A case study of travancore medical college hospital kerala, india
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    A case study of travancore medical college hospital kerala, india A case study of travancore medical college hospital kerala, india Document Transcript

    • Critically evaluate service quality as a determinant factor for patient satisfaction in gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala, India. BY ANEESH POOCHAPANDIYIL VELAYUDHAN PRASANNANSUPERVISOR : MR. CILLIERS DIEDERICKSWALES ID : 1092227390326KCB ID : 15040Submitted in fulfilment of the requirements of the Taught Masters Dissertation to theUniversity of Wales, for the degree of Masters in Business Administration (MBA).1    
    • USN:  1092227390326              2012                   DECLARATION This research work is purely the author’s own effort where the ideas of otherscholars and authors are referenced using the Harvard Referencing style. It has notbeen previously accepted in substance in any degree and in not being concurrentlysubmitted in candidature in any degree This dissertation is the result of my own investigation, except where otherwisestate, where correction services have been used, the extent and nature of thecorrection is clearly marked in footnote(s). The ethical issues have been kept intoconsideration during the preparation of this report and the responses of theindividuals to the research survey are kept confidential. I hereby give consent for my work, if accepted to be available forphotocopying and for inter-library loan, and for the title and summary to be madeavailable to outside organizations.Signed ……………………………………………………….. (Candidate)Date: 14/02/2012     2    
    • USN:  1092227390326              2012                Table of contents Page No. 1. Introduction 1 1.1 Research background 2 1.2 Research Aim 4 1.3 Objectives 4 1.4 Rationale for choosing the research topic 5 1.5 Company profile 6 1.6 Conclusion 7 2. Literature review 7 2.1 Introduction 7 2.2 Aims and objectives 7 2.3 Literature Review 8 2.4 Service Quality Conceptualization 8 2.5 Dimensions of service quality 11 2.6 Measuring Service quality 12 2.6.1. Gap Model 13 2.6.2 SERVQUAL Model 15 2.6.2.1 Advantage of SERVQUAL Model 18 2.6.2.2 Criticism of SERVQUAL Model 18 2.6.3 SERVPERF Model 20 2.7 .Patient satisfaction 20 2.8. Patient satisfaction and its dimensions 23 2.9 .Theories of customer satisfaction 24 2.10. Measure of customer satisfaction 24 2.11. Patient Loyalty 25 2.12 Importance of custom loyalty 26 2.13 Measurement of patient loyalty 27 2.14 Service quality and customer satisfaction relationship. 29 2.15 Service quality and customer loyalty relationship 29 2.16 Customer satisfaction and customer loyalty relationship 29 2.18 Conclusion 30 3    
    • USN:  1092227390326              2012                 3. Research Methodology 3.1 Introduction 31 3.2 Aims and objectives 31 3.3 Research Methodology 31 3.4 Research Design 32 3.4.1 Exploratory Research 33 3.4.2 Descriptive research 33 3.4.3 Explanatory research 33 3.4.4 Justification for research design 33 3.5 Research Philosophy 34 3.5.1 Epistemology 34 3.5.2 Positivism 34 3.5.3 Realism 34 3.5.4 Interpretivism 35 3.5.5 Ontology 35 3.5.5.1 Subjectivism 35 3.5.5.2 Objectivism 35 3.5.6 Axiology 35 3.5.7 Justification of research philosophy 36 3.6 Research approach 36 3.6.1 Justification of research approach 37 3.7 Research Strategy 38 3.7.1Quantitative data 38 3.7.2 Qualitative data 38 3.7.3 Justification of research strategy 38 3.8 Source of data 38 3.8.1 Primary data 39 3.8.2 Justification of primary data 40 3.8.3 Secondary data 40 3.8.4 Types of secondary data 41 3.8.5 Justification of secondary data 41 4    
    • USN:  1092227390326              2012                 3.9 Sampling 42 3.9.1 Probability sampling or Representative sampling 42 3.9.2 Non Probability Sampling or judgemental sampling 42 3.9.3 Justification of sampling 42 3.10 Conclusion 42 4. Research findings and Analysis 4.1 Introduction 43 4.2 Aim and Objective 43 4.3 Analysis of primary data 44 4.4 Comparing primary data with secondary data 65 4.5 Conclusion 67 5. Conclusion and Recommendation 5.1 Introduction 69 5.2 Aim and Objective 69 5.2.1 Achievement of objective 1 69 5.2.2 Achievement of objective 2 70 5.2.3Achievement of objective 3 72 5.2.4 Achievement of objective 4 72 5.3Conclusion 73 5.4Research limitation 73 5.5Recommendations 74 5.5.1 Recommendation 1 74 5.5.2 Recommendation 2 77 5.5.3 Recommendation 3 80 5.5.4 Recommendation 4 82 5.5.5 Recommendation 5 82 5.5.6 Recommendation 6 84 5.5.7 Recommendation 7 84 5.5.8 Recommendation8 84 6. Reflective summary 85 5    
    • USN:  1092227390326              2012                7 Reference 868 .LIST OF FIGURES1. Fig 2.1 Gap Model 142. Fig 2.2 Measurement of patient loyalty 273. Fig 2.3 Patient loyalty and service quality model 284. Fig 2.4 The relationship between service quality, Customer satisfaction and customer loyalty. 305. Fig 3.1 Research onion 326. Fig 3.2 Source of Data 397.Fig 3.3 Primary data 408.Fig 3.4 Secondary data 41 9. List of Tables1. Table 2.1 22 Items of SERVQUAL instruments 172. Table 2.2 Customer Benefits 263. Table 3.1 Types of Research Design 334. Table 3.2 Research Approach 375.Table 4.22 Patient satisfactory 656. Table 5.1 Gantt Chart of ERP 767. Table 5.2 Gantt Chart of recruitment of HR trainers 798. Table 5.3 Gantt chart of CCTV 819.Table 5.4 Gantt chart of purchase of medicines 839.List of Charts 1. Chart 4.1 Distribution of sample size according to age and sex 44 2. Chart 4.2 The reason for choosing hospital 45 3. Chart 4.3 The receptionist was friendly and courteous 46 4. Chart 4.4 The staff respects the patient with respect ,dignity and were Courteous in the hospital 47 5. Chart 4.5 There is a lot of paper work for admission 48 6    
    • USN:  1092227390326              2012                 6. Chart 4.6 The service cost for hospital is affordable. 497. Chart 4.7 All the staffs were in correct uniform 508. Chart 4.8 Hospital is visually attractive 519. Chart 4.9 Hospital is a convenient location 5210 Chart 4.10 Hospital has good directional science 5311. Chart 4.11 Hospital provides services at allocated time 5412. Chart 4.12 Hospital department is working effectively 5513 Chart 4.13 You felt ease during your appointment 5614 Chart 4.14 Doctors listen carefully and adhered to your needs 5715 Chart 4.15 Hospital addresses the patient complaint quickly 5816 Chart 4.16 Do you think staff responded immediately 5917 Chart 4.17 Hospital employee are sympathetic and re assuring 6018 Chart 4.18 Hospital doctor prescribes affordable medicine 6119 Chart 4.19 Average waiting time in the hospital 62 20 Chart 4.20 Charges of TMC hospital is affordable 63 21 Chart 4.21 Recommending hospital to the friends and relatives 6410. 1 Appendix 1 92 2. appendix 2 7    
    • USN:  1092227390326              2012                Chapter 1 Introduction1 Introduction All business organisations including health care organisation are interested inachieving long term financial success (Al Hawary et al., 2011). Healthcare is one ofthe most important elements of life and people always demand a better quality ofhealth to have a healthy life. This patient centric approach and consumer satisfactionbecame the fundamental requirement for healthcare providers (Desai, 2011).In therecent years the number of private and public hospitals had been increasedtremendously. In order to gain competitive advantages in the health care industryand improve the operative efficiency the hospitals have adopted quality improvementmeasures (Yasin et al., 2011) . Likewise Bullet (1996) had identified service qualityas a corporate market strategy and financial performance driver and had stated thatthe hospitals can achieve competitive advantage and operational efficiency byadopting service quality as a strategic tool. According to Shaktivel et.al (2005)customer satisfaction is one of the critical factors that judges the service qualitydelivered to the customers (Shaktivel et.al (2005); cited by Ooi et al., 2011).Impact ofpatient satisfaction in choosing hospitals are important. Research had shown thatthere are links between patient satisfaction and healthcare quality (Kessler & Mylod,2011). Woodruff in 1997 had pointed out that service providers consider customerloyalty as a competitive advantage. Many researches had proved that enhancedcustomer loyalty increase profitability of the organisation (Woodruff (1997); cited byWang & Wu, 2012). On the other hand Strasser et.al in 1995 had stated thatnegative word of mouth can cause hospitals a revenue loss of 6000$ to 400,000 $(Naidu, 2009).With the increasing no of private and public hospitals the completion tobe the top health care provider is intense. The private hospitals compete with eachother to provide the best healthcare. According to Lim and Tag (2000) the publicawareness and rising literacy rate in the population made healthcare providers toprovide high quality treatment to the patient. Every patient have expectations whattheir health care centre is going to provide them .Every healthcare centres should 8    
    • USN:  1092227390326              2012                give attention to reduce the gap between what patients actually expects and theservice that is actually delivered. (Lim and Tag (2000); cited by Suki et al., 2011). Inthis research the author will be evaluating service quality as a determinant factor forpatient satisfaction in gaining patient loyalty. First of all the author begins with the research background then the author haddiscussed about research aims and objectives then the author had talked aboutabout the reason for choosing this research topic, the company’s background andfinally will conclude by summarizing the entire research research.1.1 Research background India has been witnessing increasing demand for quality healthcare afterglobalization. Urbanization had improved quality of life which in turn had demandedquality health care. Service quality has been chosen as an important element byconsumers for selecting hospitals (Dr.Vanniarajan & Arun, 2010).India has nowbecome a medical hub and the patients from the Western countries and other partsof Asia and Africa use undergo treatment due to due to low cost and high qualitytreatment. According to KGMP report of 2011 the healthcare industry in India willgrow from USD 79 Billion in 2012 to 280 Billion in 2020 (KMPG, 2012).Eventhougthe health care spending in India is significantly low as compared to the developedcountries and other emerging countries. The average CAGR for the healthcareindustry in the next 10 years is 21%. . In India more than 50 percent of healthcareexpenditure comes from the individual against the state level governmentcontribution of less than 30 percent (Padma et al., 2010) .According to the WHOhealth statistics 2010 private sector contributes approximately 75 % of the healthsector. The key factors for the growth of healthcare sector are Increase inpopulation, rising disposable income of the population, rising literacy rate,demographic changes by 2026 there will be an increase in geriatric population fromcurrent 96 million to 126 million which means that there will be an increaseddependence on hospitals, increase in lifestyle related diseases like cardiovasculardisease, diabetes. The health care industry in India is also facing many challengeslike lack of manpower and infrastructure. The healthcare infrastructure in India lagsbehind the global average .India has only .6 doctors per 1000 population against theglobal average of 1.3 it is evident from this finding that there is a gap of man power. 9    
    • USN:  1092227390326              2012                The no of bed available per the 1000 population is only 1.27 which is less than theglobal average of 2.6%.However in the last decade there was an increaseparticipation of private sector in the healthcare industry. In the coming years thehealthcare sector will be facing stiff competition due to increased no of privatehospitals and because of the government policies allowing 100 % FDI in hospitalsector .In order to have a competitive advantage in this highly competitiveenvironment the hospitals should improve their quality standards in lieu with theircounterparts. Hospitals should implement healthcare accreditations like JCI (Padmaet al., 2010). Despite of the growth of the healthcare industry the hospitals and other healthcare organisations are struggling to deliver quality healthcare in this competitiveenvironment (Avgar et al., 2011).The service delivery system in the recent yearshave been restructured and is now patient centric (Desai, 2011).Moreover thestudies done by Sahay (2008) shows that there is a need for improvement forcustomer service (Padma et al., 2009). In recent years concern for service qualityhad gained unprecedented levels. Service quality had now become an importantdistinguishing factor between services to gain competitive advantage (Rashid &Jusoff, 2009). According to Taner and Antony (2006) health care service has aunique position among other service due to its very nature of highly involved risk.This makes measuring service quality and patient satisfaction in healthcare settingmore important and more complex (Taner & Antony, 2006; cited by Rashid & Jusoff,2009) According to Kotler in 1998 customer loyalty is an indispensable tool for profit andnon profit organisation to sustain competitive advantage and to enhance business orservice measures (Chahal, 2008). The research done by many researchers likeBerry et .al (1989) had emphasised the fact that “good service quality leads to theretention of customers and attraction of new ones, reduced cost ,enhancedcorporate image, positive word of recommendation increases profitability of anorganisation”. Service quality has become an important element in selectinghospitals by people (Berry et .al (1989) ;Reichheld and Sasser (1990);Rust andZahorik (1993) ;Cronin et.al (2000);Kang and James (2004) ;Yoon and Suh(2004); cited by Dr.Vanniarajan & Arun, 2010).According to Analeeb (1998) was inthe point of view that hospitals who don’t give importance to customer satisfaction 10    
    • USN:  1092227390326              2012                may be inviting extinction. Service quality are of great importance for the servicemarketers because they are under the direct control of the service providers and itsconsequence may improve service satisfaction and it will influence the buyersbehavioural intention which will lead to use the service again .This will ultimately leadto customer loyalty (Padma et al., 2010).By doing this research the author can findthe gaps in the service provided by the hospital and can recommend the hospital toreduce the gap between the customers expectation and the actual service deliveredso that they can increase patient satisfaction and gain patient loyalty .1.2 Research AimCritically evaluate service quality as a determinant factor for patient satisfaction ingaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,India.1.3 Objectives 1. To review literature on service quality, patient satisfaction and patient loyalty. 2. To investigate the current service quality measures adopted by Travancore Medical College Hospital 3. To evaluate the service quality offered by Travancore Medical College Hospital and its effect on patient satisfaction in gaining patient loyalty. 4. To recommend Travancore Medical College Hospital to improve the service quality so that they can increase patient satisfaction and gain patient loyalty.1.4 Rationale for choosing the research topic Service quality is an important determinant to appraise the triumph of any entity assuccess in meeting the client’s expectation is the definitive objective of business.Customer contentment has been considered as significant success factor in today’sspirited business milieu, as they facilitate in retaining customers and maintainingmarket share. It is also not different in case of hospital. It is one of the imperativebenchmark used to measure the patient satisfaction in gaining fidelity towards thehospital. Because the totality of services rendered by the hospital to its patients isthe input en route for the patients and the contentment derived is the output. 11    
    • USN:  1092227390326              2012                Escalating customer satisfaction is vital for customer allegiance. Service providersshould always manage to improve customer satisfaction it is one of the factor bywhich the patient measures the quality of the medical services offered. Hence anattempt has been done to articulate to evaluate service quality as a determinantfactor for patient satisfaction in gaining patient loyalty, for which a case study wasdone in Travancore Medical College Hospital, one of the leading private sectorhospitals in Kerala, India.1.5 Company Profile Travancore Medical College Hospital Kerala, India. The TMCH consists of 800bedded multi speciality hospital with state of the art facilities. It is a unit of Quilonmedical trust started with the view to promote medical education and health care tothe minorities of the society with the motto “service with love”. The hospital has ahighly qualified doctor, dedicated nursing staff and a technically sound paramedicalstaff. The hospital has unique facilities like 15 bedded medical ICU unit, 15 beddedemergency ICU unit, 6 bedded neuro ICU unit. There are about 10 operationtheatres in the hospital along with other laboratory units such as biochemistry It isone of the premier medical facility for trauma, emergency, critical care andambulatory care. TMCH is one of the reputed medical emergency care centres in thesouth Kerala region, and receives most complicated referral cases from many otherhospitals. The administration and medical team are highly qualified based oneducation training. The hospital is equipped with the most advanced high technologyinstruments to provide the best treatment available. The hospital has a dedicatedhighly experienced nursing staff to avoid mal practice. They have a medical collegeand a nursing college attached to the hospital .TMCH is the leading medicaleducation provider in Kerala. They admit nearly 100 students each year. Thehospitals have the best infrastructure available and the best available medicalteachers in India. The hospital has 22 department with the most experienced andeminent doctor of Kerala. As a part of the social commitment the hospital wasproviding free treatment for the patients hospitalised in the ward. The hospital alsohas satellite centres in the interior parts of the kerala where there are no hospitalsand the patients around that place fully depend on these hospitals. As a part of theprofessional development in career the hospital proves continuing medical education 12    
    • USN:  1092227390326              2012                programmes on regular basis so that all the doctors in the hospital can participateand be updated (Travancore medical college, 2012).1.6 Conclusion The author had divided the dissertation into 5 chapters. In Chapter 1 the authorgives a brief overview of the entire research which includes the research aim andobjective a brief back ground of the health care industry and the hospital selected .In Chapter 2 the author critically reviews all available literature which are in the formsof journals, books, website and newspaper which forms the secondary data. InChapter 3 the author forms a framework for the primary analysis .The author thendiscuss about the various methods adopted in research which include researchstrategy, research approach, research philosophy, sample size and the samplingmethod used. In Chapter 4 The author will be analysing the primary data,questionnaire that were distributed to the patients of the TMC hospital and then theauthor will be comparing the findings with the secondary research. In Chapter 5 theauthor draws a conclusion from the primary and secondary research and the authorput forwards some suggestions that can improve the service quality standards ofTMCH to improve patient satisfaction so gain patient loyalty. 13    
