disagree Disagree
Neither agree nor Disagree Agree
Strongly Agree
10. Available facilities for treatment are good.
Strongly Agree
11. The internal environment is attractive.
Strongly Agree
(II) Reliability:
12. Doctors and medical staff are intelligent.
Strongly Agree
13. Doctors and medical staff spend enough time with patients to evaluate the
disease.
Strongly Agree
294
14. Doctors and medical staff take efforts to maintain accurate records.
Strongly Agree
15. Your expectations are fully met with regard to services.
Strongly Agree
(III) Responsiveness:
16. Doctors and medical staff respond to patients quickly.
Strongly Agree
17. Doctors and medical staff are approachable to the patients personal problems.
Strongly Agree
18. Front office staff is cooperative and helpful.
Strongly Agree
(IV) Assurance:
19. Patients feel relaxed and assured while services are being provided.
295
Strongly Agree
20. Doctors and medical staff sincerely reassure patients.
Strongly Agree
21. Behaviour of Doctors and medical staff instills confidence in patients.
Strongly Agree
(V) Empathy:
22. Doctors and medical staff have priority for patients problems.
Strongly Agree
23. Doctors and medical staff treat patients with love and affection.
Strongly Agree
24. Doctors and medical staff show concern to patient and his family.
Strongly Agree
296
Annexure III
SPSS Output
Frequency Table
Type_of_Hosp
Frequency Percent Valid Percent Cumulative

Percent
Government
66 18.9 18.9 18.9
hospital
Valid
Public hospital 284 81.1 81.1 100.0
Total 350 100.0 100.0
Region

Percent
Mumbai 152 43.4 43.4 43.4
Navi Mumbai 50 14.3 14.3 57.7
Pune 54 15.4 15.4 73.1
Valid
Surat 56 16.0 16.0 89.1
Thane 38 10.9 10.9 100.0
Total 350 100.0 100.0
Age_of_respondent

Percent
Elderly 114 32.6 32.6 32.6
Middle 109 31.1 31.1 63.7
Valid Young 127 36.3 36.3 100.0
Total 350 100.0 100.0
297
Gender

Percent
Female 142 40.6 40.6 40.6
Valid Male 208 59.4 59.4 100.0
Total 350 100.0 100.0
Frequency_of_Hosp

Percent
First time 132 37.7 37.7 37.7
More than four
90 25.7 25.7 63.4
Valid times
Two to four times 128 36.6 36.6 100.0
Total 350 100.0 100.0
Monthly_Income

Percent
HIGH 195 55.7 55.7 55.7
LOW 52 14.9 14.9 70.6
Valid
MEDIUM 103 29.4 29.4 100.0
Total 350 100.0 100.0
N Minimum Maximum Mean Std. Deviation

Tangible_score 350 26.67 100.00 84.3429 13.89218
Reliability_score 350 20.00 100.00 82.6571 12.33822
Response_score 350 20.00 100.00 80.5524 11.36692
Assurance_score 350 20.00 100.00 81.0667 10.80663
Empathy_score 350 20.00 100.00 79.3143 12.70886
298

Govt_Tangible1 66 53.33 100.00 84.4445 10.99110
Public_Tangible 284 26.67 100.00 84.4602 14.50036
Govt_Reliable1 66 55.00 100.00 83.5606 10.14378
Public_Reliable2 284 20.00 100.00 82.8873 12.88470
Govt_Response1 66 46.67 100.00 82.0205 11.27560
Public_Response 284 20.00 100.00 80.3752 11.77661
Govt_Assurance1 66 53.33 100.00 82.0200 9.98959
Public_Assurance 284 20.00 100.00 81.3616 11.58217
Govt_Empathy1 66 46.67 100.00 81.4141 12.51369
Public_Empathy 284 20.00 100.00 78.4740 13.63660

Mumbai_Tangible 152 26.67 100.00 84.0789 13.78988
Navi_Mumbai_Tangible 50 66.67 100.00 90.2668 9.35129
Pune_Tangible 54 26.67 100.00 78.3952 16.88218
Surat_Tangible 56 40.00 100.00 83.9289 14.37017
Thane_Tangible 38 60.00 100.00 87.7195 10.10761
N Minimum Maximum Mean Std.

