Factors Influencing Customer Satisfaction in Healthcare Services

Factors influencingCustomer
satisfaction in healthcare
services.
Umar Asif
Department of Commerce, Islamia University Bahawalpur, Pakistan
Abstract
Purpose To measure the quality of health care services patient
satisfaction is used as one of the most important indicators. The study
aims to identify factors affecting patients satisfaction at primary health
care clinics.
Design/methodology/approach The data was collected during
June 1 and June 3 through a randomly-distributed questionnaire. The
questionnaires were distributed in primary healthcare clinics in Pakistan.
A total of 100 completed questionnaires, out of 125, were returned
resulting in a response rate of 80 percent.
Findings The majority (87 percent) of the patients responded that the
independent variables are the factors influencing customer satisfaction.
Research limitations/implications Its based on sample and
literature review.
Originality/value The authors hope that this study identifies areas
of dissatisfaction that can be quickly remedied and ensures enhancement
in the areas of satisfaction with ongoing attention and emphasis.
Keywords: Patient care, Health services, Customer satisfaction, Pakistan,
PaktanGovt Hospitals, patient satisfaction.
Paper type:Research paper
1. Introduction
Patient satisfaction can be defined as judgment made by a recipient of
care as to whether their expectations for care have been met or not
(Palmer et al., 1991). Themodern view of quality of care looks to the
degree to which health services meetpatients needs and expectations
both as to technical and interpersonal care (Campbellet al., 2000; Eschet
al., 2008). Investigation of patient satisfaction has been used to
meetthree main objectives in health care delivery industry (Ware et al.,
1978; Patrick et al.,1983; Al-Doghaither and Saeed, 2000). First, to
determine how and to what extentsatisfaction influences patients seeking
care in terms of complying with treatment andcontinuing to use the care.
Second, to use satisfaction as an indicator of the quality ofcare; and third
to help physicians and the health care organizations better
understandthe patients point of view, and to use this feedback to
increase accountability and toimprove the services provided.
Patient satisfaction with medical care is a multidimensional concept,
withdimension that corresponds to the major characteristics of providers
and services(Ware et al., 1983; Moretet al., 2008; Donahue et al.,
2008). Patient satisfaction withhealth care services is considered to be of
paramount importance with respect toQuality improvement programs
from the patients perspective, total qualitymanagement, and the
expected outcome of care (Vouri, 1991; Donabedian, 1992;Aggarwal
and Zairi, 1998; Brown and Bell, 2005). Within the health care
industry,patient satisfaction has emerged as an important component and
measure of thequality of care (Aharony and Strasser, 1993; Grogan et
al., 2000; Salisbury et al., 2005).Patient satisfaction plays an important
role in continuity of service utilization(Thomas, 1984). Satisfied patients
are more likely to adhere to doctorsrecommendations and medical
regimens (Ross et al., 1981). Besides, dissatisfiedpatients do not utilize
primary health care services optimally and over-utilize theemergency
rooms in the general hospitals (Shah et al., 1996; Al-Hay et al., 1997).
The quality of the communication relationship between physician and
patientshowed positive influence on patient satisfaction measure (Moretet
al., 2008; Merceret al., 2008; Lin et al., 2009).Several studies have
been performed regarding patient satisfaction and its correlates in
various countries (Rahmqvist, 2001; Margolis et al., 2003;BronfmanPertzovskyet al., 2003). Only two studies have been conducted to
dateregarding the concept of patient satisfaction in Kuwait (Bo Hamra
and Al-Zaid, 1999;Al-Doghaitheret al., 2000). They found significant
relationship of age, gender,nationality, marital status; education,
occupation, and income with patient satisfaction.
Although many studies have been done on patient satisfaction
internationally butlimited studies were done on patient satisfaction in the
Gulf region and in particular inKuwait. Identification of predictors of
patient satisfaction (what aspects of care matterthe most to patients)
enables policy makers at the Ministry of Health in Kuwait to focuson these
aspects
and
improve
them.
The
correlates
of
sociodemographiccharacteristics of patients with satisfaction allow the health
care providers to caterto the different needs of patients based on their
socio-demographic characteristics.This study aims at identifying predictors
of patient satisfaction in the primary careclinics of the Ministry of Health,
Kuwait (factors leading to patient satisfaction ordissatisfaction) and its
socio-demographic correlates.
1.1 Background
A Introduction about Pakistan Healthcare Services:

Health plays the key role in determining the human capital. Better
healthimproves the efficiency and the productivity of the labour force,
ultimatelycontributes the economic growth and leads to human welfare.
To attain better,more skilful, efficient and productive human capital
resources, governmentssubsidise the health care facilities for its people. In
this regard, the public sectorpays whole or some part of the cost of
utilising health care services. The sizeand distribution of these in-kind
transfers to health sector differs from country tocountry but the
fundamental question is how much these expenditures areproductive and
effective? It very much depends on the volume and thedistribution of
these expenditures among the people of different areas of thecountry.

Besides the nature of the existing circumstances of the human
resource,any marginal change in public sector spending on health services
may havepositive impact on the human capital and economic growth.
According to the Economic Survey of Pakistan (2005-06), thegovernment
spent 0.75 percent of GDP on health sector in order to make
itspopulation more healthy and sturdy. In this regard, a number of
vertical andhorizontal programmes regarding health facilities are
operative in Pakistan. Thefederally funded vertical programmes include:
Lady Health Worker Programme;Malaria Control Programme;
Tuberculosis and HIV/AIDS Control Programme;National Maternal and
Child Health Programme; the Expanded Programme onImmunisation;
Cancer Treatment Programme; Food and Nutrition Programme,
and; the Prime Minister Programme for Preventive and Control of
Hepatitis A &B.
To effectively address the health problems facing Pakistan, a number
ofpolicies emphasise better health care services. These include: Health
relatedMillennium Development Goals; Medium Term Development
Framework;Poverty Reduction Strategy Papers; National Health Policy,
and; Vision 2030. Inspite of these policies, to overcome the health
related problems in Pakistanseems suspicious and distrustful. The
communicable diseases are still achallenge and the statistics reveal that
the nutrition and reproductive healthproblem in communicable diseases
are still liable for the 58 percent of the BOD
in Pakistan. Non-communicable diseases (NCD), caused by sedentary
lifestyles, environmental pollution, unhealthy dietary habits, smoking etc.
accountfor almost 10 percent of the BOD in Pakistan.
Social Policy Development Centre (SPDC), 2004, demonstrates that outof
every 1,000 children who survive infancy, 123 die before reaching the
age offive. A large proportion of those who surviving suffers from
malnutrition,leading to impaired immunity and higher vulnerability to
infections.
Malnutrition is big problem in Pakistan. Human Conditions Report

(2003)clearly points out that about 40 percent children under 5 year of
age aremalnutrited. About 50 percent of deaths of children under 5
years old childrenare due to malnutrition.
Following the introduction to the research theme, Section 2 put
forwardsthe Literature Review. Health is an integral part of the social
sector and hence anumber of policies emphasising better health service
delivery in this area.Section 3 highlights Policy Emphasising Health Care
Services followed byPublic Health Care Service Delivery in Pakistan.
Research methodology anddata sources are discussed under Research
Focus in Section 5, followed byResults and Discussion, and Conclusion and
Policy Recommendations inSections 6 and 7 respectively.
Pakistan Health care takes care of 161 million lives of the Pakistani
nationals. Viewing the health in Pakistan, the Pakistan Health Ministry
has formulated certain policies to improve it. The Pakistan hospitals not
only serve the ailing with the basic health facilities but also provide
primary and secondary education on health care. There are 947
hospitals in Pakistan giving a good portion of budget on Healthcare
services.
Literature Review:
Patient safety, which has been defined as freedom from accidental injury
duringmedical care or from medical errors has become a critical topic in
medicine (Kohn et al.,1999). The desire to avoid harm has existed as a
concern in medicine since the fourthcentury BC when Hippocrates the
Father of Medicine admonished medicalprofessionals to do no harm
(Hippocrates, 2004). The healthcare industry is fraughtwith dangers for
both patients and employees (Yassi and Hancock, 2005). Thesedangers
are linked directly to the environment and culture that surrounds
medicalprofessionals and patients with their distinctive norms, values and
shared beliefs(Stone et al., 2004). Although medical professionals have
for years sought to improvequality by standardizing good processes, it is
not enough to just design better ways tocontrol errors. The organizational
climate must also encourage information sharingand support safety