    • USN:  1092227390326              2012                Chapter 2 Literature Review2 .1 Introduction In the present chapter author reviews the literature related to Service Quality,Patient satisfaction and Patient loyalty get a deep insight and understanding of thesetopics and to form the basis of future primary research .All the data’s that we collectboth the primary and the secondary should be compared so that the researcher candraw conclusions from it and suggest recommendation for improving the presentsituation. The author can suggest good recommendation’s only if the author hasdone a strong secondary research. So the author had made use of all the availabledata to frame a strong foundation for the research. First of all the author begins the chapter by restating the aim’s and objectiveand then begins reviewing the literature by discussing about the conceptualization ofservice quality then about the dimensions of service quality. The author had alsodiscussed the different models of service quality used to measure them. The author then had focused on patient satisfaction its dimensions and theories.The discussion then moves on to patient loyalty, importance of patient loyalty andmeasurement of patient loyalty. Finally the chapter had concluded by discussing therelationship between service quality and customer loyalty, relationship betweencustomer loyalty and customer satisfaction and the relationship between customersatisfaction and customer loyalty.2.2 Aim and objectiveCritically evaluate service quality as a determinant factor for patient satisfaction ingaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,India. 1. To review literature on service quality, patient satisfaction and patient loyalty. 14    
    • USN:  1092227390326              2012                 2. To investigate the current service quality measures adopted by Travancore Medical College Hospital 3. To evaluate the service quality offered by Travancore Medical College Hospital and its effect on patient satisfaction in gaining patient loyalty. 4. To recommend Travancore Medical College Hospital to improve the service quality so that they can increase patient satisfaction and gain patient loyalty2.3 Literature Review In the last few decades the hospitals are thriving to provide the highest possibleservice quality to its patients at a lowest possible cost. Morris and Bell (1995) hadstated that the issue of defining, measuring and monitoring the quality of healthcarehad been addressed from ancient times (Morris and Bell,1995; cited by Sivakumar &Srinivasan, 2010).According to Youseff et.al (1996) all hospitals in healthcare sectorprovides same type of service but different quality of service (Youseff et.al, 1996cited by; Suki et al., 2011). According to Berry et al (1988) with the constant increasein customer and increasing competition service quality is the key factor that majorservice companies have (Berry et.al, 1988 ; cited by Sainy, 2010).It is easy to seethat with the rising income of people and literacy rate of people they demand highquality healthcare.. In a patients view point service quality is ultimately how theyjudge the service they had encountered in the hospital which includes the interactionwith the doctors , nurses the staffs of the hospital outcome of the service. There foreservice quality of hospitals can be the key deciding factor for the selection ofhospitals2.4 Service Quality Conceptualization First of all there are different concepts for service quality to begin with initiallyTakeuchi and Quelch (1983) had assessed the service quality of healthcare by sixdimensions namely reliability, service quality, prestige, durability, punctuality andease of use (Takeuchi and Quelch, 1983; cited by Dr.Vanniarajan & Arun, 2010),Gravin (1984) had established 5 categories or approaches to the concept of qualitynamely transcendent based on degree of excellence, product based which involvesmeasurable characteristics of products, User based which involves meeting theneeds of the user, manufacturing based on the conformance with design or 15    
    • USN:  1092227390326              2012                specification and finally value based which involves how much of something isrelated to price (Gravin ,1984; cited byAl Hawary et al., 2011). Similarly Gonroos (1984) had stated “that the perceived service quality is anevaluation process where the customer compares his expectation with the servicethat he had received ’’. He had proposed that there are two types of service qualitythe functional ‘’service quality’’ and ‘’technical service quality’’. The functional servicequality is that the manner in which serve quality is delivered and technical servicequality is what actually the customer received from the service ( Gonroos 1984;citedby Alrubaiee & Feras, 2011). Later in 1990 Gonoroos had added image of serviceproviders as a third dimension which acted as a filter in consumers perception ofquality (Padma et al., 2009).However Lehitmere and Jukka (1985) had presented aholistic view to measure, monitor and operational customer perception of servicequality in health care organisation (Lehitmere and Jukka,1985; cited byDr.Vanniarajan & Arun, 2010). Bopp (1986) had developed a “medical service quality active satisfaction model”.The mode evaluates the service quality in consumption stage of patients purchasecycle”. The finding of the study revealed that the factors that that played a role inpatient evaluation include expressive caring, expressive professionalism andexpressive competence of the service interaction. The study results emphasised thatstaff’s with expressive caring, professionalism and physicians expressive caring hasa significant effect on patient satisfaction. (Bopp, 1986; cited by Sivakumar &Srinivasan, 2010) According to Parasuraman (1988) “service quality is defined as a globaljudgement or attitude, relating to overall superiority of the service’’ (Parasuraman1988; cited by Blery et al., 2011).John (1987) had developed an instrument tomeasure the construct the “perceived service quality”. The findings of the study wereencouraging for other researchers by revealing that the measure of perceivedservice quality is a multi dimensional construct containing variables namelycompetence, credibility, reliability, security, courtesy, communicativeness,understanding, availability, responsiveness, physical environment. This is inconsistent with generic dimensions of service quality which was later proposed byParasuraman et.al (1990). 16    
    • USN:  1092227390326              2012                 Woodside et.al (1989) had defined service quality in healthcare as the gapbetween patient expectation and perception (Woodside et.al,1989;cited by Wu,2011). Similarly Bower et .al in 1994 had studied 5 common attributes of qualityfrom SERVAQUAL model, of this caring and communication were found to beimportant and three of the generic SERVAQUAL dimension were related to patientsatisfaction: empathy, responsiveness and reliability (Bower et .al ,1994; cited byDr.Vanniarajan & Arun, 2010) Zeithmal and Bitner (1996) was in the point of view that service quality lies inproviding excellent or superior service than the customers expectation.(Zeithmal andBitner 1996 ;cited by Alrubaiee & Feras, 2011).Other researchers like Lytle andMokva (1992) argues that service quality satisfy the need of patient and patientevaluates the service quality on the basis of service output, service process andphysical environment (Lytle and Mokva ,1992; Wu, 2011). According to Zeithaml et.al (1990) there are 5 different gaps in service quality. a) “Word of mouth” b) “Personal needs” c) “Previous experience” d) “Service product content” e) “External communication of service providers with customers” The customer expectation is influenced by the first 3 factors and qualityperception is formed by the fourth factor. According to Maxell (1992) healthcare Service quality has 6 dimensionsnamely accessibility, acceptability, appropriateness, equity, effectiveness andefficiency which the patient considers important. The study done by Bell et.al (1993)resulted in identifying dimensions similar to Maxell except they added the dimensionPrivacy (Bell et.al 1993; cited by Sivakumar & Srinivasan, 2010). A study conducted by Fitzsimmons and Fitzsimmons (2000) included price as itis a service winner. They had defined price in terms of monetary and non monetaryand then added the dimension of time. Monetary price is the sum of the expense thecustomer had incurred to get the service. The non monetary price includes anyperceived sacrifice like the time spent, the inconvenience and physiological cost like 17    
    • USN:  1092227390326              2012                perception of risky anxiety (Fitzsimmons and Fitzsimmons, 2000; cited by Al Hawaryet al., 2011). Walter (2001) had judged the quality of service in health care organisation by“reliability, availability, credibility, security, competence of staff, understanding ofcustomer needs, responsiveness to customers, courtesy of staff, comfort ofsurroundings, communication with participants and associated goods provided withthe service”. (Walter, 2001; cited by Dr.Vanniarajan & Arun, 2010). The researchers started evaluating behavioural intentions like word of mouth asservice quality dimensions. Similarly researchers like Yavas .et.al (2004) andSwanson and Davis (2003) had done research to prove that word of mouth haveeffect on service quality. (Yavas .et.al, 2004; Swanson and Davis, 2003; cited byUrban, 2010). Likewise Sweetney et.al (2008), Dean and Lang (2008) and Murray in(1991) stated that word of mouth often lead to repurchase behaviour (Sweetneyet.al,2008; Dean and Lang ,2008; Murray,1991;cited by Urban, 2010) Vasso Eiriz and Jose Antonio Figueirideo (2005) had developed a frame work forthe evaluation of healthcare based on the relationship between customers andproviders. They had considered four quality items namely customer service, cost,location and competence of the staff. They were in the point of view that servicequality of hospitals should not be judged alone on patient’s evaluation. (Vasso Eiriz,Jose Antonio Figueirideo (2005); cited by Al Hawary et al., 2011).2.5 Dimensions of Service Quality Pollack,B.,L.(2008) had stated that “service quality is an multi dimensional construct“.Brandy and Cronin (2001) had stated that the advanced “hierarchicalconceptualization model of service quality consist of 3 dimensions namely outcomequality, physical quality and interaction quality”. “Outcome quality refers to thepatient’s assessment of the main service offered to them”. “The interaction qualityrefers to the customer’s assessment of service delivery and physical quality refers tothe customer’s evaluation of the tangible aspects of the service”. Lehtinin andLehtinin (1991) had stated that there are “three dimensions for service qualitynamely physical quality, interactive quality and corporate quality”. (Alrubaiee &Feras, 2011). 18    
    • USN:  1092227390326              2012                 The most popular conceptualization of “Service Quality”, “SERVQUAL model isbased on 5 dimensions which are illustrated in the diagram below namely (Markovic& Raspor, 2010) 1. “Tangibles” Include physical facility equipment and staffs 2. “Reliability” Includes ability to provide promised service accurately 3. “Responsiveness”, Includes willingness to provide prompt services and help customers 4. “Assurance” Includes knowledge and courtesy of employees to promote trust and confidence. 5. “Empathy”. Includes care and attention the organisation provides to the customer Responsiveness, Empathy and Assurance represents the interactive qualitySower, V. (2011) According to Bakar et.al (2008) the dimensions of service quality in healthcarequality can be studied in a two way approach. It was been divided in to clinicalquality and service quality. Clinical quality involves surgical skills, sufficient drugsand logistics which help in better outcome. The service quality includes patientexperience namely waiting time, hospital comfort, support from the providers,physical environment, appointment and visits (Bakar et.al 2008; cited by Atinga etal., 2011).2.6 Measuring service quality Most of the methods developed in the past two decades belong to a user basedparadigm and employ questionnaire to collect the data, some. (Sliwa & O’Kane,2011).The different methods for collecting service quality data are described below. 19    
    • USN:  1092227390326              2012                2.6.1 Gap model Parasuraman et.al (1985) developed a gap model to measure the attributes ofservice quality. This initial gap model which included following determinants ofservice quality. However according to Parasuraman et.al (1988) service quality cannot beconceptualised or evaluated by the traditional method used for evaluating the goodsquality because of its nature of “intangibility, heterogeneity and inseparability”.Moreover Service quality can be defined as the function difference betweencustomer expectation and perception of service performance. This results in a gapbetween the expectation and perception. Hence the model is also referred to as Gapmodel which is illustrated in the fig 2.2 (Parasuraman et.al, 1988; cited by Nassab etal., 2011). Consumer expectation described as what the consumers want and thesethey are formed from marketing, word of mouth, prior experience and personalneeds. Consumer perceptions are formed when they are experienced during theinteractions with the organisation. “Five main Gaps are identified that occur duringthe service process”. Four of these gaps occur during service provision and areinfluenced by the management and provider (Alin et al., 2009) 20    
    • USN:  1092227390326              2012                 Fig 2.1 Gap Model (Alin et al., 2009) a) “Gap 1 Difference between consumer expectation and management perception of consumer expectation.” b) “Gap 2 Difference between management perception of consumer expectation and service quality specification”. c) “Gap3 Difference between service quality specification and service quality actually delivered”. d) “Gap 4. Difference between service delivered and what is communicated about the service to consumers”. e) “Gap 5. It is the difference between consumer expectation and consumer perception of service delivery which is caused by the combined influence of Gap 1 to 4”. 21    
    • USN:  1092227390326              2012                 Gap 1 which is shown in fig 2.2 will arise when the management lacks tounderstand the customers expectation which were formed as a result of marketing,word of mouth, previous experience. Gap 2 shown in fig 2.2 will arise when themanagement fails to achieve the target level of perception of the patient andtransform them to the workable level. Gap 3 as illustrated in fig 2.3 arises when theactual service delivery standard set by the management will not meet expectation.Gap 4 as shown in fig 2.2 arises when usually the organisation exaggerates what willbe provided to the customers rather than the real fact it will lead to increase incustomer expectation .Gap 5 as shown in fig 2.2 arises from the difference betweencustomer expectations and actually the customer receives2.6.2 SERVQUAL MODEL The SERVQUAL method developed by Parashuraman et.al (1988) is the mostpopular method to access customer satisfaction in service industry. It measures thequality by comparing the customer’s perception of a quality of a service experiencedand what that customer expected for the service (Parashuraman et. al (1988);citedby Lonial et al., 2010). The SERVQUAL method was used in various settings like banks, hotels , dentalclinic, insurance companies, healthcare organisation , telecommunication, hospitalshotels and fast food chain. Kaul (2005) had said that SERVAQUAL scale wasextensively used in India to measure quality of services provided by retail stores.Deshpande (2006) had said that SERVQUAL SCALE is used in Hospitals.Sivakumar and Srinivas (2003) had stated that SERVQUAL was extensively used inhotels and Jain and Gupta ( 2004) had said that SERVQUAL model was used in fastfood chain (Kaul (2005); Deshpande (2006); Sivakumar and Srinivas (2003); Jainand Gupta ( 2004); cited by Mengi, 2009). SERVQUAL Model developed by Parasuraman et.al in 1988 is one of the maintool for service quality (Parasuraman et.al in 1988; cited by Mengi, 2009). TheSERVQUAL scale has a multi dimensional approach for measuring perception ofservice quality. The three dimensions that are relevant for health care are assurance,empathy and responsiveness (Karl et al., 2010). Assurance refers to customer’s 22    
    • USN:  1092227390326              2012                perception of trust how they feel with the employee or employees providing care.According to Lee and Lin (2008) reduced patient trust in care givers can lead to postdischarge non compliance which causes slow or incomplete recovery. Empathyrefers to the level of care and individual attention that is provided to each patient.(Lee and Lin, 2008; cited by Karl et al., 2010). Likewise Spigelman and Sensor(2008) had argued that patients are looking for personalised care. According toAnderson et.al (2004), Anderson et.al (2006), Roszak (2007) had stated that theresponsiveness or waiting time is an additional customer care quality factor that iscritical for the customer perception in healthcare (Anderson et.al (2004), Andersonet.al (2006), Roszak (2007) ;cited by Karl et al., 2010). SERVQUAL instrument has been designed to be applied on a variety of servicesettings. SERVQUAL is used as a diagnostic technique for uncovering qualitystrength and weakness. SERVQUAL instrument has a variety of potential applicationand is widely used for assessing the consumer expectation and perception ofService Quality. It also point out problems that require managerial attention(Yesilada, 2009). This model contains 22 items illustrated in the table 2.1 for accessing customerperception and expectation regarding the quality of service. SERVQUAL is adiagnostic technique used to uncover the quality strength and weakness 23    
    • USN:  1092227390326              2012                 Table 2.1 ,22 item of SERVQUAL Instrument (Joanna lee, 2011) The SERVQUAL scale has 22 questions which is used to measure the “5dimensions” of the “service quality” namely “Reliability”, “Tangibility”, “Security”,“Empathy” and “Responsibility” .These questions are scored in “LIKERT scale” from1 to 5 .They are marked from “strongly agree to strongly disagree ” (Nair et al.,2010). The results of perception and expectation are compared to each question and thedifference between perception and expectation gives the final score The negativeresults reveal that perceptions are below the expectation and there is anunsatisfactory service experience for the client. The positive result shows that thereis a satisfactory service experience for the client. According to Parasuraman et al in (1988) SERVQUAL is a concise scale withgood reliability and validity. Zeithaml (1987) SERVQUAL involves perceived qualitywhich is customer’s judgement about an entity’s overall excellence (Parasuraman etal ,1988, Zeithaml ,1987; cited by Yesilada, 2009). 24    