Deviation
Mumbai_Reliable 152 20.00 100.00 82.5000 13.88219
Navi_Mumbai_Reliable 50 45.00 100.00 86.9000 12.11720
Pune_Reliable 54 40.00 95.00 80.0926 11.63480
Surat_Reliable 56 60.00 100.00 82.2321 10.13184
Thane_Reliable 38 60.00 100.00 85.2632 9.14946
299

Deviation
Mumbai_Response 152 20.00 100.00 80.0434 13.25561
Navi_Mumbai_Response 50 60.00 100.00 83.1996 9.05913
Pune_Response 54 60.00 100.00 80.3704 8.91776
Surat_Response 56 40.00 100.00 79.4048 12.01207
Thane_Response 38 53.33 100.00 82.2808 10.88103

Deviation
Mumbai_Assurance 152 20.00 100.00 81.3158 12.56157
Navi_Mumbai_Assuran
50 46.67 100.00 80.7994 10.13653
ce
Pune_Assurance 54 53.33 100.00 82.9635 9.39884
Surat_Assurance 56 40.00 100.00 80.0004 11.92566
Thane_Assurance 38 60.00 100.00 83.1579 8.59280

Deviation
Mumbai_Empathy 152 20.00 100.00 78.9911 14.93183
Navi_Mumbai_Empath
50 53.33 100.00 76.8000 13.00539
y
Pune_Empathy 54 66.67 100.00 80.4935 8.76868
Surat_Empathy 56 20.00 100.00 78.3330 14.17047
Thane_Empathy 38 46.67 100.00 81.0532 12.35281
300

Deviation
Younge_age_Tangible 127 26.67 100.00 87.4539 13.91858
Middle_age_Tangible 109 40.00 100.00 84.7096 12.28258
Elderly_age_Tangible 114 26.67 100.00 80.8775 14.58725

Deviation
Younge_age_Reliable 127 20.00 100.00 84.1732 14.45798
Middle_age_Reliable 109 40.00 100.00 82.4312 11.85590
Elderly_age_Reliable 114 50.00 100.00 82.2807 10.26508

Deviation
Younge_age_Response 127 20.00 100.00 81.1020 12.92400
Middle_age_Response 109 40.00 100.00 80.7340 12.08135
Elderly_age_Response 114 46.67 100.00 80.1750 9.77468

Deviation
Younge_age_Assurance 127 20.00 100.00 81.8371 12.78453
Middle_age_Assurance 109 40.00 100.00 81.7129 12.04961
Elderly_age_Assurance 114 46.67 100.00 80.8772 8.48469
301

Deviation
Younge_age_Empathy 127 20.00 100.00 78.8450 14.88555

Middle_age_Empathy 109 20.00 100.00 80.4892 14.10416
Elderly_age_Empathy 114 46.67 100.00 77.8362 10.91609
Descriptive Statistic

Deviation
Male_Tangible 208 26.67 100.00 84.7760 13.66906
Female_Tangible 142 26.67 100.00 83.9904 14.24890
Male_Reliable 208 35.00 100.00 84.0385 11.43300
Female_Reliable 142 20.00 100.00 81.5141 13.60524
Male_Response 208 40.00 100.00 81.5704 11.69884
Female_Response 142 20.00 100.00 79.3893 11.58557
Male_Assurance 208 40.00 100.00 81.7308 10.46446
Female_Assurance 142 20.00 100.00 81.1269 12.42707
Male_Empathy 208 20.00 100.00 80.0639 13.31681
Female_Empathy 142 20.00 100.00 77.5117 13.58156
302

Deviation
First_time_
132 26.67 100.00 83.0305 14.97164
Tangible
Two_to_four
128 26.67 100.00 84.4790 14.70882
times_Tangible
More_than_four
90 60.00 100.00 86.5188 10.52805
times_Tangible
First_time_Reliable 132 50.00 100.00 82.8788 10.98440
Two_to_four
128 20.00 100.00 81.5234 15.00077
times_Reliable
More_than_four
90 55.00 100.00 85.3333 9.79567
times_Reliable
First_time_Response 132 40.00 100.00 79.6462 10.42946
Two_to_four
128 20.00 100.00 80.1037 13.41157
times_Response
More_than_four
90 46.67 100.00 83.0372 10.53690
times_Response
First_time
132 40.00 100.00 81.5153 10.88464
Assurance
Two_to_four
128 20.00 100.00 79.5311 12.85752
times_Assurance
More_than_four
90 60.00 100.00 84.2224 8.73749
times_Assurance
First_time_Empathy 132 20.00 100.00 77.1212 13.73911
Two_to_four
128 20.00 100.00 78.7496 13.94234
times_Empathy
More_than_four
90 40.00 100.00 82.2223 11.82441
times_Empathy
303