(Hofmann and Mark, 2006).
Creating a proper patient safety climate includes changing
managementbehaviours, safety systems and employee safety
perceptions that directly influencehealthcare professionals to choose
proper behaviors that enhance patient safety (Collaet al., 2005;
Fleming, 2005). However, many studies and safety interventions have
notaddressed actual safety climate, but have focused on activities such as
data collection,reporting, reducing blame, involving leaders, or focusing
on processes (Singer et al.,2003). Climate consists of shared employee
perceptions relating to the practices,procedures and behaviours that get
rewarded and supported in an organization(Schneider et al., 1998). An
organizational climate is gained by the experiencesemployees have and
how they perceive their environment. The climate influences
howorganizational members behave by how they think and feel about
their workenvironment. Employees work environment perceptions cause
them to interpretevents and develop attitudes, which dictate how they
work (Bowen and Ostroff, 2004).Although organizational climate
perceptions are significant safety indicators, therehave been few
organizational safety climate studies in hospitals and even less with
aninternational scope (Collaet al., 2005; Navehet al., 2005; Stone et al.,
2004).
Many countries and international organizations created regulations and
rules fortheir medical sectors to improve patient safety. These efforts
sought to create a patientsafety climate to improve healthcare processes
and outcomes through regulatoryprocesses.
At present, the U.S. healthcare system is of vital interest to the nations
economy and government policy (spending). The U.S. healthcare system is
characterized as the worlds most expensive yet least effective as
compared to other nations. Growing healthcare costs have made millions
of citizens vulnerable. Major drivers of the healthcare costs are
institutionalized medical practices and reimbursement policies, technology
induced costs and consumer behavior(Examining Quality and Efficiency of
the U.S. Healthcare System By Sameer Kumar1, Neha S. Ghildayal2 and

Ronak N. Shah3 ).
Management support, a proper reporting system and adequate
resources were found to influence the hospital patient safety
climate(Factors affecting the climate ofhospital patient safety By Stephen
L. Walston).
The majority (87 percent) of the patients responded that the time for
communication between physician and patient was not enough. Seventynine-percent of the surveyed patients said they would go to the
emergency room of the hospital in future if needed instead of going to
the primary care clinic. Regarding the quality of the communication
relationship between physician and patients most of the patients
responded negatively. Exploratory factor analysis identified six factors
and reliability of overall scale was found to be 0.61(Factors influencing
patient satisfaction in primary healthcareclinics in Kuwait Abdul
MajeedAlhashem, HabibAlquraini andRafiqul I. Chowdhury).
Methodology:
2.1 Sample
The study population consisted of the patients who came for services to
the primaryhealth care centers covering all health regions in Pakistan.
Patients were randomly selected a size of 125. Out of 125
Questionnaires 100 were returned with a respondents of 80 percent. In
keeping with thestandard research protocol, necessary permission was
obtained from the concernedauthorities of the Ministry of Health for data
collection.
2.2 Instrument
This descriptive cross-sectional study used a questionnaire that consisted
of 22closed-ended questions and specific questions on background
(gender, age, nationality,marital status, occupation, education, and
income) characteristics. The questionnairebased on Ware et al. (1978)

