A case study of travancore medical college hospital kerala, india


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A case study of travancore medical college hospital kerala, india

  1. 1. 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    
  2. 2. 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    
  3. 3. 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 Advantage of SERVQUAL Model 18 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    
  4. 4. 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 Subjectivism 35 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    
  5. 5. 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    
  6. 6. 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    
  7. 7. 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    
  8. 8. 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    
  9. 9. 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    
  10. 10. 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    
  11. 11. 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    
  12. 12. 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    
  13. 13. 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    
  14. 14. 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    
  15. 15. 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    
  16. 16. 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    
  17. 17. 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    
  18. 18. 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    
  19. 19. 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    
  20. 20. 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    
  21. 21. 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    
  22. 22. 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    
  23. 23. 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    
  24. 24. 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    
  25. 25. 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). 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. 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    
  26. 26. 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    
  27. 27. 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    
  28. 28. 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    
  29. 29. 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    
  30. 30. 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    
  31. 31. 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    
  32. 32. 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    
  33. 33. 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    
  34. 34. 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    
  35. 35. 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    
  36. 36. 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    
  37. 37. 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    
  38. 38. 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    
  39. 39. USN:  1092227390326              2012                 39    
  40. 40. 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    
  41. 41. 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    
  42. 42. 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 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    
  43. 43. 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    
  44. 44. 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    
  45. 45. 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    
  46. 46. 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    
  47. 47. 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    
  48. 48. 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    
  49. 49. 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    
  50. 50. 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