Deviation
Low_income_Tangible 52 53.33 100.00 86.1537 11.94403
Middle_income_Tangible 103 40.00 100.00 87.6375 11.25662
High_income_Tangible 195 26.67 100.00 82.3250 15.24337
Low_income_Reliable 52 65.00 100.00 86.0577 9.25333
Middle_income_Reliable 103 45.00 100.00 84.6117 13.20445
High_income_Reliable 195 20.00 100.00 81.3590 12.49018
Low_income_Response 52 66.67 100.00 82.3081 9.13578
Middle_income_Response 103 40.00 100.00 82.7181 12.53950
High_income_Response 195 20.00 100.00 79.1792 11.65616
Low_income_Assurance 52 53.33 100.00 81.0252 9.73632
Middle_income_Assurance 103 46.67 100.00 82.4594 11.27942
High_income_Assurance 195 20.00 100.00 81.0943 11.69260
Low_income_Empathy 52 53.33 100.00 79.7435 10.88370
Middle_income_Empathy 103 40.00 100.00 79.6116 15.04699
High_income_Empathy 195 20.00 100.00 78.5298 13.24276
Crosstab
Count
Type_of_Hosp Age_of_respondent Total
Government hospital 25 20 21 66
Total 114 109 127 350
Chi-Square Tests
Value df Asymp. Sig
(2-sided)
Pearson Chi-Square 1.169a 2 .557
Likelihood Ratio 1.157 2 .561
N of Valid Cases 350
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is
20.55.
304
Crosstab
Count
Type_of_Hosp Gender Total
Female Male
Government hospital 24 42 66
Public hospital 118 166 284
Total 142 208 350
Chi-Square Tests
Value df Asymp. Sig. Exact Sig. Exact Sig.
(2-sided) (2-sided) (1-sided)
Pearson Chi-
.597a 1 .440
Square
Continuity
.402 1 .526
Correctionb
Likelihood Ratio .603 1 .437
Fisher's Exact
.488 .264
Test

26.78.
b. Computed only for a 2x2 table
Crosstab
Count
Type_of_Hosp Monthly_Income Total
HIGH LOW MEDIUM
Government hospital 11 25 30 66
Total 195 52 103 350
305
Chi-Square Tests
Value df Asymp. Sig. (2-sided)

9.81.
Frequency Table
Que9

Percent
1.00 6 1.7 1.7 1.7
2.00 7 2.0 2.0 3.7
3.00 17 4.9 4.9 8.6
Valid
4.00 187 53.4 53.4 62.0
5.00 133 38.0 38.0 100.0
Total 350 100.0 100.0
Que10

Percent
1.00 4 1.1 1.1 1.1
2.00 7 2.0 2.0 3.1
3.00 13 3.7 3.7 6.9
Valid
4.00 190 54.3 54.3 61.1
5.00 136 38.9 38.9 100.0
Total 350 100.0 100.0
306
Que11

Percent
1.00 8 2.3 2.3 2.3
2.00 13 3.7 3.7 6.0
3.00 27 7.7 7.7 13.7
Valid
4.00 178 50.9 50.9 64.6
5.00 124 35.4 35.4 100.0
Total 350 100.0 100.0
Que12

Percent
1.00 5 1.4 1.4 1.4
2.00 14 4.0 4.0 5.4
3.00 15 4.3 4.3 9.7
Valid
4.00 181 51.7 51.7 61.4
5.00 135 38.6 38.6 100.0
Total 350 100.0 100.0
Que13

Percent
1.00 8 2.3 2.3 2.3
2.00 17 4.9 4.9 7.1
3.00 14 4.0 4.0 11.1
Valid
4.00 218 62.3 62.3 73.4
5.00 93 26.6 26.6 100.0
Total 350 100.0 100.0
307
Que14

Percent
1.00 5 1.4 1.4 1.4
2.00 10 2.9 2.9 4.3
3.00 22 6.3 6.3 10.6
Valid
4.00 219 62.6 62.6 73.1
5.00 94 26.9 26.9 100.0
Total 350 100.0 100.0
Que15

Percent
1.00 1 .3 .3 .3
2.00 15 4.3 4.3 4.6
3.00 13 3.7 3.7 8.3
Valid
4.00 224 64.0 64.0 72.3
5.00 97 27.7 27.7 100.0
Total 350 100.0 100.0
Que16

Percent
1.00 5 1.4 1.4 1.4
2.00 15 4.3 4.3 5.7
3.00 16 4.6 4.6 10.3
Valid
4.00 240 68.6 68.6 78.9
5.00 74 21.1 21.1 100.0
Total 350 100.0 100.0
308
Que17