model, is divided into six dimensions of care. Eachdimension of care
(interpersonal, technical, accessibility, convenience, availability,
andoverall) has a number of statements that measure patients satisfaction
(dependent variable) which is an ultimate outcome in evaluating quality
of medical care.Interpersonal dimension measured the satisfaction to the
amount of caring showntowards the patients and communications
between them. Technical dimension alsopertains to provider conduct,
focuses on the competence of providers and theiradherence to high
standards of diagnosis and treatment. Accessibility and
conveniencedimension measures satisfaction related to time and effort
required to get anappointment, distance and proximity to site of care,
convenience of location time toreach, hours during which care can be
obtained etc. Availability dimension focuseswhether there are enough
physicians, nurses, and other providers, and such facilities asclinics and
hospitals in the area. Other similar studies have used different names
forthe dimension and called them attributes (Otaniet al., 2005). Each
dimension used inthis study and its specific attributes were found to have
some correlations with patientsatisfaction in previous studies (Harrison,
1996; Al-Fariset al., 1996; Makhdoomet al.,1997; Gross et al., 1998;
Shelton, 2000; Saeedet al., 2001). To measure patientPatient
satisfaction 251 satisfaction, interviews or open ended questions produce
much detailed informationand allow for clarification of respondents
views but are considered difficult to analyze(Fitzpatrick, 1991a). More
structured approaches such as multiple item questionnaireswith Likert
scale response categories produce data that are easier to handle but
requireparticular attention to validity and reliability to use in a different
cultural settings
(Fitzpatrick, 1991b; Rees, 1994). In different cultural settings before
applying anyexisting scale it need re-evaluation (Kinnersleyet al., 1996;
Grogan et al., 2000).
The instrument used a modified five-point Likert scale as choices of
answer,ranging from very dissatisfied (0) to very satisfied (5). An
additional choice, notapplicable, was added to allow respondents to
choose in case of service not provided orwhere a given item was not
applicable. The majority of statements used in thequestionnaire, 17 out of
22, are positively phrased to avoid any confusion that mightresult from
using a mix of positive and negative phrasing. In addition, there were
twoquestions relating to the patients number of visits to the primary care
service duringthe past year and the patients perception of his/her own
overall health status. Thequestionnaire was translated into Arabic and
translated back into English by anindependent professional to check the
validity. Prior to the actual administration, thequestionnaire was piloted
in a small group of patients to validate the language, contentand flow of
information aimed at appropriate rapport to make necessary changes.
Bysumming 11 positive questions on different aspect of satisfactions we
computed an overall satisfaction score. The overall satisfaction score
ranges from 0 to 44. The lowestpossible score of 22 was considered as
the lowest level of satisfaction. Cronbachs alpha(reliability coefficient)
was used to determine the internal consistency of theinstrument. The value
of the alpha of the overall scale was 0.61. The construct validitywas
assessed by factor analysis using factor loadings; these ranged from
0.41 to 0.76.
2.3 Statistical analysis
Descriptive statistics (frequency distribution, mean, and standard
deviation) were usedto describe the data. Exploratory factor analysis
was used to identify theunderlying factors and Cronbachs alpha was
used to measure the internal consistencyof the scale and subscales.
Purpose To measure the quality of health care services patient
satisfaction is used as one of the most important indicators. The study
aims to identify factors affecting patients satisfaction at primary health
care clinics.
Dependent
Variable
Independent
Variable
Satisfied
Customers
Quality Control
Availability of
Medicines & other
suport staff
Patient Safety
Caring Staff
3. Theoretical Frame Work:
Quality
control
H1
Caring Staff
Patient Safety
H2
H3
H4
Dependent
variable
H5
Governmental
Restrictions
Avalability of
Medicines &
other suport
staff
Quality Control:
Patient determined quality literature inconclusively predicts the direction
ofsatisfaction and quality from the patients perspective (Tucker and
Adams, 2001).Quality is positively correlated with satisfaction; however,
the direction and strength ofthe predictive relationship between quality
and satisfaction remains unclear. Someauthors believe that complex
healthcare services and the patients lack of technicalknowledge to assess
them should incorporate broader healthcare quality measures,
including financial performance, logistics, professional and technical
competence (Eirizand Figueiredo, 2005). Quality is a judgmental concept
(Turner and Pol, 1995) andoperational quality definitions, as we have
seen, are based on values, perceptions andattitudes (Taylor and Cronin,
1994). The implication thus is to develop qualitymeasures based on
expert judgement, specifically insightful customers and
respectedpractitioners (Turner and Pol, 1995).
Quality Control is one of the most important factor consider by patients
to there satisfaction level in health care. The Results observed from
questionnaires suggested that quality control will play a vital role in
Customer satisfaction for health care services in Pakistan. Thus we can
Hypothes it as H1.
H1: Significant relation ship between independent Variable Quality Control and Dependent
variable.
Patient Safety:
A key positive patient safety climate dimension is managerial support
and its ability todirect staff to formulate proper strategic plans and
priorities. Organizational climate islinked to managerial behaviours
(Schneider et al., 1998). Managerial and physiciansupport play
significant roles in the success of any patient safety activity, as eachdirect
a portion of the organization and care provision (Cooper, 2000).
Involvingmanagers and physicians is especially critical because they are
ultimately responsiblefor hospital policy and decisions that affect the

