Service quality in hospitals

Dr J Sivakumaran

If a comparison is made between any two leading branded hospitals of a city, we can always find that the facilities/infrastructure/ equipment/technology are all at par with each other. Even in the tariff, difference would be minimal. Other parameters being equal, what is driving the patients to prefer a particular hospital? For example, when all the nationalised banks offer the same interest rate, why we chosse to operate with a particular bank? Social scientists have found that service quality is an important element in this decision making process. Hospitals may appear to offer the same variety of services but the quality may not be the same. Superficially, the services may look alike but the experiences will not be alike. So, if service quality is the main criteria for choosing a hospital, how do we measure whether a hospital has met the expected level of service quality or not?

Measuring of service quality is always not an easy task. Products can be measured as they are tangible, homogeneous and separable. But services are totally different. The services are intangible, heterogeneous and inseparable. When there is no object to measure then how far will anyone be successful in assessing and measuring service quality? This is the challenge before us. The only way to do it is by measuring consumers’ perceptions of quality. There is no yardstick to quantitatively measure the consumers’ perceptions which are more subjective. The consumer’s judgment on overall excellence of a service is the perceived quality. Perceived service quality is the degree of variations between consumers’ perceptions and expectations. Quality ought to be seen as manifested and felt as expected.

Hospitals have two types of quality. One is technical quality and the other is functional quality. Technical quality is ‘what patients get’ and functional quality is ‘how they get it’. In other words, technical quality is the level of accuracy of the diagnoses and procedures while functional quality is the manner in which the services are delivered.

Assume that a patient has a heart problem. Right from diagnosing the blockage, assessment of patient, doing the procedure, post operative care etc., till medicine prescribing before discharge is classified as a technical quality. The waiting time at OPD/ billing/cathlab/OT/discharge, well behaved hospital staff, communication on progress of the patient to relatives, neatness of the room/linen/wash rooms, taste of food served etc., would form part of functional quality.

Knowledge of technical quality of healthcare services remain within the purview of healthcare professionals. The patients do not have sufficient knowledge to understand and assess the technical quality. In the absence of this, they only try to observe, understand and asses the functional quality. There are evidences to suggest that perception of functional quality is the single most important variable influencing consumer’s value perceptions. In association with the Marketing Science Institute, a scale called SERVQUAL was developed by researchers. It measures the gap between perception and expectation of the patients and this is considered to be the yardstick for judging the quality of a hospital. For a scientific evaluation of a hospital, questionnaires based on SERVQUAL scale have to be answered by patients before and after the service experience. After analysing these questionnaires, we will come to know the level of satisfaction of the patients and quality of service provided by the hospital. This will be a time/resource consuming exercise. But this is a scientific method authenticated by researchers.

In any activity, if there is a difference between expectations (before availing services) and experience (after availing services), there will be a gap of unfulfilled satisfaction. The more the closeness of these two, the less will be the gap. Based on the SERVQUAL model, there are five identified gaps which are essential for hospitals to identify and narrow down to improve the quality. These five gaps are

1. Knowledge gap
2. Standards gap
3. Delivery gap
4. Communication gap
5. Perception /expectation gap (net result of gaps 1 to 4).

Gap 1: The knowledge gap arises out of the differences between the expectations of the customer and management perceptions of customer expectations. For example, hospitals will have a mix of rooms to suit various strata of society. Assume that based on a market survey, a hospital is constructed with more number of rooms in private/suite category and less number of rooms in general/semi private category. But if the patients’ demand is more for general/semi private rooms than private/suite rooms, then there is a mismatch and gap. Not understanding the market pulse and insufficient market research would lead to these problems.

Gap 2: The standards gap is the difference between the management perceptions of customer expectations and service quality specifications. This arises due to the inadequate commitment to service quality by the management, absence of service quality goals and the lack of perception of feasibility. For example, in a sample collection room, proper identification of patients, using a disposable vacutainer, using disposable gloves for each patient, proper protocol for labelling the sample etc. are required as standards to improve quality. In the absence of such standards, quality will downslide and a gap will arise.

Gap 3: The delivery gap is the difference between service quality specifications and actual service delivery. This happens due to the role ambiguity, role conflict, poor employee or technical knowledge fit, poor supervision and lack of team work. If the standards mentioned in the example of Gap 3 is only at a policy level and not implemented and followed by the concerned staff, then there is a gap. Mere documentation of standards will not be sufficient but it should be functionally in place to avoid this gap.

Gap 4: The communication gap is found, when service delivery promises do not match the actual delivery. This is due to the inadequate horizontal communication between various departments and due to the habit of over promising by the hospitals to attract the patients. Always hospitals should try to propagate what could be actually delivered by them. The level of expectations of the patients shall be in line with the promises made. But if the actual delivery is not up to the promised level, then there will be a gap.

Gap 5: The perception/ expectation gap is the resultant of Gaps 1 to 4. This happens due to a difference between the patient’s expectations and the actual experience on a particular/overall service. The expectation of a patient about a hospital or a particular service in a hospital is influenced by external communication, word of mouth messages, past experiences and brand knowledge. The level of satisfaction will be directly proportional to the level at which the perceived expectations match with the actual experiences.

If a patient’s expectations are not met, then he is dissatisfied. If his expectations are met he is satisfied. If it exceeds, he is delighted. Hence, it is necessary for the hospitals to focus on creating patient delightfulness to build up the reputation and image. This exercise could not be done on an on-going and a day-to-day basis. Though patient feedback forms are not an alternative to SERVQUAL method of evaluation, the patient feedback forms, if it is utilised properly, are more informative, practical and useful. It should be ensured that every patient is filling up this form before discharge happens. If these forms are genuinely analysed with intention to improve the service, we will get lot of clues from this. It is not possible to rectify/implement all the suggestions given by them. Hospitals will have lot of financial/space constraints. But complaints/suggestions which are having possibilities of rectification/implementation by the hospitals should be attempted without delay. This will highlight how much scope is there for hospitals to improve. For example, if a general ward patient wants toilet to be nearer his bed, it will be difficult to modify and satisfy the patient. But if the general ward patient suggests having a call bell inside the toilet room (to call someone in case of emergency), it will be a useful suggestion and could be implemented without much cost. If we treat the complaints as a gift given by the patients, then sky is the limit for improvement.

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