Percent
1.00 2 .6 .6 .6
2.00 12 3.4 3.4 4.0
3.00 29 8.3 8.3 12.3
Valid
4.00 242 69.1 69.1 81.4
5.00 65 18.6 18.6 100.0
Total 350 100.0 100.0
Que18

Percent
1.00 5 1.4 1.4 1.4
2.00 13 3.7 3.7 5.1
3.00 25 7.1 7.1 12.3
Valid
4.00 231 66.0 66.0 78.3
5.00 76 21.7 21.7 100.0
Total 350 100.0 100.0
Que19

Percent
1.00 1 .3 .3 .3
2.00 8 2.3 2.3 2.6
3.00 18 5.1 5.1 7.7
Valid
4.00 248 70.9 70.9 78.6
5.00 75 21.4 21.4 100.0
Total 350 100.0 100.0
309
Que20

Percent
1.00 4 1.1 1.1 1.1
2.00 8 2.3 2.3 3.4
3.00 18 5.1 5.1 8.6
Valid
4.00 255 72.9 72.9 81.4
5.00 65 18.6 18.6 100.0
Total 350 100.0 100.0
Que21

Percent
1.00 6 1.7 1.7 1.7
2.00 10 2.9 2.9 4.6
3.00 29 8.3 8.3 12.9
Valid
4.00 239 68.3 68.3 81.1
5.00 66 18.9 18.9 100.0
Total 350 100.0 100.0
Que22

Percent
1.00 4 1.1 1.1 1.1
2.00 13 3.7 3.7 4.9
3.00 36 10.3 10.3 15.1
Valid
4.00 238 68.0 68.0 83.1
5.00 59 16.9 16.9 100.0
Total 350 100.0 100.0
310
Que23

Percent
1.00 7 2.0 2.0 2.0
2.00 14 4.0 4.0 6.0
3.00 37 10.6 10.6 16.6
Valid
4.00 230 65.7 65.7 82.3
5.00 62 17.7 17.7 100.0
Total 350 100.0 100.0
Que24

Percent
1.00 6 1.7 1.7 1.7
2.00 6 1.7 1.7 3.4
3.00 41 11.7 11.7 15.1
Valid
4.00 223 63.7 63.7 78.9
5.00 74 21.1 21.1 100.0
Total 350 100.0 100.0
311
Crosstabs
HYPOTHESIS-1
Notes
Output Created 27-APR-2014 08:04:34
Comments
C:\Users\User\Desktop\New
Data
PH D\Prof Bedi\Data.sav
Active Dataset DataSet1
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are treated as missing.
Statistics for each table are
Missing Value Handling based on all the cases with
Cases Used valid data in the specified
range(s) for all variables in
each table.
CROSSTABS
/TABLES=Type_of_Hosp
BY Tangible_level
Reliability_level
Response_level
Assurance_level
Syntax
Empathy_level
/FORMAT=AVALUE
TABLES
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Processor Time 00:00:00.02
Elapsed Time 00:00:00.01
Resources
Dimensions Requested 2
Cells Available 174762
Type_of_Hosp * Tangible_level
312
Crosstab
Count
Type_of_Hosp Tangible_level Total
High Low Medium
Total 95 35 220 350
Chi-Square Tests

6.60.
Type_of_Hosp * Reliability_level
Crosstab
Count
Type_of_Hosp Reliability_level Total
High Low Medium
Total 48 39 263 350
Chi-Square Tests

313
7.35.
Type_of_Hosp * Response_level
Crosstab
Count
Type_of_Hosp Response_level Total
High Low Medium
Total 36 39 275 350
Chi-Square Tests

6.79.
Type_of_Hosp * Assurance_level
Crosstab
Count
Assurance_level Total
High Low Medium
Type_of_Hosp
Total 60 34 256 350
Chi-Square Tests
Value df Asymp. Sig. (2-
sided)
314
6.41.
Type_of_Hosp * Empathy_level
Crosstab
Count
Empathy_level Total
High Low Medium
Type_of_Hosp
Total 65 38 247 350
Chi-Square Tests

7.17.
Report
Mean
Type_of_Hosp Tangible Reliability Response Assurance Empathys
score score score score core
Private hospital 82.9343 80.5458 79.1784 80.2113 79.1080
Public hospital 90.4040 91.7424 86.4646 84.7475 80.2020
Total 84.3429 82.6571 80.5524 81.0667 79.3143
315
Notes