whole organization (Nieva and Sorra,
2003).
H2: Significant relation ship between independent variable patient safety and dependent
variable Customer Satisfaction.
Caring Staff:
Staff plays a vital role in Satisfaction of customers by giving positive
attitude and responses. If Staff cares about its patients then its all
needed for a customer to be satisfied. Thus a Hypothesis can be
developed.
H3: Significant relation ship between independent variable Caring Staff and dependent
variable Customer Satisfaction.
Availability of Medicines and other support staff:

If a Health care service station like hospital has proper equipment and
required medicines which is needed for the treatment of special cases
like cancer is available then it will be playing most important role in
patient satisfaction. Thus a Hypothesis can be developed.
H4: Significant relation ship between independent variable availability of medicines,
other support staff and dependent variable Customer Satisfaction.
Governmental Restrictions:
Government Restrictions in quality control, Patient Safety, Availability of
Medicines and other support stuff, and Staff Responsibilities defined by
government is the Moderating variable thus a hypothesis can be

developed.
H5: Significant relation ship lays between independent variable and dependent variable
the Moderating variable.
Findings
Statistics
Do Pakistan
Will Discounts
health care
influence
industry needs a Which Hospital

research?
N
Valid
you Preffer?
customer
satisfaction?
100
100
100
Missing
Do Pakistan health care industry needs a research?

Cumulative
Frequency
Valid
Total
Valid Percent
Percent
Yes
96
95.0
96.0
96.0
No
4.0
4.0
100.0
100
99.0
100.0
1.0
101
100.0
Total
Missing
Percent
System
95%
95%
Ho: Its Tested that Research on Healthcare industry is Needed

Which Hospital you Prefer?
Cumulative
Frequency
Valid
Total
Valid Percent
Percent
Private
61
60.4
61.0
61.0
Government
39
38.6
39.0
100.0
100
99.0
100.0
1.0
101
100.0
Total
Missing
Percent
System
60%
37%
H1: Large number of people trend to go to Private hospitals rather then

governmental free of cost.
Will Discounts influence customer satisfaction?

Cumulative
Frequency
Valid
Total
Valid Percent
Percent
Yes
75
74.3
75.0
75.0
No
25
24.8
25.0
100.0
100
99.0
100.0
1.0
101
100.0
Total
Missing
Percent
System
74%
25%
H4: Discounts offered in medicines trend towards customer satisfaction
Statistics
Will patient
Valid
Missing
Will Caring staff
Will Medicines
How much
Will Quality control safety influence
influence
&suport stuff
Doctor's Fee
What is your
influence customer
customer
customer
customer
you can
Income level?
satisfaction?
satisfaction?
satisfaction?
satisfaction?
afford?
100
100
100
100
100
100
What is your Income level?

Cumulative
Frequency
Percent
Valid Percent
Percent
Valid
Less then 10,000
30
29.7
30.0
30.0
10,000 to 20,000
26
25.7
26.0
56.0
20,000 to 30,000
20
19.8
20.0
76.0
30,000 and above
24
23.8
24.0
100.0
Total
100
99.0
100.0
System
1.0
101
100.0
Missing
Total
24%
30%
20%
26%
Will Quality control influence customer satisfaction?