    • USN:  1092227390326              2012                 According to researchers like Bahia and Natel (2000), Sachdev and Verma(2004) and Chiu (2002) SERVAQUAL is the best known leading instrument used bymanagers of different industrial, commercial and non profit setting (Bahia and Natel2000 ,Sachdev and Verma ,2004 ,Chiu,2002 ; cited by Urban, 2010). Likewise Sureshchandra et.al (2003) had identified 5 factors for service qualityfrom customers perspective which includes core services or service product, Humanelement of service delivery, systemization of service delivery, tangibles of service,social responsibility (Akbar & Parvez, 2009).According to Taner and Antony (2006)SERVQUAL and Service quality gap model are the widely accepted tool in healthcare setting (Taner and Antony (2006); cited by Jane Li & Ying Huang, 2011).2.6.2.1 Advantages of SERVQUALAccording to Rohini and Mahadevappa (2006) the advantages of SERVQUALinclude (Rohini and Mahadevappa ,2006;cited by Padma et al., 2009). 1. The SERVQUAL instrument is used as a standard instrument for accessing different dimension of Service Quality 2. The SERVQUAL instrument has shown its credibility for a number of service situations 3. The SERVQUAL instrument has been reliable 4. The SERVQUAL instrument has a limited number of items so it can be easily filled by customers and employers.2.6.2.2 Criticism of SERVQUAL Model SERVQUAL model has also drawn many criticisms, Cronin and Taylor (1992) andOliver (1993) had criticized SERVQUAL model for using attitudinal model in place ofdisconfirmation model(Taylor (1992),Oliver (1993);cited by Padma et al.,2009).Cronin and Taylor (1992) and Boulding et.al in (1993) had criticizedSERVQUAL model for conceptualization for service quality as gap betweenperception and expectation(Cronin and Taylor (1992) , Boulding et.al in(1993);Padma et al., 2009). Cronin and Taylor (1992) and Richard Allaway (1993)had criticized for focusing only on functional quality rather than technical quality.Babakus and Boller (1991) and Carman (1990) had criticises SERVQUAL fornumber and structure and dimension, polarity of the scale and variance extracted in 25    
    • USN:  1092227390326              2012                explaining service quality. Caraman had also criticised SERVQUAL for Itemcomposition, Ambiguity and usage of expectations battery, Moment of truth (Padmaet al., 2009).Sureshchandra et.al (2001) had criticised SERVQUAL for exclusion ofcrucial factors such as core service, image, value, physical ambience, serviceencounters. Caruana et,al (2000) had criticised it for the order effect of expectationsand perceptions (Sureshchandra et.al ,2001, Caruana et,al ,2000; cited by Padmaet al., 2009).According to Tan and Pawitra (2001) had argued that there is somelimitation to SERVQUAL method. They said that SERVQUAL assumes a linearrelationship between customer satisfactions and service attributes which can’t betrue at all the situations (Tan and Pawitra, 2001; cited by Yesilada, 2009). SERVQUAL method was criticized for its applicability in other service industry.Developing a list of service dimension required for an industry requires determiningfactors that are required by the customers in that industry. As a result of criticism,alternative measures of service quality for specific setting were developed. Knutsonet.al (1991) had developed LODGSERV a model used to measure the quality oflodging industry. The model contains 5 original SERVQUAL dimensions and 26items. Getty and Thompson (1994) introduced another specific model for hotelsetting called LODGQUAL model which has 3 dimensions namely tangible, reliabilityand contact (Knutson et.al (1991), Getty and Thompson (1994); cited by Markovic &Raspor, 2010). In 1999 Wong Ooi Mei et.al developed a HOLSERV model which includes 27items grouped in 5 original SERVQUAL dimensions. Steven Knutson and Patton(1995) had developed DINESERV for measuring the service quality in restaurants. In2000 O’Neil et.al had developed DIVEPERF model to measure the perception ofdiving services. Sower (2001) had developed eight dimension of Hospital service quality. Itincludes respect and caring, the way in which the hospital staff interacts with thepatients. Effectiveness and continuity, transition from unit to unit or hospital to homehandling .Appropriateness, include the physical facility and staff professionalism.Information, keeping patient and family members informed about the procedures.Efficiency includes billing procedure. Meals include quality and efficiency of the meal 26    
    • USN:  1092227390326              2012                service. The first impression includes the first contact with the hospital and Staffdiversity, Sower, V. (2011). In (2003) Kahn had introduced ECOSERV it was used to utilize the service qualityexpectation in ecotourism it uses 30 items and dimensions of SERVQUALKahn,2003; cited by Markovic & Raspor, 2010).Kettinger and Lee (1994) hadidentified 4 dimension in a study of information system quality and did not have atangible dimension. Cronin and Taylor (1992) had developed one factormeasurement instrument instead of 5 factor proposed by Parasuraman et.al (1988)(Cronin and Taylor (1992), Kettinger and Lee (1994); cited by Akbar & Parvez,2009). Ramsaran –Fowdar R. ( 2008) had proposed a modified SERVQUAL scalefor private healthcare PRIVHEALTHQUAL two more dimensions were added namelycore medical services and information dissemination (Ramsaran –FowdarR,(2008);Alrubaiee & Feras, 2011).2.6.3 SERVPERF Model Cronin and Taylor (1992) had argued “that performance is the measure that bestexplains the customer’s perception of customer’s expectation so expectation shouldnot be included in the service quality measurement instrument”. They formed aperformance only scale called SERVPERF model (Cronin and Taylor (1992); citedby Blery et al., 2011). Beside theoretical argument they provided empirical evidencethat SERVPF model is superior over SERVQUAL across 4 industries namely Bank,Pest control, Dry clean and Fast food. SERVPERF model uses 22 questions and 5dimensions of SERVEQUAL model but does not include expectation. Mazis et al,Cronin and Taylor was on the point of view that because of its unweightedmeasurement of performance it is a better method of measuring service quality. Ahigher perceived performance implies higher service quality (Blery et al., 2011).2.7 Patient satisfaction Anderson and Suvillian (1993) had stated that increasing customer satisfaction isvital for customer loyalty. According to Bolton (1998) service providers always seeks 27    
    • USN:  1092227390326              2012                to manage and increase customer satisfaction (Wu & Wang, 2012).Patientsatisfaction is an important factor as it measures the quality of the medical serviceoffered. Customer satisfaction also gives the information of the provider’s success inmeeting the client’s expectation as they are the ultimate authority (Habbel, 2011).According to Dimitriades in (2006) stated that satisfied customers tends to be lessinfluenced by competitors less price sensitive and they stay loyal longer. Customersatisfaction has been considered as critical success factor in today’s competitivebusiness environment as they helps in retaining customers and maintaining marketshare (Dimitriades, 2006;cited by Ooi et al., 2011) According to Ware et.al in 1983, Moret et.al (2008) and Donahue et.al (2008)patient satisfaction in medical care is an multi dimensional concept with dimensionsthat corresponds to major characteristics of providers and services (Ware et.al in1983, Moret et.al, 2008 and Donahue et.al, 2008; cited by Alhashem et al., 2011).Likewise Donabedian (1980) had stated that informal assessment of satisfaction hasan important role in physician client interaction, since it can be used continuously bythe practitioner to monitor and guide that interaction and in the end how successfulthe interaction was (Donabedian 1980; cited by Habbel, 2011). However client satisfaction has some limitation as a measure of quality. Patientsgenerally have an incomplete understanding of the medical treatment in hospital.Moreover the patient sometimes demand and expect thing that would be wrong forthe practitioner because they may be professionally or socially forbidden (Habbel,2011). Donabedian (1980) was in the point of view that these limitations will not lower thevalidity of patient satisfaction as a measure of quality, but they are the bestrepresentation of certain components of definition of quality, namely, clientexpectation and valuation (Habbel, 2011).Mano and Oliver (1993) and Westbrook in(1987) had stated that satisfaction is both cognitive and an affective evaluation ofservice experience. Armstrong and Kotler (1996) interpreted satisfaction as a feeling which resultsfrom a process of evaluation what has been received against what was expectedincluding the purchase decision and needs and wants associated with the purchase(Akbar & Armstrong and Kotler ,1996;cited by Parvez, 2009).Oliver (1997) is 28    
    • USN:  1092227390326              2012                defined “customer satisfaction” as a “consumer’s fulfilment response”. (Oliver 1997;cited by Wittmer et al., 2011). Kane et.al (1997) had said that customer satisfactionis a complex concept that includes cognitive and affective components. He was ofthe view that satisfaction is an “attitude response to value judgement that patientsmake about their clinical encounter” (Kane et.al, 1997; cited by Alrubaiee & Feras,2011). Some researchers like Hogg and Gabbott (1998) had suggested that customersatisfaction is an antecedent for service quality. Likewise Bitner (1990),Bolton andDrew (1991), Parasuraman et.al (1988) was in the point of view that accumulation ofa satisfaction and dissatisfaction creates an overall assessment of service quality.Eventhought satisfaction and service quality are considered to be two differentconstruct they are related (Sivakumar & Srinivasan, 2010). In (1998) Gabbott & Hogg had acknowledged the work of Bitner andHubbert (1995) which distinguishes the different hierarchical level of satisfactionwhich is related to quality judgement (Sivakumar & Srinivasan, 2010). According to Moordian and Oliver (1997) satisfied customers can increasethe profitability by providing new referral through positive word of mouth. Brahme2000-2001 was in the point of view that these satisfied customers act as unpaidambassadors of the service providers business (Moordian and Oliver,1997;cited bySivakumar & Srinivasan, 2010).Johnson et.al (2006) had described the basicconcept of satisfaction into transaction specific and cumulative. Transaction specificis customer’s transient evaluation of a particular product or service experience and inthe other hand Cumulative satisfaction is the total consumption experience of theproduct to the date (Johnson et.al 2006; cited byTuu & Olsen, 2012). According to Hesselink and Wiele satisfaction is a positive affective stateresulting from the appraisal of all aspects of party’s working relationship with eachother (Akbar & Parvez, 2009).Zeithaml and Bitner (2003) had said that satisfaction iscustomer’s evaluation of a product or a service in terms of whether that product orservice had met their needs and expectation. They had also said that “customersatisfaction is a boarder concept.” (Zeithaml and Bitner ,2003; Akbar & Parvez,2009).Pakdil and Harwood (2005) had said that “satisfaction is the most importantquality dimension and key success indicator in healthcare”. Zineldin in 2006 had 29    
    • USN:  1092227390326              2012                defined satisfaction as ‘’an emotional response’’ (Pakdil and Harwood 2005; citedbyAlrubaiee & Feras, 2011). Piporas et.al (2008) had said that patient expectationand perception are not simply related because medical or health service is nottechnically comprehensive. So patient will not have a clear idea of expectation in theclinical setting (Piporas et.al, 2008; cited by Alrubaiee & Feras, 2011). Jackson et.al in 2001 (Alrubaiee & Feras, 2011) had stated that afterclinical visit the “patient satisfaction” is strongly influenced by the communicationbetween patient and doctor. Patient age and functional status also influences“patient satisfaction”. According to them patient satisfaction can be used for fourpurposes a) “Compare different healthcare programmes”. b) “To evaluate quality of care”. c) “To identify the aspect of service needed”. d) “To assist the organization to identify consumers”. Parasuraman et al (1994) was in the point of view that greatercustomer satisfaction will lead to positive customer behaviour such as repeatedpurchases, positive word of mouth communication which will lead to increasedmarket share and increased profit margin of the company (Parasuraman et al, 1994;Sainy, 2010).2.8 Patient satisfaction and its Dimensions According to Conway and Willcock (1997) cure is the fundamental expectation inhealth care service. Linde- Peltz (1982) was in the point of view that patientsatisfaction is an evaluation of health care dimension. Tucker and Adams in (2001)had stated that patient satisfaction is predicted by factors relating to caring, empathy,reliability and responsiveness (Naidu, 2009). Ware et.al (1978) had identified the factors such as physicians conduct, serviceavailability, continuity, confidence, efficiency and outcome. Fowdar (2005) hadincluded core service, customization, professional credibility, competence and 30    
    • USN:  1092227390326              2012                communication. Woodside et .al in (1989) had included admission, discharge,nursing care, food housing keeping and technical services (Naidu, 2009).2.9 Theories of customer satisfaction According to Expectancy-Disconfirmation theory by Oliver (1980)customer purchases products and services with pre purchase expectation ofanticipated performance. Once the product or service is used the outcome iscompared against the expectation. When outcome matches expectation confirmationoccurs. Disconfirmation occurs when there is a difference between outcome andexpectation .Satisfaction is caused by confirmation or positive disconfirmation ofexpectation and dissatisfaction is caused by negative disconfirmation of consumerexpectation (Oliver, 1980; cited byPadma et al., 2010). According to Personal Control Theory proposed by Rotter (1969) satisfactionwith one’s life experience or job is related to person’s perception of psychologicalcovariance between their actions and desired outcomes (Rotter, 1969; cited byPadma et al., 2010). According to Boulding et.al (1993) and Oliver (1993), in transaction specific modelcustomer relation has been modelled as function of psychological constructs such asattitude, expectation and disconfirmation. Whereas Gustaffson and Johnson (2004)had proposed cumulative satisfaction model in which the benefit is derived from theproduct or service attributes form the primary antecedent to satisfaction (Bouldinget.al, 1993, Oliver, 1993 Gustaffson and Johnson, 2004; cited byPadma et al., 2010).2.10 Measuring customer satisfaction Measuring customer satisfaction is an extremely difficult challenge given to thechanging healthcare industry. Evenhaim (2000) had said that measuring customersatisfaction is important for programme planning, identifying patient concern, qualityimprovement as well as customer relationship management and strategic planninginitiatives. Ford et.al (1997) had said that healthcare staff should measure patientsatisfaction in order to identify the patient related service problems and come withsolutions to improve patient satisfaction. 31    
    • USN:  1092227390326              2012                 According to Ford et.al (1997), the commonly used qualitative andqualitative instruments to measure satisfaction may vary substantially in cost,accuracy, generalizability and convenience. (York & McCarthy, 2011).2.11Patient Loyalty According to Woodruff (1997) customer loyalty is considered as an importantsource of competitive advantage (Woodruff, 1997; cited by Wang & Wu,2012).Patient loyalty is the surrogate of customer satisfaction and service qualitymeasures as understanding these measures are the first step in improving a patientprovider relationship. Customer loyalty can be described as customer’s willingness tocontinue to do business with a firm over long term by purchasing and using its goodsand services repeatedly and recommending the firms product and services to friendsand relatives. It is more expensive to win a new customer than retaining an existingcustomer. The net return of investment for company would be higher on retentionstrategies than investing in attracting new customers (Blery et al., 2011). John and Sasser defined “customer loyalty” as the “feeling of attachmentto or affection for the company’s people, product or service” (Blery et al., 2011).According to Hallowell,R (1996) “customer loyalty” can be defined as “attitudeloyalty” and “behavioural loyalty” . “Attitude loyalty is customer’s affection for theproduct or service willingness to recommend the service and behavioural loyalty isthe customer’s intention to repurchase” (Hallowell,R ,1996; Blery et al., 2011). According to Pearson (1996) “customer loyalty is a mindset ofcustomers who hold a favourable attitude to the company, shows intention torepurchase the products and recommend the product service to others”. Oliver(1981) had argued that customer first becomes loyal in a cognitive sense when theconsumer belief in one brand and is preferred than its alternatives because of theknowledge or information of the brand attributes. The second stage is affectiveloyalty where the consumer develops a liking and good attitude for the brand basedon cumulative satisfying usage occasionally. At the third stage is Conative loyaltywhere the customer is committed to rebuying the same product it is due to 32    
    • USN:  1092227390326              2012                behavioural intention. This leads to action loyalty where the consumer exhibitsconsistent repurchase behaviour (Oliver, 1981; cited by Sainy, 2010).2.12 Importance of Customer Loyalty. Reichheld (1996) and Soderland M (1998) was on the view that high level ofcustomer loyalty increases a firms profit through different ways like lower marketingcost, ability to charge a premium price, increased customer referral and loweroperating cost (Reichheld, 1996,Soderland M,1998;cited by Sainy, 2010).It is moreexpensive for the organisations to attract to customers. Research done by Petersonand Barnes (1995) shows that long term relationship of both customers and the firmshould have mutual benefits (Peterson and Barnes, 1995; cited by Blery et al.,2011). The customer benefits according to the researchers are presented in theTable below: Table 2.2 Customer benefitsBarlow, 1992 Social benefit associated with personal recognition from employeesBarnes, 1994 Social Benefits include familiarity, personal recognition, social supportBitner, 1995 Confidence benefits, faith in the trustworthiness of the service provider.Shetha & Parvitar, reduction of choices by engaging in an ongoing1995 loyalty programme by the marketersBerry, 1995 Risk reductionKemperer,1987 Economic advantage like treatment benefitsPeterson,1995 Special pricing considerationRosenblatt,1977 Freedom from having to make decision.Zeithmal,1981 Providers gain knowledge of consumers taste and this ensures better treatment. Author (2012) 33    