Comments
C:\Users\User\Desktop\N
Data ew PH D\Prof
Bedi\Data.sav
Input Filter <none>
Weight <none>
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350
Data File
User-defined missing
Definition of Missing values are treated as
missing.
Statistics for each table
Missing Value Handling
are based on all the cases
Cases Used with valid data in the
specified range(s) for all
variables in each table.
CROSSTABS
/TABLES=Region BY
Tangible_level
Reliability_level
Response_level
Assurance_level
Syntax
Empathy_level
/FORMAT=AVALUE
TABLES
/STATISTICS=CHISQ
/CELLS=COUNT
/COUNT ROUND CELL.
Resources
Region * Tangible_level
316
Crosstab
Count
Tangible_level Total
High Low Medium
Mumbai 29 18 105 152
Region Pune 10 2 42 54
Surat 26 6 24 56
Thane 19 3 16 38
Total 95 35 220 350
Chi-Square Tests
sided)
a. 1 cells (6.7%) have expected count less than 5. The minimum expected count is
3.80.
City * Reliability_level Hypothesis-2
Crosstab
Count
Reliability_level Total
High Low Medium
Mumbai 22 22 108 152
Surat 0 6 50 56
Thane 20 2 16 38
Total 48 39 263 350
317
Chi-Square Tests
sided)
4.23.
Region * Response_level
Crosstab
Count
Response_level Total
High Low Medium
Mumbai 15 28 109 152
Surat 1 5 50 56
Thane 7 2 29 38
Total 36 39 275 350
Chi-Square Tests
Value df Asymp. Sig.
(2-sided)
3.91.
318
Region * Assurance_level
Crosstab
Count
High Low Medium
Mumbai 23 19 110 152
Surat 0 7 49 56
Thane 15 4 19 38
Total 60 34 256 350
Chi-Square Tests

(2-sided)
3.69.
Region * Empathy_level
Crosstab
Count
Region Empathy_level Total
High Low Medium
Mumbai 23 12 117 152
Pune 2 1 51 54
Surat 1 3 52 56
Thane 7 18 13 38
Total 65 38 247 350
319
Chi-Square Tests

(2-sided)
4.13.
ANOVA
Sum of df Mean F Sig.

Squares Square
Between
2530.482 4 632.620 3.367 .010
Tangible_ Groups
Total 67354.413 349
Between
4460.869 4 1115.217 7.906 .000
Reliability_ Groups
Total 53128.857 349
Between
4493.333 4 1123.333 9.546 .000
Response_ Groups
Total 45093.206 349
Between
3029.361 4 757.340 6.925 .000
Assurance_ Groups
Total 40757.333 349
Between
6811.215 4 1702.804 11.854 .000
Empathy_ Groups
3score Within Groups 49557.547 345 143.645
Total 56368.762 349
320
Report
Mean
Region Tangible Reliability Response Assurances Empathy

score score score core score
Mumbai 82.0175 80.9868 78.3772 80.3070 78.9912
Navi
86.5333 85.7000 88.4000 86.0000 88.0000
Mumbai
Pune 83.0864 79.9074 79.8765 80.3704 79.6296
Surat 86.0714 81.0714 78.0952 76.6667 78.0952
Thane 90.0000 91.5789 83.5088 85.0877 70.5263
Total 84.3429 82.6571 80.5524 81.0667 79.3143
321
Notes

Comments
C:\Users\User\Desktop\
Data New PH D\Prof
Bedi\Data.sav
Input Filter <none>
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CROSSTABS
/TABLES=Gender BY
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Reliability_level
Response_level
Assurance_level
Syntax Empathy_level
/FORMAT=AVALUE
TABLES
/STATISTICS=CHISQ
/CELLS=COUNT
/COUNT ROUND
CELL.
Resources
Gender * Tangible_level Hypothesis-3
322
Crosstab
Count
High Low Medium
Female 39 10 93 142
Gender
Male 56 25 127 208
Total 95 35 220 350
Chi-Square Tests
sided)
14.20.
Gender * Reliability_level
Crosstab
Count
High Low Medium
Female 21 13 108 142
Gender
Male 27 26 155 208
Total 48 39 263 350
323
Chi-Square Tests
(2-sided)

15.82.
Gender * Response_level
Crosstab
Count
High Low Medium
Female 19 20 103 142
Gender
Male 17 19 172 208
Total 36 39 275 350
Chi-Square Tests
sided)

14.61.
324
Gender * Assurance_level
Crosstab
Count
High Low Medium
Female 30 13 99 142
Gender
Male 30 21 157 208
Total 60 34 256 350
Chi-Square Tests

13.79.
Gender * Empathy_level
Crosstab
Count
Empathy_level Total
High Low Medium
Female 25 20 97 142
Gender
Male 40 18 150 208
Total 65 38 247 350
Chi-Square Tests
(2-sided)