Cumulative
Valid
Missing
Total
Frequency
Percent
Valid Percent
Percent
Strongly Disagree
21
20.8
21.0
21.0
Disagree
18
17.8
18.0
39.0
Nither agree nor Disagree
15
14.9
15.0
54.0
Agree
30
29.7
30.0
84.0
Strongly Agree
16
15.8
16.0
100.0
Total
100
99.0
100.0
1.0
101
100.0
System
16%
21%
18%
30%
15%
H1: Quality control is one of the tested variable of customer satisfaction.
Will patient safety influence customer satisfaction?

Cumulative
Valid
Missing
Frequency
Percent
Valid Percent
Percent
Strongly DIsagree
11
10.9
11.0
11.0
Disagree
24
23.8
24.0
35.0
Nither agree nor disagree
17
16.8
17.0
52.0
Agree
34
33.7
34.0
86.0
Strongly Agree
14
13.9
14.0
100.0
Total
100
99.0
100.0
System
1.0
101
100.0
Total
14%
11%
24%
34%
17%
H2: Patient safety is a tested independent variable to wards customer satisfaction.

Will Caring staff influence customer satisfaction?
Cumulative
Valid
Missing
Frequency
Percent
Valid Percent
Percent
Strongly DIsagree
15
14.9
15.0
15.0
Disagree
30
29.7
30.0
45.0
Nither agree nor disagree
13
12.9
13.0
58.0
Agree
28
27.7
28.0
86.0
Strongly Agree
14
13.9
14.0
100.0
Total
100
99.0
100.0
System
1.0
101
100.0
Total
14%
15%
28%
30%
13%
95
H3: Majority of test samples suggest Caring staff is a key towards customer
satisfaction.
Will Medicines &suport stuff customer satisfaction?

Cumulative
Valid
Missing
Frequency
Percent
Valid Percent
Percent
Strongly Disagree
12
11.9
12.0
12.0
Disagree
29
28.7
29.0
41.0
Nether agree nor disagree
12
11.9
12.0
53.0
Agree
37
36.6
37.0
90.0
Strongly Agree
10
9.9
10.0
100.0
Total
100
99.0
100.0
System
1.0
101
100.0
Total
10%
12%
37%
29%
12%
H4: Its tested majority of people agree medicines and support stuff leads towards
customer satisfaction.
How much Doctor's Fee you can afford?
Cumulative
Valid
Missing
Frequency
Percent
Valid Percent
Percent
Rs. 200
47
46.5
47.0
47.0
Rs. 400
26
25.7
26.0
73.0
Rs. 600
20
19.8
20.0
93.0
Rs. 800
6.9
7.0
100.0
Total
100
99.0
100.0
System
1.0
101
100.0
Total
7%
20%
47%
26%
Majority of customers in health care services are willing to pay less in health care services.
Crosstabs:
Case Processing Summary
Cases
Valid
N
What is your Income level? *
Which Hospital you Preffer?
Missing
Percent
Total
Percent
Percent
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%

Will Quality control influence
customer satisfaction?
Will patient safety influence

Will Caring staff influence
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
Will Medicines &suport stuff
Will Discounts influence
customer satisfaction? *
customer satisfaction? * Will
Quality control influence
patient safety influence
Caring staff influence
Medicines &suport stuff
How much Doctor's Fee you
can afford? * Which Hospital
you Preffer?
can afford? * Will Quality
control influence customer
satisfaction?
can afford? * Will patient
safety influence customer
satisfaction?

can afford? * Will Caring staff
influence customer
100
99.0%
1.0%
101
100.0%
100
99.0%
1.0%
101
100.0%
satisfaction?
can afford? * Will Medicines
&suport stuff customer
satisfaction?
Crosstabs been taken of all the questions which were used in questioners. They were matched
by the dependent variable and independent variables. Below is the Detailed report of all the
crosstabs.
What is your Income level? * Which Hospital you Preffer? Crosstabulation