    • USN:  1092227390326              2012                2.13 Measurement of Patient loyalty According to Peltier et.al (1999) patient loyalty can be measured by (Peltier et.al (1999); cited by Chahal, 2008) . The figure below shows the 3 factors lead to patient loyalty a) “Using provider again for same treatment” (UPAS), b) “Using same provider for different treatment” (UPAD), c) “Referring providers for others” (RPO). Figure 2.2 Measurement of patient Loyalty (Chahal, 2008) a) “Using provider again for same treatment (UPAS) Using the provider again for the same treatment expresses the willingness of reusing the same healthcare provider for previously received service. The level of patient satisfaction and perceived service quality influenced the patient’s willingness to reuse the same healthcare facility b) “Using same provider for different treatment (UPAD) 34    
    • USN:  1092227390326              2012                 Visiting the same unit for different treatment is considered to be the second long term measure of patient loyalty c) Referring providers for others (RPO) This is the strongest measure of patient loyalty as they are associated with positive referral from existing patients and it is based on their personal experience . The patient loyalty concept used above fig 2.2 signify the perception of carereceived by patient during their hospital care, the perceived care received by thestaff later on as well as the overall impression and intention to recommend thefacility. In other words the patient develops loyalty towards a hospital is based uponthe interpersonal experience that they had during the interaction with the doctor,nursing staff and the operation quality of the hospital. According to Ostwald et.al(1998) the patient uses the associated facility and human factor to gauge the qualityof hospital service and influence of customer satisfaction. The fig 2.3 below reflectsthat the physician performance, nursing performance, operational performance andoverall service quality supplement the patient loyalty to measure to have a betterinsight of process (Ostwald et.al (1998); cited by Chahal, 2008) 35    
    • USN:  1092227390326              2012                 Figure 2.3 Patient loyalty and service quality model (Chahal, 2008)2.14 Service Quality and Customer Satisfaction relationship Sureshchandra et.al (2003) had identified that a strong relationshipexist between “service quality” and “customer satisfaction” while emphasizing that“these two are made of different conceptual constructs in customer’s point of view”.(Sureshchandra et.al, 2003; cited by Akbar & Parvez, 2009) Spreng and Mckoy (1996) had said that “service quality leads tocustomer satisfaction”. Thus the researcher can argue “that perceived service qualityhas a positive effect on Customer satisfaction”. (Spreng and Mckoy,1996;cited byAkbar & Parvez, 2009)2.15 Service quality and customer loyalty relationship Boulding et.al (1993) had conducted various “research on the relationshipbetween service quality and customer loyalty”. Boulding et.al in 1993 had done aresearch on “elements of repurchasing as well as willingness to recommend “and hisstudy was able to establish a “positive relation between service quality andrepurchase intention and willingness to recommend”. Thus the researcher can arguethat there is a positive relation between service quality and customer loyalty since 36    
    • USN:  1092227390326              2012                repurchase intention and recommendations forms the basis of customer loyalty.(Akbar & Parvez, 2009)2.16 Customer satisfaction and Customer loyalty relationship Numerous studies done by various researchers like Andreson & Suvllivanin 1993, Bolton& Drew 1991, Fronell in 1992 had found a “positive correlationbetween customer satisfaction and customer loyalty”. Similarly studies in servicesector by Anderson & Suvillian 1993,Bansal & Taylor in 1999 ,Cronin & Taylor in2000 had also “empirically validated the relationship between customer satisfactionand customer loyalty”. Hart and Johnson in 1999 had stated that “true customerloyalty is total satisfaction”. Thus the researcher can argue that customer satisfactionhas a positive effect on customer loyalty. (Akbar & Parvez, 2009)2.17 Relation between service quality and patient satisfaction Relationship Between Service Quality, Customer Satisfaction & Customer Loyalty Figure 2.4 (Mengi, 2009) Thus the researcher can argue that Service quality is a focussed evaluationof “customer’s perspective of reliability, responsiveness, assurance, empathy andtangibles”. “Customer satisfaction is influenced by perceived service quality, productquality, price along with personal and situational factors”. The customer loyalty isinfluenced by both service quality and customer satisfaction. The fig 2.4 shows the 37    
    • USN:  1092227390326              2012                relation between “the customer perception of service quality, customer satisfactionand customer loyalty” and their interrelationship.2.18 Conclusion Service quality is an important determinant factor that is considered in meeting theclient’s expectation. Service quality is of prime importance because it is in the handof the service providers. Studies have been shown that service quality plays animportant role in customer satisfaction and there is a relation between customersatisfaction service quality and patient loyalty each customer has their ownperceived perceptions for service quality. In healthcare sector the perceptions of thepatients will always cannot be taken in to account as they lacks the knowledge ofthe technical aspects of the hospital. 38    
    • USN:  1092227390326              2012                 39    
    • USN:  1092227390326              2012                Chapter 3 Research Methodology3.1Introduction The author begins the chapter by restating the research aims andobjectives then the author discusses about the research philosophy, then he talksabout research strategy research approach and about data collection and thenmoves on to discusses about the sample size of the research the samplingtechnique to be adopted and finally concludes the chapter3.2 Aim and objectiveCritically evaluate service quality as a determinant factor for patient satisfaction ingaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,India. 1. To review literature on service quality, patient satisfaction and patient loyalty. 2. To investigate the current service quality measures adopted by Travancore Medical College Hospital 3. To evaluate the service quality offered by Travancore Medical College Hospital and its effect on patient satisfaction in gaining patient loyalty. 4. To recommend Travancore Medical College Hospital to improve the service quality so that they can increase patient satisfaction and gain patient loyalty3.3 Research Methodology According to Burns (1997) research can be defined as a systematic investigationto find a solution for a problem (Burn,1997: cited by Kumar, 2011). Saunders et.al(2007) stated that “research process is a series of linked stages and gives theappearance of being organized in a linear manner” (Saunders et al., 2007).Dr.C.Rajendra Kumar (2008) was on the point of view that “research methodology isa way to systematically solve the research problem” (Kumar, 2008). 40    
    • USN:  1092227390326              2012                3.4 Research Design “Research Design” is the general plan how research will be done. Saunderset.al in 2007 had classified the research in to six stages and labelled them asresearch onion in fig 3.1. They had divided research into philosophies, approach,strategy, choices, time horizon, technique and procedure. Saunders “research onionis the way of exhibits the issue underlying your choice of data collection method ormethods and peeled away the outer two layers the research philosophy andresearch choice.” (Saunders et al., 2009). “Research Philosophies”, “Research” and“time horizon” guide the researcher to “desired process of Research Design”.“Research Philosophies” and “Research Design” helps to answer the “researchquestion”. “Research Strategy” depends upon “research topic”, “data collection”,“analysis” and “time factors”. “Research design” can be classified as “Exploratory”,“Descriptive” and “Explanatory”. Figure 3.1 Research onion (Saunders et al., 2009) 41    
    • USN:  1092227390326              2012                3.4.1 Exploratory research It is an attempt to have an develop an initial understanding of the newphenomenon (Babbie, 2010).The difference between the different research is givenin table 3.1.3.4.2Descriptive Research It is the precise measurement and reporting of characteristics of somepopulation or phenomenon .It also involves analysing the existing data (Babbie,2010) .The3.4.3Explanatory Research It is a study which involves establishing a cause effect relationship betweendifferent aspects of phenomenon under study (Babbie, 2010). Types of Research Design Table 3.1 (Saunders et al., 2009)3.4.4 Justification for this research designThe researcher had used “explanatory design” to because the researcher is trying totrying to find the relationship between the different aspects of phenomenon of study. 42    
    • USN:  1092227390326              2012                3.5 Research Philosophy”“Research Philosophy contains important assumptions, in which research will beconducted”. It forms the basics of research strategy and is influenced by practicalconsideration.3.5.1EpistemologyIn this the researcher has a role of a scientist and resources are selected objectively.Epistemology refers to the nature of the knowledge in the way we conceive oursurrounding Epistemology is of three types Positivism, Realism, Interpretism.3.5.2 Positivism If we intent to adopt an approach similar to natural scientist then our approach ispositivist. In positivism theory is explored to develop a hypothesis. It’s a value freeresearch observations which are quantifiable and statistical analysis can be carriedout (Wilson, 2010). If we are following a positive approach for our study then webelieve that we are independent of our research and is truly objective. Positivists arein the point of view that the research should be done in a scientific manner. It is anempirical research which is done under strict guidelines of polices by trainedscientist. The research is usually carried out in a deductive approach moving fromtheory to observation. In general positivist wants their findings to be applicable to thewhole of the population (Wilson, 2010).3.5.3 RealismIt is a scientific approach to the development of knowledge which is similar topositivismRealism is truth and is divided in to 1. Direct realism In direct realism researcher does just observations and recording of what we experience through our senses. 2. Critical realism the researcher sees the entire research as a part of bigger picture.. 43    
    • USN:  1092227390326              2012                 Critical realism the researcher can experience the world in two ways. First one is the thing by itself and the sensation it conveys and the second is the mental processing that goes on sometimes after sensation meets our senses. On the other hand Direct realism says that only first step is enough (Saunders et al., 2009).3.5.4 InterpretivismIn this research the researcher take an active role in carrying out research. This typeof research the emphasises the need for conducting research on people rather thanon objects. The researcher looks in to a particular subject in depth. The purpose ofthe research is not to generalise but to actively engage in high level of participationand interactions (Wilson, 2010).Interpretivism comes from two intellectual traditions 1. Phenomenology: - We can make sense about the world around us. 2. Symbolic Interactions: - We are continuously Interpreting other actions and making new meaning by combining our views and their action (Saunders et al., 2009).3.5.5 Ontology It deals with that which is at least in principle that can be categorised. Ontology isthat which can be rationally understood or at least partially (Poli, 2010).Ontology isconcerned with the nature of reality (Saunders et al., 2009). It is divided into subjectivism and objectivism3.5.5.1 SubjectivismIn subjectivism here is a continuous interaction with constantly changing world3.5.5.2 ObjectivismIn objectivism everything has its own identity 44    
    • USN:  1092227390326              2012                3.5.6 AxiologyAxiology is that which studies the judgement of the value. It is a more credible formof research. Philosophy is based on the value of researches with respect to datacollected. if we want our research to be credible we have to uphold our values ineach stage of research process. (Saunders et al., 2009).3.5.7Justification of research philosophy The researcher had adopted positivist approach because it does not emphasise onhuman interest and aims to analyse quantitative data in a statistical analysis.3.6 Research Approach According to Saunders in 2007 there are “two approaches deductive andinductive”.In deductive approach a hypothesis are developed and research strategy isdesigned to test the hypothesis. Table 3.2 shows that deductive approach is a highlystructured approach. In this the researcher is independent of what is beingresearched. In deductive approach it explains the relationship between differentvariables. There is a collection of quantitative data.While in “inductive approach” “data are collected and theory is developed as a resultof data analysis” (Saunders et al., 2009). Table 3.2 shows that inductive approachinvolves understanding the human attach to the event. There is a collection ofqualitative data. The researcher is the part of the research process. 45    
    • USN:  1092227390326              2012                 Research Approach Table 3.2 (Saunders et al., 2009)3.6.1 Justification Of research approach The researcher will be adopting a deductive approach because of thePositivist research philosophy. It also relies on prior conceptual and theoreticalframework covered by a large number of quantitative data. It also tests the existingtheory where the findings can be generalised. 46    
    • USN:  1092227390326              2012                3.7 Research strategy. Is study method used to gather the data which can be divided in to:-3.7.1Quantitative data It emphasizes the production of generalized and precise statistical finding.Qualitative Data is used when we want to verify whether a cause produces an effect(Rubin & Babbie, 2011). 3.7.2 Qualitative data The first challenge faced by the researchers is to select the best qualitativemethod to answer the research question. The qualitative method had developedfrom a philosophical perspective each of which had developed the influence ofassociated methodology (Issel, 2009). In qualitative data we are we get the innermeanings of humans through observation which are intended to gen theoreticalobservation and are not easily reduced to numbers. (Rubin & Babbie, 2011). 3.7.3 Justification of Research Strategy The researcher had chosen quantitative research strategy. The researcher willbe using questionnaires .The researcher will be testing the hypothesis and the theorywith data. Qualitative researchers consider prime importance to state hypothesis andtest the hypothesis with the data to see if they are supported.3.8 Source of Data We can divide the data as archival data or secondary data which already existin some forms e.g. pay rolls and Primary data which have to be collected in the duecourse of the research (Burt et al., 2009) 47    
    • USN:  1092227390326              2012                 Fig 3.2 Source of data (Burt et al., 2009).3.8.1 Primary Data “Primary Data” are those data fig 3.3 which have do be collected in the duecourse of research. They can be collected by different ways by observation,questionnaire, personal interview, telephonic interview. Primary data can becollected either by quantitative research or qualitative research. Quantitative technique includes survey, observation and experimentsand Qualitative technique includes in depth interview, Projective technique and focusgroup. (Wiid & Diggines, 2009).It is illustrated in the diagram below. 48    
    • USN:  1092227390326              2012                 Fig 3.3 Primary Data (Wiid & Diggines, 2009)3.8.2 Justification of “Primary Data” The research will be carried out by distributing questionnaire. They will beformulated in a semi structured method so that the respondent can give moreinformation.3.8.3 Secondary Data Secondary Data are those which already exists that had been gathered for aprevious studies (Churchill Jr & Iacobucci, 2010). 49    
    • USN:  1092227390326              2012                3.8.4 Types of Secondary Data. “Secondary data” can be classified in to several types most important oneis internal data those found within an organisation .External data can be againdivided into that are regularly published and we get the information for free forexample, census report, statics and that are published by different commercialorganisations and sells the information eg AC Neilson (Churchill Jr & Iacobucci,2010). Figure 3.4 Secondary Data (Churchill Jr & Iacobucci, 2010)3.8.5 Justification for secondary Data Secondary data will be collected from theHospitals website since the website will be biased the researcher will also collectdata from government statistics, newspaper articles, journals and books. 50    
    • USN:  1092227390326              2012                3.9 Sampling “Sample is a subset of a population” (Lohr, 2010). “Sampling techniques” are of twotypes :-3.9.1Probability Sampling or Representative sampling With “probability sample the chance, or probability, of each case beingselected from the population is known and is usually equal for all cases”. (Saunderset al., 2009). 3.9.2 Non Probability Sampling or Judgemental Sampling For a “non Probability sampling the probability of each casebeing selected for total population is not known and it is impossible to answer theresearch question or address the research objectives that require statisticalinterference about the characters of the population” (Saunders et al., 2009).3.9.3 Justification of sampling The researcher will be using probability sampling. The researcher had used simplerandom sampling the research. The researcher will be distributing 500questionnaires to the patient of the hospital.3.10 Conclusion This chapter discusses about the primary research of the research method. Theauthor had adopted explanatory research as research design in the light of this hehad adopted deductive approach and positivism as research philosophy. Booksjournals and the hospital website will be used for secondary research and primarydata will be collected by distributing questionnaires to 500 patients. Simple randomsampling of Probability sampling will be uses as sampling technique. 51    
    • USN:  1092227390326              2012                Chapter 4 Research Findings and Analysis 4.1IntroductionIn this chapter the author had stated by restating the aims and objectives .Next theauthor will be analysing the questionnaires that he had distributed in the hospital.The author had distributed 500 questionnaires in the TMC hospital and had a totalrespondent of 291. The respondents were selected using simple random probabilitysampling and the data were analyses quantitatively using Chi square test .Rho testwas done to analyse the factors for patient satisfaction.4.2 Aim and objectiveCritically evaluate service quality as a determinant factor for patient satisfaction ingaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,India. 1. To review literature on service quality, patient satisfaction and patient loyalty. 2. To investigate the current service quality measures adopted by Travancore Medical College Hospital 3. To evaluate the service quality offered by Travancore Medical College Hospital and its effect on patient satisfaction in gaining patient loyalty. 4. To recommend Travancore Medical College Hospital to improve the service quality so that they can increase patient satisfaction and gain patient loyalty 52    