325
15.42.
ANOVA
Squares Square
Between
398.207 1 398.207 2.070 .151
Groups
Tangible_
Within
score 66956.206 348 192.403
Groups
Total 67354.413 349
Between
193.197 1 193.197 1.270 .261
Groups
Reliability_
Within
score 52935.660 348 152.114
Groups
Total 53128.857 349
Between
24.108 1 24.108 .186 .666
Groups
Response_
Within
score 45069.098 348 129.509
Groups
Total 45093.206 349
Between
139.586 1 139.586 1.196 .275
Groups
Assurance_
Within
score 40617.747 348 116.718
Groups
Total 40757.333 349
Between
80.905 1 80.905 .500 .480
Groups
Empathy_
Within
score 56287.857 348 161.747
Groups
Total 56368.762 349
Report
Mean
Gender Tangible_ Reliability_ Response_ Assurance_ Empathy_
Female 85.6338 83.5563 80.2347 81.8310 78.7324
Male 83.4615 82.0433 80.7692 80.5449 79.7115
Total 84.3429 82.6571 80.5524 81.0667 79.3143
326
Crosstabs
Notes
Comments
C:\Users\User\Desktop\New
Data
PH D\Prof Bedi\Data.sav
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Cases Used valid data in the specified
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CROSSTABS
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Response_level
Assurance_level
Syntax
Empathy_level
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TABLES
/STATISTICS=CHISQ
/CELLS=COUNT
/COUNT ROUND CELL.
Resources
327
Age_of_respondent * Tangible_level Hypothesis-4
Crosstab
Count
High Low Medium
Elderly 36 5 73 114
Age_of_respondent Middle 43 5 61 109
Young 16 25 86 127
Total 95 35 220 350
Chi-Square Tests

10.90.
Age_of_respondent * Reliability_level
Crosstab
Count
High Low Medium
Elderly 18 8 88 114
Young 14 25 88 127
Total 48 39 263 350
328
Chi-Square Tests
(2-sided)
12.15.
Age_of_respondent * Response_level
Crosstab
Count
High Low Medium
Elderly 12 8 94 114
Young 12 25 90 127
Total 36 39 275 350
Chi-Square Tests
(2-sided)
11.21.
329
Age_of_respondent * Assurance_level
Crosstab
Count
High Low Medium
Elderly 20 6 88 114
Young 21 22 84 127
Total 60 34 256 350
Chi-Square Tests

(2-sided)
10.59.
Age_of_respondent * Empathy_level
Crosstab
Count
Empathy_level Total
High Low Medium
Elderly 24 12 78 114
Young 26 22 79 127
Total 65 38 247 350
330
Chi-Square Tests

(2-sided)
11.83.
ANOVA
Squares Square
Between
3584.949 2 1792.474 9.754 .000
Tangible_ Groups
Total 67354.413 349
Between
1714.597 2 857.299 5.786 .003
Reliability_ Groups
Total 53128.857 349
Between
658.120 2 329.060 2.570 .078
Response_ Groups
Total 45093.206 349
Between
298.720 2 149.360 1.281 .279
Assurance_ Groups
Total 40757.333 349
Between
744.583 2 372.291 2.322 .100
Empathy_ Groups
Total 56368.762 349
331
Report
Mean
Age_of_respon Tangible Reliability Response Assurance Empathy

dent score score score score score
Elderly 86.6082 84.2982 81.4620 81.7544 80.0000
Middle 86.9113 84.3578 81.7125 81.7737 80.7951
Young 80.1050 79.7244 78.7402 79.8425 77.4278
Total 84.3429 82.6571 80.5524 81.0667 79.3143
332
Crosstabs
Notes
Comments
C:\Users\User\Desktop\N
Data ew PH D\Prof
Bedi\Data.sav
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Response_level
Assurance_level
Syntax
Empathy_level
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TABLES
/STATISTICS=CHISQ
/CELLS=COUNT
/COUNT ROUND CELL.
Resources
333
Monthly_Income * Tangible_level Hypothesis- 5
Crosstab
Count
High Low Medium
HIGH 47 16 132 195
Monthly_Income LOW 18 7 27 52
MEDIUM 30 12 61 103
Total 95 35 220 350
Chi-Square Tests
(2-sided)
5.20.
Monthly_Income * Reliability_level
Crosstab
Count
High Low Medium
HIGH 7 16 172 195
MEDIUM 23 15 65 103
Total 48 39 263 350
334
Chi-Square Tests