Count
Private
What is your Income level?
Goverment
Total
Less then 10,000
17
13
30
10,000 to 20,000
16
10
26
20,000 to 30,000
10
10
20
30,000 and above
18
24
61
39
100
Total
Crosstabs : Income level Vs Hospital preffred:
In this crosstabs you can see majorty of people look towards private hospitals rather then
governmental hospitals. But people with high income trend more towards Private hospitals
What is your Income level? * Will Quality control influence customer satisfaction? Crosstabulation
Count
Will Quality control influence customer satisfaction?
Strongly
Nither agree
Disagree
What is your Income Less then 10,000
level?
Disagree
nor Disagree
Strongly
Agree
Agree
Total
10
30
10,000 to 20,000
26
20,000 to 30,000
20
30,000 and above
24
21
18
15
30
16
100
Total
Crosstabs : Income level VsQuality Control:
In this cross tabs majority of people agreed that quality control is a

key towards customer satisfaction.
What is your Income level? * Will patient safety influence customer satisfaction? Crosstabulation
Count
Will patient safety influence customer satisfaction?
Strongly
Nither agree
DIsagree
What is your Income Less then 10,000
level?
Total
Disagree
nor disagree
Strongly
Agree
Agree
Total
13
30
10,000 to 20,000
26
20,000 to 30,000
20
30,000 and above
24
11
24
17
34
14
100
Crosstabs : Income level Vspatient Satisfaction:
In this cross tabsmajority of people agreed Patient safety is the key

towards customer satisfaction and they are from all income levels.
Crosstabs : Income level VsMedical & other support stuff:
In this cross tabs majority of people agreed Medical & other

support stuffis the key towards customer satisfaction and they are from
all income levels.
Crosstabs : Income level VsCaring stuff:
In this cross tabs majority of people disagreed Caring staffis the

key towards customer satisfaction and they are from all income levels.
Will Discounts influence customer satisfaction? * Which Hospital you

Preffer? Crosstabulation
Count
Private
Goverment
Total
Yes
50
25
75
No
11
14
25
61
39
100
Total
Crosstabs : Income level VsCaring stuff:
In this cross tabs majority of people agreed Discountsis the key

towards customer satisfaction and they are from all income levels.
Crosstabs : DiscountsVsQuality control:
In this crosstabs majority of people agreed Quality controlis the key

towards customer satisfaction.
Crosstabs : DiscountsVspatient Safety:
In this cross tabs majority of people agreed patient safetyis the key
towards customer satisfaction.
Crosstabs : DiscountsVsCaring stuff:
In this cross tabs majority of people disagreed caring staffis the

key towards customer satisfaction.
Crosstabs : DiscountsVsmedicines & other support stuff:
In this cross tabs majority of people agreed Medicines and other

support stuffis the key towards customer satisfaction
How much Doctor's Fee you can afford? * Which Hospital you Preffer?
Crosstabulation
Count
Which Hospital you Prefer?
Private
How much Doctor's Fee you Rs. 200
Government
26
21
Total
47
can afford?
Rs. 400
15
11
26
Rs. 600
14
20
Rs. 800
61
39
100
Total
Crosstabs : Doctors FeeVsPrivate of Govt hospital:
In this cross tabs majority of people willing to pay more has more
trend to go to govt hospital rather then lowest fee level like 200 which
has some what equal percent chance.
Crosstabs : Doctors FeeVsQuality control:
In this cross tabs majority of people willing to pay low Fee200 has
more trend to agree on Quality Control rather then highest fee level like
800 which has some what equal percent chance.
Crosstabs : Doctors FeeVsQuality control:
In this cross tabs majority of people willing to pay low Fee 200 has
more trend to agree on Quality Control rather then highest fee level like
800 which has some what equal percent chance.
Crosstabs : Doctors FeeVspatient Safety:
more trend to agree on patient Safety rather then highest fee level like
800 .
Crosstabs : Doctors FeeVscaring Staff:
more trend to agree on caring Staffrather then highest fee level like 800
which has some what equal percent chance.
Crosstabs : Doctors FeeVsMedicines & Other Suport Stuff:
more trend to agree on Medicines and other support Stuff rather then
highest fee level like 800.
Conclusion:
This study has demonstrated the relationship between satisfaction and specific Independent variables.
The subject is important enough to recommend that theMinistry of Health conduct patient satisfaction
studies on a regular basis. This practicewill identify areas of dissatisfaction that can quickly be
remedied and ensureenhancement in satisfaction. More studies should be conducted in the primary
caresetting to reexamine those variables examined in the current study which have notproven to be
significant and to validate the significant relationship found in this study.Before using patients
satisfaction questionnaire which was developed for differentcultural settings one should validate it in
local context to measure the patientsatisfaction.
Result of This Research:
This Research showed me Some Factors which were backed by the samples results showing they will
influence them towards customer satisfaction. Hence this report is accepted. Independent Variables are
the factors which will influence customer satisfaction.
References
1. Health care service quality perception in Japan by Miss amiraeleuchepkoubaa Vol. 24