    • USN:  1092227390326              2012                4.3 Analysis of questionnaire The author had distributed 500 questionnaires and had only found 291 questionnaires useful for the research of this sample size 52% were males and 48% respondents were femaleQ1. About you and age Chart 4.1:- Distribution of sample size according to age and sex. 30   27.63   25.89   23.02   23.8   25   20.86   21.05   19.42   20   14.47   15   13.15   10.79   10   5   0   <25  Age   25-­‐40  Age   40-­‐50  Age   50-­‐65  Age   >65  Age   Males  %   Females  %  Author (2012) From the Table 4.1 (appendix 1) it is clear that the total distribution of samplepopulation of the family is 291; among this the male representation is 152 (52%) andfemale representation is 139 (49%). The Chart 4.1 illustrates that the highestrepresentation is included in the range 50-65 age group where male’s form 27.63%and 20.86 % of females were considered. The obtained chi-square value shows that there is no significant association in thedistribution of sample for age and sex group of patients in the hospital . It means thatthe difference in the distribution of sample age and sex from the hospital is notsignificant, independent and not associated to each other. 53    
    • USN:  1092227390326              2012                 Q.2. Are you employed. The ratio of earners to non-earning dependents indicates to the work participationratio and the division of the society into productive and unproductive members. Thework participation rate at younger age is comparatively low in the sample. The Table 4.2 (appendix 1) shows that there are 133 earners in a total of291 members and thus, the ratio of earners to non-earning dependents is 0.841:1.The proportion of earners to total members is only 45.70%, which leads to a higherdependency ratio. The lower work participation rate of the younger age groups andthat of women and the higher proportion of people above 65 probably explain thehigher dependency ratio. In the three areas, not much of difference is noted in theseratios. A very high ratio shows that the number of earning members and dependentsare related. Q3. Why did you choose the hospital? Chart 4.2 :- The reason for choosing the hospital 40   36.69   35   30.26   30   25   23.74   25   18.42   19.42   20   16.44   15.1   15   9.86   10   5.03   5   0   Cost   Gp   Consultant   Refferals   Previous  visit   Males   Females  Author(2012) As per Table 4.3 (appendix), affordable cost was the key reason for choosingthe hospital raised by patients, whereas for meeting consultants was the next reasonopined by the patients for their reason for selecting this hospital. The chart 4.2 54    
    • USN:  1092227390326              2012                illustrates that 30.26% of males and 36.69% of females of the total 91 respondentshad selected the hospital due to affordable cost. Followed to this, GP was thereason cited by the patients for their interest shown to this hospital for the treatment. From the Table 4.3 (appendix 1), it can also be seen that the chi-square value(3.31) obtained is not significant at 0.05 level. For the various factors of selecting thehospital. i.e., there is an independent association among the reasons and genderwise classifications. Q4.The receptionist was friendly and courteous? Chart 4.3:- The receptionist was friendly and courteous 35   30.93   30   27.63   26.61   24.34   25   20   18.7   17.6   15.13   15.1   15.13   15   10   8.63   5   0   Strongly  Agree   Agree   Neutral   Strongly  Disagree                 Disagree   Males  %   Females  %  Author (2012)The Table 4.4 (appendix) & chart 4.3 shows that 80 patients (24.34% males &30.93% females) as the status “strongly agree”, for the question receptionist wasfriendly and courteous. From the Table 4.4(Appendix), it can also be seen that the chi-square value(28.37) shows that there is significant association in the distribution of sample andgender wise group of patients in the hospital. i.e. It means that the difference in the 55    
    • USN:  1092227390326              2012                opinion about the receptionist for the attitude of friendly and courteous and genderwise group of patients in the hospital significant and associated to each other.Q5. The staff treated you with respect, dignity and was courteous in the hospital? Chart 4.4:- The staffs treated you with respect, dignity and were courteous in thehospital? 30   25.89   25   22.36   23.02   22.36   21.05   20.86   19.07   19.42   20   15.13   15   10.79   10   5   0   Strongly  Agree   Agree   Neutral   Strongly  Dis  agree   Disagree   Males  %   Females  %   Author(2012) From the Table 4.5 (appendix 1) and Chart 4.4 it is It is interesting tonote that 70 patients 22.36% males and 25.89% females) have observed that thestatus “strongly disagree” about the discipline of the staff in the hospital. From the table 4.5(appendix1) , chart 4.4 it can also be seen that the chi-squarevalue (4.47) obtained is not significant at 0.05 level shows that there is no significantassociation in the distribution of sample for the opinion about the discipline of thestaff in the hospital and gender wise group of patients in the hospital. It means thatthe difference in the opinion about the discipline of the staff in the hospital andgender wise group of patients in the hospital is not significant and not associated toeach other. This shows that the staffs are not treating the patients with care andrespect. 56    
    • USN:  1092227390326              2012                Q6. There is a lot of paper work for admission? Chart 4.5 There is a lot of paper work for admission. 30   23.68   24.46   25   22.36   20.14   20.86   20.39   20   17.98   18.42   16.54   15.13   15   10   5   0    Strongly  Agree   Agree   Neutral    Disagree   Strongly  Disagree   Males  %   Females  %  Author (2012)From the Table 4.6 (appendix) and Chart 4.5 it is clear that the opinion about the 57patients (18.42% males and 20.86% females) have observed it as the status “noopinion”. It is interesting to note that 65 patients (20.39% males and 24.46%females) have observed that the status “disagree” about the paper work foradministration in the hospital. From the Table 4.6, it can also be seen that the chi-square value (2.79)obtained is not significant association in the distribution of sample for the opinionabout the paper work for administration in the hospital and gender wise group ofpatients in the hospital. It means that the difference in the opinion about the paperwork for administration in the hospital and gender wise group of patients in thehospital is not significant and not associated to each other. This shows that paperwork for the admission to the hospital consumes much time, what others cantolerate. 57    
    • USN:  1092227390326              2012                Q7 The service cost of hospital is affordable? Chart 4.6 :- The service cost of hospital is affordable 35   30.92   30   25.89   25   25.17   25   20   17.76   16.54   16.44   15.82   16.54   15   9.86   10   5   0   Strongly  Agree   Agree   Neutal   Disagree   Strongly  Disagree   Males  %   Females  %   Author (2012)From the Table 4.7 (appendix1) and Chart 4.6 it is clear that the opinion about thepaper work for administration in the hospital is supported by 83 patients (30.92%males and 25.89% females) as the status “strongly agree”, where as the status“agree’ is supported by 73 respondents (25% males and 25.17% females) out of thetotal respondents of 291 patients. 50 patients (17.76% males and 16.54% females)have observed it as the status “no opinion”. From the table4.7 (appendix1), it can also be seen that the chi-square value(3.20) shows that there is no significant association in the distribution of sample forthe opinion about the affordability of service cost and gender wise group of patientsin the hospital. It means that the difference in the opinion about the affordability ofservice cost in the hospital and gender wise group of patients in the hospital is notsignificant and not associated to each other. 58    
    • USN:  1092227390326              2012                 Q8. All Staff were in correct uniform? Chart 4.7 All Staff were in correct uniform 30   23.68   24.46   25   22.36   20.14   20.86   20.39   20   17.98   18.42   16.54   15.13   15   10   5   0   Strongly  Agree    Agree   No  OpLon   Disagree   Strongly  Disagree   Males  %   Females  %   Author (2012) From the Table 4.8 (appendix) and Chart 4.7 it is clear that the opinionabout the employees towards neatness in the hospital is supported by 82 patients(28.89% males and 28.09% females) as the status “strongly agree”, where as thestatus “agree’ is supported by 69 respondents (15.13% males and 17.98% females)out of the total respondents of 291 patients. 43 patients (18.42%males and 20.86%females) have observed it as the status “no opinion”. From the Table4.8 (appendix 1), it can also be seen that the chi-square value(0.78) shows that there is no significant association in the distribution of sample forthe opinion about the employees towards neatness and gender wise group ofpatients in the hospital. It means that the difference in the opinion about the staffwearing the correct uniform and gender wise group of patients in the hospital is notsignificant and not associated to each other. Most of the patients were not satisfiedwith the staff because they were not wearing proper uniform 59    
    • USN:  1092227390326              2012                Q9 The hospital is visually attractive?Chart 4.8 The hospital is visually attractive 30   27.63   28.05   25   23.68   23.02   20   18.07   17.76   16.54   15.13   15   13.78   13.66   10   5   0   Strongly  Agree   Agree   Neutral   Strongly  Disagree   Disagree   Males  %   Females  %   Author (2012) From the Table 4.9 (appendix 1) and Chart 4.8 it is clear that the opinion about thehospital towards attractiveness and comfortable physical facilities is supported by 81patients (27.63 % males and 28.05% females) as the status “strongly agree”, whereas the status “agree’ is supported by 68 respondents (23.68% males and 23.02%females) out of the total respondents of 291 patients. 50 patients have observed itas the status “no opinion”(13.78% males and 18.07% females) From the Table 4.9 (appendix 1), it can also be seen that the chi-square value(2.44) shows that there is no significant association in the distribution of sample forthe opinion about the hospital towards attractiveness and comfortable physicalfacilities and gender wise group of patients in the hospital. It means that thedifference in the opinion about the hospital towards attractiveness and comfortablephysical facilities and gender wise group of patients is not significant and notassociated to each other. This shows that the patients have a general complainttowards the attractiveness of the hospital 60    
    • USN:  1092227390326              2012                Q10. Is the hospital in a convenient location? Chart 4.9 Is the hospital in a convenient location 30   25   24.46   25   23.68   22.3   19.07   19.42   20   17.98   17.1   15.82   15.13   15   10   5   0   Strongly  Agree   Agree   No  opinion   Disagree   Strongly  Disagree   Males  %  Author (2012)From the Table 4.10 (appendix1) and Chart 4.9 it is clear that the opinion about thelocation of the hospital is supported only by 51 patients (19.07% males & 15.82%females) as the status “strongly agree”, where as the status “agree’ is supported by53 respondents(17.10% males & 19.42% females) out of the total respondents of291 patients. 48 patients (15.13% males & 19.98% females) have observed it as thestatus “no opinion”. It is interesting to note that 72 patients (25% males & 17.98%females) have observed that the status “strongly disagree “about the fact thathospital is not in a convenient location. From the Table 4.10 (appendix1), it can also be seen that the chi-square value(37.86) shows that there is significant association in the distribution of sample for theopinion about the location of the hospital and gender wise group of patients in thehospital. It means that the difference in the opinion about the location of the hospitaland gender wise group of patients in the hospital is significant and associated to 61    
    • USN:  1092227390326              2012                each other. The analysis of the findings shows that the hospital is in a convenientlocation and it is a favourable factor in attracting patients.11. Does the hospital have good directional signs?Chart 4.10 Does the hospital have good directional signs 25   23.02   22.36   20.39   20.86   21.05   19.42   19.07   19.42   20   17.1   17.26   15   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Female  %   Author (2012) From the Table 4.11 (appendix1) and Chart 4.10 it is clear that theopinion about the directional signs in the hospital is supported by 60 patients as thestatus “strongly agree” (20.39 %males and 20.86% females), where as the status“agree’ is supported by 53 respondents(17.1 % males and 19.42% females) out ofthe total respondents of 291 patients. 61 patients (19.07% males and 23.02%females) have observed it as the status “no opinion”. From the Table 4.11 (appendix1), it can also be seen that the chi-square value(1.61) shows that there is no significant association in the distribution of sample forthe opinion about the directional signs in the hospital and gender wise group ofpatients in the hospital. It means that the difference in the opinion about thedirectional signs in the hospital and gender wise group of patients is not significantand not associated to each other. The analysis of the findings shows that theexpectations of the management for the well being of the patients are not strictlyadhere in the hospital 62    
    • USN:  1092227390326              2012                Q 12. Does the hospital provide services at the allocated time? Chart 4.11 Does the hospital provide services at the allocated time 30   27.63   25.89   24.46   23.68   25   20   18.7   17.76   16.54   15.78   15.13   14.38   15   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Females  %  Author (2012)From the Table 14.12 (appendix1) and Chart 14.11 .It is interesting to note that 78patients (27.63% males and 25.89% females) have observed that the status“strongly disagree” about the timely service at the time of appointment. From the Table 14.12 (appendix1)     it can also be seen that the chi-squarevalue (0.19) there is no significant association in the distribution of sample for theopinion about the timely service at the time of appointment and gender wise group ofpatients in the hospital. It means that the difference in the opinion about the timelyservice at the time of appointment in the hospital and gender wise group of patientsis not significant and not associated. The analysis of the findings shows that thepatients cannot expect a timely service from the hospital at the time of appointment. 63    
    • USN:  1092227390326              2012                Q13 The department is working effectively? Chart 4.12 The department is working effectively 30   28.28   28.05   25   22.36   22.3   19.42   20   17.76   16.44   16.54   15.13   15   13.66   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Females  %   Author (2012)From the Table 4.13(appendix1) and chart 4.12 it is clear that the opinion about thesufficient staff in the hospital is supported by 82 patients (28.28% males and 28.05%females) as the status “strongly agree”, where as the status “agree’ is supported by65 respondents (22.36%males and 22.3% females) out of the total respondents of291 patients. 52 patients (16.44% males and 19.42% females) have observed it asthe status “no opinion”. From the Table 4.13 (appendix1), it can also be seen that the chi-squarevalue (0.53) shows that there is no significant association in the distribution ofsample for the opinion about the sufficient staff in the hospital and gender wise groupof patients in the hospital. It means that the difference in the opinion about the 64    
    • USN:  1092227390326              2012                sufficient staff in the hospital and gender wise group of patients is not significant andnot associated. The analysis of the data points out that the department in thehospital is not running effectively.Q14You felt ease during your appointment? Chart 4.13: You felt ease during your appointment 30   23.68   24.46   25   21.05   20.39   20.86   20.83   20   17.98   17.76   17.1   15.82   15   10   5   0   Strongly  Agree   Agree   Neutral   Agree   Strongly  Agree   Males  %   Females  %   Author 2012From the findings of Table4.14 (appendix1) and Chart 4.13 that the that you felt easeduring the appointment only by 54 patients (20.15% males and 15.82 % females) asthe status “strongly agree”, where as the status “agree’’ is supported by 60respondents(20.39% males and 20.86% Females) out of the total respondents of291 patients. 61 patients (23.68% Males and 17.98% Females) have observed it asthe status “no opinion”. From the Table4.14 (appendix1), it can also be seen that the chi-square value(4.47) shows that there is no significant association in the distribution of sample forthe opinion about feeling ease and gender wise group of patients in the hospital. Itmeans that the difference in the opinion about the nursing staff with regard the 65    
    • USN:  1092227390326              2012                capacity to inspire trust and confidence among the patient and gender wise groupof patients is not significant and not associated.Q15 Doctors listen carefully and adhered to your needs?Chart 4.14 Doctors listen carefully and adhered to your needs 30   23.68   23.74   24.34   24.46   25   21.05   20.86   20   16.44   16.54   14.47   13.66   15   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Females  %   Author (2012) From the Table 4.15 (appendix1) and chart 4.14. It is interesting to note that 72patients (24.34%males and 24.46%females) have observed that the status “stronglydisagree” about the attitude of doctors as to willingness to listen carefully and helppatients. From the Table 4.15 (appendix1), it can also be seen that the chi-squarevalue (0.06) shows that there is no significant association in the distribution ofsample for the opinion about the timely service at the time of appointment andgender wise group of patients in the hospital. This shows that the relationship ofdoctors and patients are not cordial to each other and doctors simply treat patientsjust for the reward namely “fees”. 66    