(2-sided)
5.79.
Monthly_Income * Response_level
Crosstab
Count
High Low Medium
HIGH 8 17 170 195
MEDIUM 22 12 69 103
Total 36 39 275 350
Chi-Square Tests
(2-sided)

5.35.
335
Monthly_Income * Assurance_level
Crosstab
Count
High Low Medium
HIGH 15 13 167 195
MEDIUM 31 14 58 103
Total 60 34 256 350
Chi-Square Tests
(2-sided)

5.05.
Monthly_Income * Empathy_level
Crosstab
Count
Empathy_level Total
High Low Medium
HIGH 14 16 165 195
MEDIUM 38 9 56 103
Total 65 38 247 350
336
Chi-Square Tests

a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 5.65.
ANOVA
Squares Square
Between
267.690 2 133.845 .692 .501
Tangible_ Groups
Total 67354.413 349
Between
1218.998 2 609.499 4.074 .018
Reliability_ Groups
Total 53128.857 349
Between
1060.600 2 530.300 4.179 .016
Response_ Groups
Total 45093.206 349
Between
674.798 2 337.399 2.921 .055
Assurance_ Groups
Total 40757.333 349
Between
1531.507 2 765.754 4.846 .008
Empathy_ Groups
Total 56368.762 349
337
Report
Mean
Monthly_Inco Tangible_ Reliability_ Response_ Assurance_ Empathy
me score score score score score
HIGH 83.5897 81.0000 79.1453 79.8291 78.4274
LOW 85.7692 85.0962 80.7692 82.6923 76.5385
MEDIUM 85.0485 84.5631 83.1068 82.5890 82.3948
Total 84.3429 82.6571 80.5524 81.0667 79.3143
Crosstabs
Notes

Comments
C:\Users\User\Desktop\New PH
Data
D\Prof Bedi\Data.sav
Input Filter <none>
Weight <none>
Split File <none>
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based on all the cases with valid
Cases Used
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all variables in each table.
CROSSTABS
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BY Tangible_level
Reliability_level Response_level
Syntax Assurance_level Empathy_level
/FORMAT=AVALUE TABLES
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/CELLS=COUNT
/COUNT ROUND CELL.

Resources
338
Frequency_of_Hosp * Tangible_level Hypothesis- 6
Crosstab
Count
High Low Medium
First time 16 15 101 132
Frequency_of_Hosp More than four times 37 7 46 90
Two to four times 42 13 73 128

Total 95 35 220 350
Chi-Square Tests
a
Pearson Chi-Square 26.236 4 .000
Frequency_of_Hosp * Reliability_level
Crosstab
Count
High Low Medium
First time 5 17 110 132

Total 48 39 263 350
Chi-Square Tests
a
339
Frequency_of_Hosp * Response_level
Crosstab
Count
High Low Medium
First time 5 15 112 132

Total 36 39 275 350
Chi-Square Tests
a
Frequency_of_Hosp * Assurance_level
Crosstab
Count
High Low Medium
First time 12 16 104 132

Total 60 34 256 350
340
Chi-Square Tests
a
Frequency_of_Hosp * Empathy_level
Crosstab
Count
Empathy_level Total
High Low Medium
First time 17 12 103 132

Total 65 38 247 350
Chi-Square Tests
a
341
ANOVA
Sum of df Mean Square F Sig.

Squares
Between Groups 2828.307 2 1414.154 7.605 .001

Tangible_
Within Groups 64526.105 347 185.954
score
Total 67354.413 349
Between Groups 3159.393 2 1579.697 10.970 .000
Reliability_
Within Groups 49969.464 347 144.004
score
Total 53128.857 349
Between Groups 501.186 2 250.593 1.950 .144
Response_
Within Groups 44592.020 347 128.507
score
Total 45093.206 349
Between Groups 766.660 2 383.330 3.326 .037
Assurance_
Within Groups 39990.673 347 115.247
score
Total 40757.333 349
Between Groups 366.402 2 183.201 1.135 .323
Empathy_
Within Groups 56002.360 347 161.390
score
Total 56368.762 349
Report
Mean
Frequency_of_Hosp Tangible Reliability Response Assurance Empathy
First time 80.7071 79.6591 79.0909 79.2929 79.0909

More than four
86.9630 87.3333 82.0000 81.3333 77.9259
times
Two to four times 86.2500 82.4609 81.0417 82.7083 80.5208
Total 84.3429 82.6571 80.5524 81.0667 79.3143
342
Crosstabs
Notes

Comments
C:\Users\User\Desktop\New PH
Data
D\Prof Bedi\Data.sav
Input Filter <none>
Weight <none>
Split File <none>
N of Rows in Working Data File 350
User-defined missing values are
treated as missing.
Statistics for each table are based
on all the cases with valid data in
Cases Used
the specified range(s) for all
CROSSTABS
/TABLES=Type_of_Hosp BY
Monthly_Income
Syntax /FORMAT=AVALUE TABLES
/STATISTICS=CHISQ
/CELLS=COUNT
/COUNT ROUND CELL.