    • USN:  1092227390326              2012                 Q 16 Do you think the hospital address the patient complaint quickly? Chart 4.15 Hospital address the patient complaint quickly 30   25.65   23.74   24.46   25   22.36   18.7   19.42   20   18.42   17.1   16.44   15   13.66   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Females  %   Author(2012)From the Table 4.16 (appendix) & chart 4.15 it is clear that the hospital in addressingthe patient’s complaint quickly is supported only by 45 patients (17.1% Males and13.66 % Females) as the status “strongly agree”, where as the status “agree’ issupported by 51 respondents (16.44% male and 18.7% females) out of the totalrespondents of 291 patients. 61 patients (22.36% males and 19.42 % females) haveobserved it as the status “no opinion”. It is interesting to note that 73 patients(25.65% males and 24.46% females) have observed that the status “strongly disagree”about the procedure in addressing the patient complaint quickly. 67    
    • USN:  1092227390326              2012                 From the Table 4.16 (appendix) , it can also be seen that the chi-square value(2.08) value shows that there is no significant association in the distribution ofsample for the opinion about the hospital in addressing the patient’s complaintquickly and gender wise group of patients in the hospital. It means that the differencein the opinion about the hospital in addressing the patient’s complaint quickly andgender wise group of patients is not significant and not associated.Q.17 Do you think the staff responded immediately when called? Chart 4.16 Do you think the staff responded immediately on call 25   23.02   23.02   22.3   21.71   21.05   20.39   19.42   20   18.42   18.42   15   12.23   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Females  %   Author (2012) From the Table 4.17 (Appendix), Chart 4.16 it is clear that the response of thestaff when called is supported only by 63 patients (21.05% males and 22.3%females) as the status “strongly agree”, where as the status “agree’ is supported by65 respondents (21.71% males and 23.02% females) out of the total respondents of291 patients. 55 patients (18.42% males and 19.42% females) have observed it asthe status “no opinion”. It is interesting to note that 63 patients (20.39% males and23.02% females) have observed that the status “disagree” about the swift responseof the staff when called and help patients. 68    
    • USN:  1092227390326              2012                 From the Table 4.17 (Appendix), it can also be seen that the chi-square value(2.18) value shows that there is no significant association in the distribution ofsample for the opinion about the swift response of the staff when called and genderwise group of patients in the hospital. i.e., there is an independent associationamong the distribution of opinion about the swift response of the staff when calledand gender wise group of patients in the hospital they belong. This shows thatattitude of the staff for swift response when called is not supported by the patients. Q 18 Do you think that the hospital employees are sympathetic and reassuring? Chart 4.17 Hospital employees are sympathetic and reassuring 25   23.74   23.02   21.71   22.3   20.39   19.42   19.07   20   17.98   16.54   15.78   15   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  Disagree   Males  %   Females  %   Author(2012) From the Table 4.18 (appendix) and Chart 4.17 it is clear that the sympatheticand reassuring attitude of the employees is supported only by 47 patients(15.78%males and 16.54% females) as the status “strongly agree”, where as the status“agree’ is supported by 58 respondents(20.39% males and 19.42%females) out ofthe total respondents of 291 patients. 54 patients(19.07% males and17.98%females) have observed it as the status “no opinion”. It is interesting to note 69    
    • USN:  1092227390326              2012                that 68 patients (23.02% males and 23.74% females) have observed that the status“strongly disagree” about the sympathetic and reassuring attitude of the employees. From the Table 4.18 (appendix), it can also be seen that the chi-square value(0.13) value shows that there is no significant association in the distribution ofsample for the opinion about the sympathetic and reassuring attitude of theemployees and gender wise group of patients in the hospital. . It means that thedifference in the opinion about the sympathetic and reassuring attitude of theemployees and gender wise group of patients is not significant and not associated.Q 4.19 Do you think in the hospital doctor prescribes affordable medicines?Chart 4.18 The hospital doctor prescribes affordable medicines 30   25   23.68   24.46   22.36   20.86   19.42   20   18.24   17.98   18.24   17.1   17.26   15   10   5   0   Strongly  Agree   Agree   Neutral   Disagree   Strongly  disagree   Males   females   Author(2012) From the Table 14.19 (appendix) and chart 14.18 it is clear that the attitude ofdoctors in prescribing affordable medicines to patients is supported only by 70patients as the status “strongly agree”, where as the status “agree’ is supported by63 respondents out of the total respondents of 291 patients. 53 patients haveobserved it as the status “no opinion”. From the Table 14.19 (appendix1) , it can also be seen that the chi-squarevalue (0.14) value shows that there is no significant association in the distribution of 70    
    • USN:  1092227390326              2012                sample for the opinion about the attitude of doctors in prescribing affordablemedicines to patients and gender wise group of patients in the hospital. . It meansthat the difference in the opinion about the attitude of doctors in prescribingaffordable medicines to patients and gender wise group of patients is not significantand not associated. This shows that it is difficult for the patients to purchase lifesaving drugs prescribed by the doctors according to their money. That means theprescribed medicines for treatment are not affordable for patients.Q 20 Cross tabular questions from 22 to 25. Chart 4.19 Opinion about the average waiting time in hospital. 80   68.96   70   60   52.92   50   38.84   40.89   40   33.95   31.95   29.55   30   21.64   20.96   16.49   15.46   16.49   17.52   20   13.4   9.7   10   0   RecepLon   ConsultaLon   Pharmacy   lab  InvesLgaLon   <10  min   10-­‐20  min   20-­‐30  min   30-­‐45  min   >45  min   Author (2012)From the Table 4.20 (appendix 1), chart 4.19 it is clear that 180 respondents(68.96%) opined that the average time taken for completing the procedure atreception counters comes to 20-30 minutes. Similarly 93 patients (31.95%) opinedthat they have to wait an average time for 20-30 minutes for the consultation with thedoctors even after having the appointment time. Whereas 119 respondents(40.89%) are of the opinion that they have to patiently wait at least 30-45 minutes atthe pharmacy counters for getting the prescribed medicines. At the same time it is 71    
    • USN:  1092227390326              2012                noted that 154 patients (52.92%) were as common in their opinion as to the waitingtime for the lab investigation report, which is more than 45 minute.The average waiting time taken for various junctures are different and hence it is adefective decision by the management for not concerned about the precious time ofthe patients.  Q 21.Are the charges of TMC hospital affordable when compared charges ofdifferent services rendered by other private hospitalsChart 4.20 The charges of TMC hospital affordable when compared charges ofdifferent services rendered by other private hospitals 35   32.64   30.58   29.55   30   28.17   26.11   26.8   25.08   25.08   25   20.96   19.24   20   18.21   15.8   16.49   14.43   14.77   15   12.37   12.37   11.68   9.9   9.6   10   5   0   ConsultaLon  fees   Sugery  Fees   Pharmacy  fees   lab  InvesLgaLon   Strongly  agree  %    Agree  %   Neutral  %   Disagree  %   Strongly  Disagree  %  Author (2012) From the Table 4.20 (appendix1) and Chart.19 it is clear that the opinion of patientsregarding fee charged by the hospital towards various services rendered whencompared to other private hospitals shows unique opinion among the patients. 72    
    • USN:  1092227390326              2012                 From the Table 4.20 (appendix1), it can also be seen that the chi-square value(12.63) shows that there is significant association in the distribution of sample for theopinion of patients regarding fee charged by the hospital towards various servicesrendered when compared to other private hospitals and gender wise group ofpatients in the hospital. It means that the difference in the opinion regarding feecharged by the hospital towards various services rendered when compared to otherprivate hospitals and gender wise group of patients in the hospital significant andassociated to each other. This shows that fee charged by the hospital towardsvarious services rendered when compared to other private hospitals is almostsimilar, and there is no difference in the charges favourable to patientsWill you recommend this hospital to relatives and friends? From the Table 4.22 (appendix), chart 4.21 it can also be seen that the chi-square value (4.47) shows that there is no significant association in the distribution ofsample for the opinion about recommending this hospital to relatives and friends andgender wise group of patients in the hospital. It means that the difference in theopinion about recommending this hospital to relatives and friends and gender wisegroup of patients is not significant and not associated. This shows that patients areunique in supporting the fact that they will not recommend this hospital to theirfriends and relative for treatments. 73    
    • USN:  1092227390326              2012                Chart 4.21 Will you recommend this hospital to relatives and friends 30   23.68   24.46   25   21.05   20.39   20.86   20.83   20   17.98   17.76   17.1   15.82   15   10   5   0   Strongly  agree   Agree   Males   oFemales   No   pinion   Disagree   Strongly    Disagree  Author (2012)Patient satisfaction factorsTable 4.22 Patient satisfaction factor1 Affordable charges for services rendered 3 62 Lower Service cost 2 83 Sense of wellbeing you felt in the hospital 4 34 Prompt services( no waiting time) 9 25 Services provided as expected 5 76 Location easily accessible 1 107 Efficiency of admitting procedure 7 58 Friendly and courteous staff/doctors 10 99 Healthy, neat and clean environment 8 410 Prompt diagnosis of diseases 6 1Author(2012) From the Table 4.22 it is clear that the ranks assigned by the male andfemale respondents were separated and analysed. It is clear that “Location easily 74    
    • USN:  1092227390326              2012                accessible” is the first rank assigned by male respondents; where as femalerespondents are giving preference for prompt diagnosis of diseases at right time.The second rank is for Lower Service cost opined by male respondents, where as itis the prompt services by the hospital as opined by the female respondents. It isalso note that male respondents gave third rank to Affordable charges for servicesrendered and that of female it is sense of wellbeing felt in the hospital.Based on the findings “Rho test” was done. The value obtained is -0.07. Thisshows that there is low negative relationship among the ranks assigned by the maleand female regarding various factors relating to satisfaction towards the hospitalwhich shows that there is independent opinion regarding gender wise respondents ofthe hospital.4.4 Comparing Primary research with Secondary research In the second chapter the author had explained the relationship between Servicequality, patient satisfaction and patient loyalty with the help secondary data likejournals and books. So the final findings from the primary data should be comparedwith the secondary data to give the final conclusion to the research. In the chapter 2 (2.3) the author had discussed price of a service is one of the keyfactor which acts as a service winner for an organisation which is coherent with thefindings of table 4. This shows that the main reason for the selection of the hospitalis the cost. In the chapter 2 (2.1) the author had discussed the interaction quality ofthe staff of an organisation evaluates the service quality of the hospital .The findingsof the chapter 4 supports the fact that the receptionist are very cordial to the patient.The patients usually have the first interaction with the receptionist they are the faceof the organisation. In the chapter 2 (2.4) the author had discussed that location ofthe hospital is an important dimensions of service quality and it is proved by thefindings of chapter 4 that patient considers it as an important factor. In the chapter 2 (2.4) the author had discussed that the patient measuresthe service quality of the hospital on the interaction quality i.e. It refers to theinteraction they encounter with the different staff of the hospital even though theyhad warm welcome from the receptionist the interactions with the other staff wasdisappointing. The finding of this chapter points out that the patient were not 75    
    • USN:  1092227390326              2012                satisfied in the way they were treated by the staff, they were in the that the staff werenot in proper uniform and the staff had a swift response when asked for help andthey were feeling uneasiness during their appointment. In chapter 2 (2.3 and 2.5.2) the author had discussed time as a dimensionof service quality and had stated that waiting time is an important customer carequality factor that is critical for health care facility. The patient considers the timespent for the service as a factor which measures the service quality of the hospital.The findings of this chapter shows that the patient has disappointed with the paperwork in the hospital and it has caused an increased waiting time in all thedepartments of the hospital. In the chapter 2 (2.4) the author had discussed patients evaluation of tangibleassets of the organisation which includes the physical facility and staff. It is evidentfrom the finding of this chapter that the patients are not satisfied with the visualappearance of the hospital and the directional’s signs of the hospital. In the chapter 2(2.7) the author had discussed that patient satisfaction is anantecedent of service quality and patient satisfaction enhanced by the interaction ofpatients and doctor but the findings of this study points out that patients are notsatisfied with the attitude of the doctors not listening to them and prescribingexpensive medicines. In the chapter 2 (2.13) the author had discussed about that the strongestmeasure of customer loyalty is referring the service providers to others is thestrongest form of patient loyalty. But the findings of the research done on TMCHshows that they will not be recommend the hospital to their friends and hospital. Based on the findings “Rho test” was done. The value obtained is -0.07. Thisshows that there is low negative relationship among the ranks assigned by the maleand female regarding various factors relating to satisfaction towards the hospitalwhich shows that there is independent opinion regarding gender wise respondents ofthe hospital 76    
    • USN:  1092227390326              2012                4.5 ConclusionThe analysis of the findings shows that there is an independent association amongthe distribution of sample age and sex group of patients and the hospital theybelong. It means that the difference in the distribution of sample age and sex fromthe hospital is not significant and not associated to each otherThe analysis of primary data and comparing it with secondary data aided the authorto achieve the research objective. The conclusions the author made from theresearch is as follows. Even though the management of hospital had managed toreduce the gap between the patient expectation and the actual service delivered insome areas. There are certain gaps in the service which the management of theTMCH hospital must give attention in order to improve patient satisfaction to gainpatient loyalty.The findings of this chapter support the fact that the receptionists are very cordial tothe patient. The patients usually have the first interaction with the receptionist theyare the face of the organisation which is coherent with the secondary data.The finding of this study shows that the main reason for the selection of the hospitalis the cost which is coherent with the secondary dataThe findings of the study shows that location of the hospital which is an importantdimensions of service quality is the factor for the selection of the hospital which iscoherent with the secondary data The finding of this study shows that even though they had warm welcome from thereceptionist the interactions with the other staff was disappointing. The finding of thischapter points out that the patient were not satisfied in the way they were treated bythe staff, they were in the opinion that the staff were not in proper uniform and thestaff had a swift response when asked for help and they were feeling uneasinessduring their appointment. The patients measures the service quality on interactionquality the management of the hospital should attention to reduce this service gap . The patient considers the time spent for the service as a factor which measures theservice quality of the hospital .The findings of this chapter shows that the patient 77    
    • USN:  1092227390326              2012                were disappointed with the paper work in the hospital and it has caused anincreased waiting time in all the departments of the hospital. The management of thehospital should pay attention to reduce the this gap in the service,The patient satisfaction is an antecedent of service quality and patient satisfaction isenhanced by the interaction of patients and doctor but the findings of this studypoints out that patients are not satisfied with the attitude of the doctors not listeningto them and prescribing expensive medicines. The management should payattention to this service gap.The patient evaluates the tangible assets of the organisation which includes thephysical facility and staff. It is evident from the finding of this chapter that the patientsare not satisfied with the visual appearance of the hospital and the directional’s signsof the hospital. The management of the hospital should reduce this service gap,The strongest measure of customer loyalty is referring the service providers to othersis the strongest form of patient loyalty. But the findings of the research done onTMCH shows that they will not be recommend the hospital to their friends andhospital 78    
    • USN:  1092227390326              2012                Chapter 5 Conclusion and Recommendation5.1 Introduction In this chapter the author had presented a general conclusion for the entire researchand had put forward recommendation to improve the service quality of TMCH so thatthey can increase patient satisfaction and gain patient loyalty. The Author begins the chapter by restating the aims and objectives of the researchwhich is followed by the discussion how objectives were achieved. The author then5.2 Aim and objectiveCritically evaluate service quality as a determinant factor for patient satisfaction ingaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,India. 1. To review literature on service quality, patient satisfaction and patient loyalty. 2. To investigate the current service quality measures adopted by Travancore Medical College Hospital 3. To evaluate the service quality offered by Travancore Medical College Hospital and its effect on patient satisfaction in gaining patient loyalty. 4. To recommend Travancore Medical College Hospital to improve the service quality so that they can increase patient satisfaction and gain patient loyalty 5.2.1 Achievement of objective 1. The author had critically reviewed the literature available on service quality, patientsatisfaction and patient loyalty. In the beginning of the chapter 2 the author had firstdiscussed about the service quality then moved on to the how to measure service 79    
    • USN:  1092227390326              2012                quality. Then discussed about different models of service quality. Then the authorhad talked about patient satisfaction ,patient satisfaction and its dimensions, theoriesof customer satisfaction and measuring customer satisfaction. Then the author haddiscussed about patient loyalty then its importance and measurement of patientloyalty. Then the author had discussed about service quality and its relationshipbetween customer satisfaction, then about service quality and its relationshipbetween customer loyalty, and finally the relation between customer satisfaction andcustomer loyalty.5.2.2 Achievement of objective 2The author had coined the objective of analysing the current service qualitymeasures adopted by TMCH was made to find the present service quality standardsoffered by the hospital. Without knowing the present status the author cannot putforward recommendation for the improvement of the organisation. For understandingthe service quality of the TMCH parameters of the service quality were consideredlike cost, interaction quality of the staff, responsiveness of staff, the infrastructure,the atmospherics of the hospital, patient satisfaction.The analysis of the findings shows that there is an independent association amongthe distribution of sample age and sex group of patients and the hospital theybelong. It means that the difference in the distribution of sample age and sex fromthe hospital is not significant and not associated to each other.After the analysis of the primary data and by comparing it with secondary datahelped the author to achieve the second objective by having the data of currentservice quality mesaures .Even though the management of hospital had managed toreduce the gap between the patient expectation and the actual service delivered insome areas. There are certain gaps in the service which the management of theTMCH hospital must give attention in order to improve patient satisfaction to gainpatient loyalty.The findings of this chapter support the fact that the receptionists are very cordial tothe patient. The patients usually have the first interaction with the receptionist theyare the face of the organisation which is coherent with the secondary data. 80    
    • USN:  1092227390326              2012                The finding of this study shows that the main reason for the selection of the hospitalis the cost which is coherent with the secondary dataThe findings of the study shows that location of the hospital which is an importantdimensions of service quality is the factor for the selection of the hospital which iscoherent with the secondary data The finding of this study shows that even though they had warm welcome from thereceptionist the interactions with the other staff was disappointing. The finding of thischapter points out that the patient were not satisfied in the way they were treated bythe staff, they were in the opinion that the staff were not in proper uniform and thestaff had a swift response when asked for help and they were feeling uneasinessduring their appointment. The patients measures the service quality on interactionquality the management of the hospital should attention to reduce this service gap bygiving more customer relation training. The patient considers the time spent for the service as a factor which measures theservice quality of the hospital .The findings of this chapter shows that the patientwere disappointed with the paper work in the hospital and it has caused anincreased waiting time in all the departments of the hospital. The management of thehospital should pay attention to reduce the this gap by investing in the ITinfrastructure of the hospital.The patient satisfaction is an antecedent of service quality and patient satisfaction isenhanced by the interaction of patients and doctor but the findings of this studypoints out that patients are not satisfied with the attitude of the doctors not listeningto them and prescribing expensive medicines. The management should payattention to this service gap and enhance patient centred consultation.The patient evaluates the tangible assets of the organisation which includes thephysical facility and staff. It is evident from the finding of this chapter that the patientsare not satisfied with the visual appearance of the hospital and the directional’s signsof the hospital. The management of the hospital should reduce this service gap byinvesting in the interior of the reception in the first phase and alteron continuing afterevaluation. 81    
    • USN:  1092227390326              2012                5.2.3 Achievement of objective 3 Even though the management of hospital had managed to reduce thegap between the patient expectation and the actual service delivered in some areas.There are certain gaps in other areas service where the management of the TMCHhospital must give attention in order to improve patient satisfaction to gain patientloyalty. From the findings it is clear that “Location easily accessible” is the first rankassigned by male respondents, where as female respondents are giving preferencefor prompt diagnosis of diseases at right time. The second rank is for Lower Servicecost opined by male respondents, where as it is the prompt services by the hospitalas opined by the female respondents. It is also note that male respondents gavethird rank to Affordable charges for services rendered and that of female it is senseof wellbeing felt in the hospital. “Rho test” value obtained is -0.07 and there is lownegative relationship among the ranks assigned by the male and female whichshows that there is independent opinion regarding gender wise respondents of thehospital. However the strongest measure of customer loyalty, referring the serviceproviders to others is the strongest form of patient loyalty. But the findings of theresearch done on TMCH shows that they are unique in the opinion that will not berecommend the hospital to their friends and hospital. This pinpoints a fact that thereis a serious lapse of customer quality measures adopted by TMCH and themanagement of TMCH should immediately take steps to reduce the gaps in theservice. As Analeeb (1998) had said that hospitals that fail to understand theimportance of customer satisfaction are inviting a possible extinction. (Analeeb,1998; cited by Padma et al., 2010)5.2.4 Achievement of objective 4 Steps to take to improve the service quality measures of TMCH have beendiscussed by the author under the topic ‘Recommendation’ later in this chapter thereachieving the fourth objective. 82    
    • USN:  1092227390326              2012                5.3 Conclusion In the conclusion part the author will be summarizing from Chapter 1 to Chapter 4.The author begins the chapter 1 by giving a brief overview of the entire research.Then the author starts the second chapter by restating the aims and objectives ofthe research then the author had talked about the service quality, the dimensions ofservice quality, measuring of service quality, the gap model of service quality theSERVQUAL model and the author had criticised SERVQUAL model. Then authorhad discussed about the patient satisfaction, then its dimension and theories andhow to measure it. Later the author had discussed about the Patient loyalty, how tomeasure the service quality, and discussion had further moved on to service qualityits relationship between customer satisfaction and patient loyalty and customersatisfaction and patient loyalty. The author had started the chapter 3 by restating the aims and objectives discussesabout the primary research of the research method. The author had adoptedexplanatory research as research design. The research approach was deductiveapproach and positivism as research philosophy. Books journals and the hospitalwebsite will be used for secondary research and primary data will be collected bydistributing questionnaires to 500 patients. Simple random sampling of Probabilitysampling will be uses as sampling technique. In the chapter 4 the author had started by stating the aims and objectives .It is themost important part as it deals with the analysis of primary data and later own theauthor had done a discussion by comparing the primary data with the secondary.5.4 Research limitationsTime was the main constrain for my research. The author could have done a betteranalysis by using of SPSS. 83    
    • USN:  1092227390326              2012                5.5 Recommendation 5.5.1 Recommendation 1 Implementation of Enterprise Resource Planning (ERP) The findings of table highlight that there is predicament in the admission procedurein the hospital due to bungling paper work at the time of admission. The authorfeels that Implementation of ERPin the hospital will improve the overall efficiency ofthe hospital. ERP helps in streamlining and integrating the day to day activity of thehospital and information flow in the hospital to synergize the resources like theStaffs, the equipment, operational activities, administration, discipline and the cashflow. By the implementation of EPR, it is possible to integrate information system ofthe hospital covering all departments of the hospital. By the execution ofERP, it is possible to trim down the admission process,the billing procedure of both inpatient and outpatient, retrieving old patient file quicklyby entering the registration no. with the help of Electronic medical record, thereceptionist can dispatch the patient file directly to the doctor’s computer.ERP canconnect to the Radiology department and pathological labs. If the doctor needs afurther examination, he/she can send the report directly to the laboratory or theradiology department and the doctor can access the results as soon as it enters inthe respective departments. It will help in tumbling the waiting time of the results.The patient will also have a print out of prescription or the discharge summary.Introduction of all these procedures will standardize the procedures of the hospitaland improve the hospital brand image. With the help of this system the receptionistor the front desk staff can give flexible appointment to the patients of the visitingdoctors. In his way it is possible to reduce the waiting time significantly and will easethe pressure on doctors and staff. 84    
    • USN:  1092227390326              2012                 With the help ERP it is possible to improve inventory stockmanagement of the pharmacy more easily and thereby it helps the management inreducing operational cost.In order to implement, a detailed project report on the HIS must be submitted to thetop management of the company. After the approval of the management,advertisement for bid for ERP should be given on news paper and the company site.From the bidders we should choose the most credible bidder with good track recordsof implementing healthcare ERP. The training for the ERP can be finished in 10-15days . The ERP can be implemented in 5 weeks time and it is shown in Table 5.1.Inthis hospital we can opt for a phased approach so that it will not disturb the normalbusiness of the hospital. Implementation of ERP in the hospital is a costly procedureand the project should be implemented with the given time. Many hospitals hadacknowledged that after the implementation of ERP there was a increase inoperation efficiency. 85    
    • USN:  1092227390326              2012                 Table 5.1: Gantt chart for implementation of Enterprise resource planning Time FrameWork Wee Wee Wee Wee Wee Wee Wee Wee Wee k1 k2 k3 k4 k5 k6 k7 k8 k9Approval fromthe officialsBiddingProcedureSelection ofBidderAwardingContractImplementationTraining 86    
    • USN:  1092227390326              2012                5.5.2 Recommendation 2Recruitment of HR trainers for motivating the doctors and the staffs of the hospital toimplement a patient cantered approachIt is evident that the present approach adopted by the hospital is directive approachin which the doctor and the management have an upper hand over the patients. Thehospital should change its approach to patient centred approach. The healthcare managers and executives must ensure that there should be aproper system in hospital for regular collection and reporting of patient care. Themanager should ensure that while executing health service action plan theorganisation should consider the quality improvement feed backs of the patientsexperience in the hospital along with the clinical and operational data. The managersshould adopt evidence based patient centred care by recording and publishingchanges in the patient outcome in regular intervals. l. The managers should developand implement policies and procedure to involve patient families and care in servicelevel quality improvement and patient safety initiatives and healthcare design can beimproved. The managers should implement customised training strategies to buildcapacity for all staff to support patient centred approach. The top managementshould also focus on working environment, work culture and satisfaction of staff asthey play a vital role for improving patient centred care. Monitoring of the workenvironment can be done at regular intervals through survey of workforce, reviewingthe recruitment policies of the staff and monitoring the retention rates of the staff.The managers can integrate the care experience of patients they had in the hospitalin tune with staff performance appraisal and will foster patient culture. There aredifferent methods to promote patient cultured approach. By implementing patient centred consultation the interaction time between thedoctors and patients are increased and this will lead to patient satisfaction which inturn will lead to patient loyalty 87    
    • USN:  1092227390326              2012                 The hospital should change the tradition way of delivering health care. Newmethods should be adopted by the management which includes more interactionwith the patients and employees. The managers should foster a culture to go aroundeach department and have a chat with the employees so that they will have first anexperience about what happening around each unit. Also the managers should havechat with the patients who are using the service of the hospital. The direct interactionwill help the organisation to reduce the service gaps. The managers should alsoinvite employees to have a chair side chat so that they can have an in depthknowledge of what is happening in each unit. The managent should develop apatient centred advisory council in which the staffs and clinicians of the hospital areincludes all these fosters patient centred culture in the hospital. In patient centred approach the importance should be also give to the staff andclinicians of the hospital as they are the care givers and any factors that affect themwill also affect the end users. So the hospital should motivate the employees byimplementing employee of the month programme, public acknowledgement of staffmember in the news letter which is published by the hospital for their impact onpatient experience. The more informal approach includes thanking the staff duringroutine manager staff rounding. The staff satisfaction can be monitored by closemonitoring of the managers of the employees and addressing their issues with thework place. An open door policy should be adopted by the management to addressthe problems. They can be also monitored by surveys as we have mentioned earlier.Value training is another factor that helps in achieving patient centred approach isemployee’s behaviour. Only when the employee’s personal value stimulates, thecore value of the organisation the cultural transformation takes place.. We should implement these training programmes in a phased manner in eachdepartment within 7 weeks so that there will be smooth transition from the existingdirective work culture to the patient centred work culture. We can implement all thesestrategies by recruiting an induction team of experienced HR trainers in the humanresource department. new trainers will be enough for the existing team. The salaryfor the HR trainer will be around 240,000 Rs to 300,000 Rs per annum. The firstevaluation of the training can be done after 2 weeks of implementation departmentwise 88    
    • USN:  1092227390326              2012                 The return of the investment can be seen in within 6 months and the progresscan be evaluated by the feedback of patient experience in the hospitalTable 5.2: Gantt chart for Recruitment of HR TrainersWork Week Week Week Week Week Week Week 1 2 3 4 5 6 7ApprovalAdvertisementInterviewRecruitmentFraming ofpoliciesImplementationDepartmentwise training Evaluation 89    
    • USN:  1092227390326              2012                 5.5.3 Recommendation 3 Implementation of surveillance camera to close monitors the overall functions of thehospital. As it is evident from the findings that the patients are not satisfied withthe support staff. It shows that there is a lapse of close monitoring of staff by themanagement. Since it is large hospital with 800 beds employing more and more midlevel manager will be a financial burden for the hospital. The available option will beimplementation of CCTv camera in and around the hospital and appoint an CCtvoperator. In a long run it will be feasible than appointing more people. First of all a project report should be submitted to the top officialsthen we should seek their approval and then it should be send to the financedepartment of the hospital for approval. After that a tender for the implementation oftender should be published in a leading news paper. As soon as the biddingprocedure is completed the tender should be awarded to a company which has goodtrack record and credible. The CCTv can be implemented in 2 weeks Soon after theimplementation of the CCTv The HR department have to recruit the CCTv operator.The average salary for a CCTv operator in India will be nearly 70,000 per year. Thereturn of investment can be appreciated earlier as it is more cost effective thanimplementing more staffs for closes monitoring of staffs. The evaluation of the CCTvimplementation can be done on the 9th week. 90    
    • USN:  1092227390326              2012                Table 5.3: Implementation of CCTV Time FrameWork Wee Wee Wee Wee Wee Wee Wee Wee Wee k1 k2 k3 k4 k5 k6 k7 k8 k9ApprovalBiddingprocedureSelection ofbidderAwardingcontractImplementation of CCTvRecruitmentof CCTvoperatorTrainingEvaluation ofprogress 91    