Resources
Type_of_Hosp * Monthly_Income Crosstabulation

Count
Monthly_Income Total
HIGH LOW MEDIUM

Type_of_Hosp
Total 195 52 103 350
343
Chi-Square Tests

Correlations
Tangible Reliability Response Assurance Empathy
Pearson
1 .737** .576** .615** .400**
Tangible_ Correlation
score Sig. (2-tailed) .000 .000 .000 .000
N 350 350 350 350 350
Pearson
.737** 1 .718** .774** .557**
Reliability_ Correlation
score Sig. (2-tailed) .000 .000 .000 .000
N 350 350 350 350 350
Pearson
.576** .718** 1 .713** .675**
Response_ Correlation
score Sig. (2-tailed) .000 .000 .000 .000
N 350 350 350 350 350
Pearson
.615** .774** .713** 1 .624**
Assurance_ Correlation
score Sig. (2-tailed) .000 .000 .000 .000
N 350 350 350 350 350
Pearson
Empathy_ .400** .557** .675** .624** 1
Correlation
score
Sig. (2-tailed) .000 .000 .000 .000
N 350 350 350 350 350
**. Correlation is significant at the 0.01 level (2-tailed).
344

Impact of Healthcare Services On Outpatient Satisfaction in Public and Private Hospitals A Study of Hospitals in Mumbai Navi Mumbai Thane Pune and Surat Satvinder Singh Bedi PDF

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Impact of Healthcare Services On Outpatient Satisfaction in Public and Private Hospitals A Study of Hospitals in Mumbai Navi Mumbai Thane Pune and Surat Satvinder Singh Bedi PDF

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Impact of Healthcare services on Outpatient Satisfaction in

Public and Private Hospitals: A study of Hospitals in Mumbai,

Thesis Submitted to D.Y.Patil University, Navi Mumbai

D.Y. Patil University, Navi Mumbai

Date: Signature of the student

Enrolment No: DYP-PhD-116100009

Signature of the Signature of the Guide

I am greatly indebted to D. Y. Patil University, Department of Business Management

I am extremely grateful to Prof Dr R. Gopal my guide, for his professional

I express special thanks:

Chapter No Title Page

1.2 Human Resource Management in Indian Hospitals 3

1.3 Emerging Healthcare in India 5

1.4 Understanding Indian Healthcare 6

1.5 Surveys of inpatients and outpatients widely used 8

1.6 Patient care Innovation 11

1.7 Patient Satisfaction 12

1.8 Service Encounter 14

1.9 Healthcare Business Process 16

1.10 ERP Systems in Healthcare Institutions 19

1.11 Gaining Patients Trust 21

1.12 Human Performance Improvement in the Health Care 25

1.13 Retaining Customers 27

Factors affecting patient satisfaction and healthcare 30

1.16 The service quality dimensions and patient satisfaction 31

Community Hospital Healthcare System 61

4 GLOBAL HEALTHCARE SCENARIO 81

4.1 The global healthcare services market 81

4.2 Healthcare adapts to a global outlook 81

4.3 Global Healthcare Industry 82

4.4 Key Market Segments 83

4.5 Market Overview 84

4.6 Market Segmentation 84

4.7 Geography segmentation 84

4.8 Healthcare in the Global Market place 85

4.9 International Healthcare Ventures 86

4.10 Global Healthcare Strategies 87

4.11 Health Insurance 89

4.12 Preparing the 21st century global healthcare workforce 89

4.13 Movement of Personnel 91

4.14 Push and Pull Factors 92

4.15 Nursing Shortage: A global problem 93

4.16 Outsourcing in the Healthcare sector 97

INDIAN HEALTHCARE INDUSTRY 106

Hospital Services Market in India 128

Table No Title Page

2. Sample size (Respondents ) 79

3. Type of Hospital 160

5. Age group 162

7. Frequency of visit 164

8. Monthly Income 165

10. Tangible score 168

11. Tangible level 168

12. Reliability 169

13. Reliability score 170

14. Reliability level 171

15. Responsiveness 172

16. Response score 173

17. Response level 173

18. Assurance 174

19. Assurance score 175

20. Assurance level 176

21. Empathy 177