    • USN:  1092227390326              2012                 5.5.4 Recommendation 4 It is evident from the findings that the patients are not satisfied with theatmospherics of the hospital and the uniform of the staff as they were not in properuniform. The management should invest in the interior of the waiting area andreception. They should provide a television and magazines to the waiting area, sothat it can make feel of comfort to the patients. The management should also investin buying hospital furniture’s like chairs and tables in the reception. The managementshould implement a dress code for each section of staff. All the front desk staffshould be given same uniform likewise administrative department should have adifferent uniform each section of the department should be given different uniform.There should be a uniformity in uniform in each department The management shouldprovide identity card to all the staff. The management should emphasise that theyshould greet the patients with a smile. It can be implemented within a time frame of 3 months. wecan give a advertisement in the leading newspaper inviting bids for hospital furniture,dress for staff and identity card. From the potential bidders we can choose crediblebidder with good track record. By opting this method the hospital can save lot ofmoney.5.5.5 Recommendation 5 It is evident from the finding that the medicines prescribed by the doctors are notaffordable for the patients. The first step in this regard is to ask the doctors toprescribe generic medicines .But it is the sole decision of doctor to choose whichcompany’s medicine. Steps may also taken to negotiate directly with company ofreputed in nature to supply bulk quantity at reduced/concessional price, so that thebenefit received can further extend to the patients. After getting the list of stock needed for the pharmacy an advertisement can beplaced in the local newspaper so that the potential bidders can bid for the contract of 92    
    • USN:  1092227390326              2012                the medicines. After the contract process we can purchase the medicine from thebidders who have a good track record. Before placing the order for the medicines ameeting with the clinical staff to ensure the quality of the medicine that we will bepurchasing. The entire process can be done within 9 weeks, Table 5.4. Evaluation ofthe progress of the sales of medicines can be done after 4 weeksTable 5.4 Gantt chart for the purchase of medicines at competitive price Time FrameWork Week Week Week Week Week Week Week Week Week 1 2 3 4 5 6 7 8 9ApprovalBiddingprocedureDiscussionwith doctorsSelection ofbidderAwardingcontractArrival ofstockAvailable inpharmacyEvaluationof progress 93    
    • USN:  1092227390326              2012                5.5.6 Recommendation 6The TMC hospital should start their own health care insurance programmes byhaving tie up with leading insurance agents. This will prove a competitive advantagefor the hospital as the hospital can provide cashless treatment for the patients whocome there for service. By having this insurance system the patients will come againand again to avail treatment and this will ultimately lead to patient loyalty. There isan increased penetration of health care insurance sector. Indian govt is also takingsteps to cover the poor people under insurance schemes.5.5.7 Recommendation 7The TMC hospital should implement a quality cell in the hospital where all the issuesof the quality will be dealt with. Since there are service gaps in the hospital adedicated wing quality assessors should be recruited. The Hr department of thehospital should place an advertisement on newspaper and all other medium. Aninterview date should be placed in the advertisement .Soon after the intervieweligible experienced guys should be recruited. Soon after their placement theyshould implement new policies to improve the quality of the hospital. Performanceappraisal of the newly recruited should be conducted on a regular internal.5.5.8 Recommendation 8 TMC hospital should work toward the implementation accreditation of JCI (JointCommission International) in the hospital which will help in maintaining the servicequality standards of the hospital as they often conduct standard checks. By havingJCI standards it opens a new horizon of business. The hospital can attract more andmore foreign patients. As the hospital is located in one of the famous tourismdestination .The hospital can attract more foreign patient and this will enhance the 94    
    • USN:  1092227390326              2012                profitability of the hospital. By having the accreditation it will improve the brandimage of the hospital. 95    
    • USN:  1092227390326              2012                 Chapter 6 Reflective summaryIn this chapter the author will discuss his experience throughout this course andcompleting this dissertation. They have also developed skill after completing MBAand my dissertation within the time frame was one of the greatest challenge theauthor have faced in his life. By completing this dissertation the author have alsodeveloped some skill which will be useful for future the author learned how to workunder pressure and meet deadlines. The multicultural experience that the author hadin UK will also help him to shape his career. 96    
    • USN:  1092227390326              2012                 97    
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    • USN:  1092227390326              2012                Appendix 1Tabular column for the questionnaires for the research1. About youTable 4.1:- Distribution of sample size according to age and sexCross tabular column for age and sexStatus Male Female Total No % No % No %<25 Age 22 14.47 15 10.79 37 12.7125-40 Age 20 13.15 32 23.02 52 17.8641-50 Age 36 23.68 27 19.42 63 21.6451-64 Age 42 27.63 29 20.86 71 24.39>65 Age 32 21.05 36 25.89 68 23.36Total 152 52 139 48 291 100χ 2test 7.43Table value for df 4at 0.05 level 9.49 Source: Author(2012) 104    
    • USN:  1092227390326              2012                3. Are you employed? Table 4.2:- Earners and Non-earning dependents in the sample Status (No.) Total members 291 Earners 133 Non-earning members 158 Proportion of earners to total members 45.83 Ratio of Earners to non-earning 84:1 members Average number of earners in the 2.18 household Average number of non earners in the 1.85 household Source: Author(2012) 105    
    • USN:  1092227390326              2012                 4. Why did you choose this hospital? Table54.3:- The reason for choosing the hospital Males Females Total Category No % No % No % Cost 46 30.26 51 36.69 97 33.33 GP 28 18.42 27 19.42 55 18.90 Consultant 38 25 33 23.74 71 24.39 Referrals 25 16.44 21 15.10 46 15.80 Previous visit 15 9.86 7 5.03 22 7.56 152 52 139 48 291 100 χ 2test 3.31 Table value for df 4 at 0.05 level 9.49 Source: Author(2012) 106    
    • USN:  1092227390326              2012                 5 The receptionist was friendly and courteous? Table 4.4:- The receptionist was friendly and courteous? Males Females Total No % No % No % Strongly Agree 37 24.34 43 30.39 80 27.49 Agree 42 27.63 37 26.61 79 27.14 Neutral 23 15.13 26 18.70 49 16.83 Disagree 27 17.76 21 15.10 48 16.49 Strongly Disagree 23 15.13 12 8.63 35 12.02 Total 152 100 139 100 291 100 χ 2test 28.37 Table value for df 4 at 0.05 level 9.49 Source: Author (2012) 107    
    • USN:  1092227390326              2012                6. The staff treated you with respect, dignity and was courteous in the hospital? The staffs treated you with respect, dignity and were courteous in the hospitalTable 4.5 Males Females Total No % No % No % Strongly Agree 29 19.07 15 10.79 44 15.15 Agree 34 22.36 32 23.02 66 22.6 Neutral 23 15.13 27 19.42 50 17.18 Disagree 32 21.05 29 20.86 61 20.96 Strongly Disagree 34 22.36 36 25.89 70 24.05 152 100 139 100 291 100 χ 2test 4.47 Table value for df 4 at 0.05 level 9.49 Source : Author (2012) 108    
    • USN:  1092227390326              2012                7. There is a lot of paper work for admission?Table 4.6 :Opinion about the paper work for admission Males Females Total No % No % No % Strongly Agree 36 23.68 28 20.14 64 21.99 Agree 23 15.13 25 17.98 48 16.49 Neutral 28 18.42 29 20.86 57 19.58 Disagree 31 20.39 34 24.46 65 22.33 Strongly Disagree 34 22.36 23 16.54 57 19.58 152 48 139 52 291 100 χ 2test 2.79 Table value for df 4 at 0.05 level 9.49 Source: Author (2012) 109    
    • USN:  1092227390326              2012                8. The service cost of hospital is affordable? Table 4.7: The service cost of hospital is affordable Males Females TotalStatus No % No % No %Strongly Agree 47 30.92 36 25.89 83 28.52Agree 38 25 35 25.17 73 25.08Neutral 27 17.76 23 16.54 50 17.18Disagree 25 16.44 22 15.82 47 16.15Strongly Disagree 15 9.86 23 16.54 38 13.05 152 100 139 100 291 100 χ2test 3.20 Table value for df 4 at 0.05 level 9.49 Source :Author( 2012) 110    
    • USN:  1092227390326              2012                9. All Staff were in correct uniformTable 4.8:- All Staff were in correct uniform Males Females Total No % No % No %Strongly Agree 43 28.28 39 28.05 82 28.17Agree 34 22.36 35 25.17 69 23.71Neutral 22 14.47 21 15.10 43 14.77Disagree 26 17.10 24 17.26 50 17.18Strongly Disagree 27 17.76 20 14.38 47 16.15 152 100 139 100 291 100 χ 2test 0.78 Table value for df 4 at 0.05 level 9.49 Source : Author (2012) 111    
    • USN:  1092227390326              2012                10. The hospital is visually attractive?Table 4.9: The hospital is visually attractive? Males Females TotalStatus No % No % No %Strongly Agree 42 27.63 39 28.05 81 27.83Agree 36 23.68 32 23.02 68 23.36Neutral 24 13.78 26 18.70 50 17.18Disagree 27 17.16 23 16.54 50 17.18Strongly Disagree 23 15.13 19 13.66 42 14.43 152 100 139 100 291 100 χ 2test 2.44 Table value for df 4 at 0.05 level 9.49 Author (2012) 112    
    • USN:  1092227390326              2012                11. Is the hospital in a convenient location?Table 4.10 Is the hospital in a convenient location? Males Females TotalStatus No % No % No %Strongly Agree 29 19.07 22 15.82 51 17.52Agree 26 17.10 27 19.42 53 18.21Neutral 23 15.13 25 17.98 48 16.49Disagree 36 23.68 31 22.30 67 23.02Strongly Disagree 38 25 34 24.46 72 24.74 152 100 139 100 291 100 χ 2test 37.86 Table value for df 4 at 0.05 level 9.49Source: Author (2012) 113    
    • USN:  1092227390326              2012                12 Does the hospital have good directional signs?Table 4.11 Does the hospital have good directional signs Males Females TotalStatus No % No % No %Strongly Agree 31 20.39 29 20.86 60 20.61Agree 26 17.10 27 19.42 53 18.21Neutral 29 19.07 32 23.02 61 20.96Disagree 32 21.05 24 17.26 56 19.24Strongly Disagree 34 22.36 27 19.42 61 20.96 152 139 291 χ 2test 1.61 Table value for df 4 at 0.05 level 9.49Source Author (2012) 114    
    • USN:  1092227390326              2012                13 Does the hospital provide services at the allocated time? Table 4.12 Does the hospital provide services at the allocated time Male Female TotalStatus No % No % No %Strongly Agree 23 15.13 20 14.38 43 14.77Agree 27 17.76 26 18.70 53 18.21Neutral 24 15.78 23 16.54 47 16.15Disagree 36 23.68 34 24.46 70 24.05Strongly Disagree 42 27.63 36 25.89 78 26.80 152 100 139 100 291 100 χ 2test 0.19 Table value for df 4 at 0.05 level 9.49 115    
    • USN:  1092227390326              2012                14 The department is running effectively?Table 4.13 The departments are running effectively Males Females TotalStatus No % No % No %Strongly Agree 43 28.28 39 28.05 82 28.17Agree 34 22.36 31 22.30 65 22.33Neutral 25 16.44 27 19.42 52 17.86Disagree 27 17.76 23 16.54 50 17.18Strongly 23 15.13 19 13.66 42 14.43Disagree 152 100 139 100 291 100 χ 2test 0.53 Table value for df 4 at 0.05 level 9.49Source Author (2012) 116    
    • USN:  1092227390326              2012                15 You felt ease during your appointment? Table 4.14 You felt ease during your appointment Male Female TotalStatus (No) % (No.) % (No) %Strongly Agree 32 21.05 22 15.82 54 18.55Agree 31 20.39 29 20.86 60 20.61Neutral 36 23.68 25 17.98 61 20.96Disagree 27 17.76 29 20.83 56 19.24Strongly Disagree 26 17.10 34 24.46 60 20.61Total 152 100 139 100 291 100 χ 2test 4.47 Table value for df 4 at 0.05 level 9.49 Source Author (2012) 117    
    • USN:  1092227390326              2012                16 Doctors listen carefully and adhered to your needs?Table 4.15 Doctors listen carefully and adhered to your needs? Males Females TotalStatus (No) % (No) % (No) %Strongly Agree 22 14.47 19 13.66 41 14.08Agree 25 16.44 23 16.54 48 16.49Neutral 32 21.05 29 20.86 61 20.96Disagree 36 23.68 33 23.74 69 23.711Strongly Disagree 37 24.34 35 24.46 72 24.74 152 100 139 100 291 100 χ 2test 0.06 Table value for df 4 at 0.05 level 9.49 118    
    • USN:  1092227390326              2012                17 Do you think the hospital address the patient complaint quickly?Table 4.16 Do you think the hospital address the patient complaint quickly? Males Females Total (No) % (No) % (No) %Strongly Agree 26 17.10 19 13.66 45 15.46Agree 25 16.44 26 18.70 51 17.52Neutral 34 22.36 27 19.42 61 20.96Disagree 28 18.42 33 23.74 61 20.96Strongly Disagree 39 25.65 34 24.46 73 25.08 152 139 291 χ 2test 2.08 Table value for df 4 at 0.05 level 9.49 119    
    • USN:  1092227390326              2012                18 Do you think the staff responded immediately when called?Table 4.17 the staff responded immediately when called? Total Male FemaleStatus (No) (%) (No) (%) (No) (%)Strongly Agree 32 21.05 31 22.30 63 21.64Agree 33 21.71 32 23.02 65 22.33Neutral 28 18.42 27 19.42 55 18.90Disagree 31 20.39 32 23.02 63 21.64Strongly Disagree 28 18.42 17 12.23 45 15.46 152 100 139 100 291 100 χ 2test 2.18 Table value for df 4at 0.05 level 9.459 120    
    • USN:  1092227390326              2012                20 Do you think that the hospital employees are sympathetic and reassuring?Table 4.18 Hospital employees are sympathetic and reassuring Males Females TotalStatus No (%) No (%) No (%)Strongly Agree 24 15.78 23 16.54 47 16.151Agree 31 20.39 27 19.42 58 22.22Neutral 29 19.07 25 17.98 54 20.68Disagree 33 21.71 31 22.30 64 21.99Strongly Disagree 35 23.02 33 23.74 68 18.55 152 139 291 100 χ 2test 0.13 Table value for df 4 at 0.05 level 9.49 121    
    • USN:  1092227390326              2012                21 Do you think in the hospital doctor prescribes affordable medicines?Table 4.19Opinion about the attitude of doctors in prescribing affordable medicines to patients. Males Females TotalStatus No % No % No %Strongly Agree 36 23.68 34 24.46 70 24.05Agree 34 22.36 29 20.86 63 21.64Neutral 28 18.24 25 17.98 53 18.21Disagree 28 18.24 27 19.42 55 18.90Strongly Disagree 26 17.10 24 17.26 50 17.18 152 100 139 100 291 100 χ 2test 0.14 Table value for df 4 at 0.05 level 9.49 122    
    • USN:  1092227390326              2012                22 Average waiting time in the different a cross tabular questions from 22 to 25Table 4.20Cross tabular column for Question 22 to 25 Lab Total Reception Consultation PharmacyStatus investigation No % No % No % No % No %Less than10 minutes 48 16.49 39 13.40 27 9.7 -- -- 291 10010-20minutes 63 21.64 54 38.84 48 16.49 -- -- 291 10020-30minutes 180 68.96 93 31.95 97 33.33 51 17.52 291 10030-45minutes -- -- 45 15.46 119 40.89 86 29.55 291 100More than45 minutes -- -- 60 20.96 -- -- 154 52.92 291 100Author (2012) 123    
    • USN:  1092227390326              2012                Are the charges of TMC hospital affordable when compared charges of differentservices rendered by other private hospitalsTable 21Cross tabular column for question 26 to 29 Lab Total Consultation Surgery Pharmacy investigation fee feeStatus Fee Fee No % No % No % No % No %Stronglyagree 95 32.64 53 18.21 73 25.08 86 29.55 291 100Agree 89 30.58 76 26.11 82 28.17 78 26.80 291 100Neutral 42 14.43 61 20.96 56 19.24 48 16.49 291 100Disagree 29 9.9 73 25.08 34 11.68 36 12.37 291 100StronglyDisagree 36 12.37 28 9.6 46 15.80 43 14.77 291 100 χ 2test 12.63 Table value for df 12 at 0.05 level 7.43Author (2012) 124    
    • USN:  1092227390326              2012                Q30 Will you recommend this hospital to relatives and friends?Table 4.22 :- Will you recommend this hospital to relatives and friends? Male Female TotalStatus No % No % No %Strongly Agree 32 21.05 22 15.82 54 18.55Agree 31 20.39 29 20.86 60 20.61Neutral 36 23.68 25 17.98 61 20.92Disagree 27 17.76 29 20.83 56 19.24Strongly Disagree 26 17.10 34 24.46 60 20.16Total 152 100 139 100 291 100 χ 2test 4.47 Table value for df 4 at 0.05 level 9.49Source :Author( 2012) 125    
    • USN:  1092227390326              2012                Appendix 2 Questionnaires for the patientsI Aneesh .Prasannan is doing a survey questionnaire and collecting the data fromthe most valuable patients of the TMC hospital. Your opinion is very critical in mydissertation research. My analysis and recommendations are based on the responseyou give to the questioner. All the information submitted by you will be utilized for theacademic purpose. Thanks for your co-operation.Title: Critically evaluate service quality as a determinant factor for patient satisfactionin gaining patient loyalty. A case study of Travancore Medical College HospitalKerala, India.For the following question please tick one of the following.1. About youMale Female 2. Age groupUnder 18 19-34 35-5 55-74 75 and above3. Are you employed?Yes No4. Why did you choose this hospital?Cost GP Consultant Referral Previous visit5 The receptionist was friendly and courteous?Strongly agree Agree Neutral Disagree Strongly 126    
    • USN:  1092227390326              2012                 disagree6. The staff treated you with respect, dignity and was courteous in the hospital?Strongly agree Agree Neutral Disagree Strongly disagree7. There is a lot of paper work for admission?Strongly agree Agree Neutral Disagree Strongly disagree8. The service cost of hospital is affordable?Strongly agree Agree Neutral Disagree Strongly disagree9. All Staff were in correct uniform?Strongly agree Agree Neutral Disagree Strongly disagree10. The hospital is visually attractive?Strongly agree Agree Neutral Disagree Strongly disagree11. Is the hospital in a convenient location?Strongly agree Agree Neutral Disagree Strongly disagree12 Does the hospital have good directional signs? 127    
    • USN:  1092227390326              2012                Strongly Agree Agree Neutral Disagree Strongly Disagree13 Does the hospital provide services at the allocated time?Strongly Agree Agree Neutral Disagree Strongly Disagree14 The department is running effectively?Strongly agree Agree Neutral Disagree Strongly disagree15 You felt ease during your appointment?Strongly agree Agree Neutral Disagree Strongly disagree16 Doctors listen carefully and adhered to your needs?Strongly agree Agree Neutral Disagree Strongly disagree17 Do you think the hospital address the patient complaint quickly?Strongly agree Agree Neutral Disagree Strongly disagree18 Do you think the staff responded immediately when called?Strongly agree Agree Neutral Disagree Strongly disagree20 Do you think that the hospital employees are sympathetic and reassuring?Strongly agree Agree Neutral Disagree Strongly disagree 128    
    • USN:  1092227390326              2012                21 Do you think in the hospital doctor prescribes affordable medicines?Strongly agree Agree Neutral Disagree Strongly disagree22 The average waiting time in receptionLess than 10 10 -20 min 20-30 min 30-45 min More than 45min min23 The average waiting time in ConsultationLess than 10 10 -20 min 20-30 min 30-45 min More than 45min min24 The average waiting time in pharmacyLess than 10 10 -20 min 20-30 min 30-45 min More than 45min min25 The average waiting time in laboratory.Less than 10 10 -20 min 20-30 min 30-45 min More than 45min min26 While comparing with other hospitals the consultation fee is affordable?Strongly agree Agree Neutral Disagree Strongly disagree27 While comparing with other hospitals the surgery fee is affordable? 129    
    • USN:  1092227390326              2012                Strongly agree Agree Neutral Disagree Strongly disagree28 While comparing with other hospitals the pharmacy fee is affordable?Strongly agree Agree Neutral Disagree Strongly disagree29 While comparing with other hospitals the lab investigation is affordable?Strongly agree Agree Neutral Disagree Strongly disagree30 Will you recommend this hospital to relatives and friends?Strongly agree Agree Neutral Disagree Strongly disagree 130