Iss: 6 2011.
2. Does patient satisfaction affect patient loyalty by Daniel P. Kessler, Deirdre Mylod Vol.
24 Iss: 4, 2011,?
3. A case study of collaborative communications within healthcare logistics by Jerry D.
VanVactor, (2011) Vol. 24 Iss: 1.
4. Relational impact of service providers' interaction behavior in healthcare by Sanjaya
Singh Gaur, YingziXu, Ali Quazi, Swathi Nandi, (2011) Vol. 21 Iss: 1.
5. Factors influencing patient satisfaction in primary healthcare clinics in Kuwait by Abdul
MajeedAlhashem, HabibAlquraini, Rafiqul I. Chowdhury, (2011) Vol. 24 Iss: 3.
6. Predictors of satisfaction with child birth services in public hospitals in Ghana by
Gertrude SikaAvortri, Andy Beke, Gordon Abekah-Nkrumah, (2011) Vol. 24 Iss: 3.
7. Patient safety analyses using Lombardy administrative archives by Pietro Giorgio
Lovaglio, (2011) Vol. 24 Iss: 2.
Proposal
To:
From: Imrana Shamas, Misbah
Research Topic : Factors influencing customer satisfaction in healthcare services.
Purpose:
To read the impact of brand judgment from different alternative.

Aim to develop a model that includes self congrueces, attitude satisfaction explain their role on
behavior.
How people are satisfied?
Literature Review:
Patient satisfaction can be defined as judgment made by a recipient of care as to whether their
expectations for care have been met or not (Palmer et al., 1991). Themodern view of quality of care
looks to the degree to which health services meetpatients needs and expectations both as to technical
and interpersonal care (Campbellet al., 2000; Eschet al., 2008). Investigation of patient satisfaction has
been used to meetthree main objectives in health care delivery industry (Ware et al., 1978; Patrick et
al.,1983; Al-Doghaither and Saeed, 2000). First, to determine how and to what extentsatisfaction
influences patients seeking care in terms of complying with treatment andcontinuing to use the care.
Second, to use satisfaction as an indicator of the quality ofcare; and third to help physicians and the
health care organizations better understandthe patients point of view, and to use this feedback to
increase accountability and toimprove the services provided.
Patient satisfaction with medical care is a multidimensional concept, withdimension that corresponds
to the major characteristics of providers and services(Ware et al., 1983; Moretet al., 2008; Donahue et
al., 2008). Patient satisfaction withhealth care services is considered to be of paramount importance
with respect toQuality improvement programs from the patients perspective, total qualitymanagement,
and the expected outcome of care (Vouri, 1991; Donabedian, 1992;Aggarwal and Zairi, 1998; Brown and
Bell, 2005). Within the health care industry,patient satisfaction has emerged as an important
component and measure of thequality of care (Aharony and Strasser, 1993; Grogan et al., 2000;
Salisbury et al., 2005).Patient satisfaction plays an important role in continuity of service
utilization(Thomas, 1984). Satisfied patients are more likely to adhere to doctorsrecommendations and
medical regimens (Ross et al., 1981). Besides, dissatisfiedpatients do not utilize primary health care
services optimally and over-utilize theemergency rooms in the general hospitals (Shah et al., 1996; AlHay et al., 1997).
The quality of the communication relationship between physician and patientshowed positive influence
on patient satisfaction measure (Moretet al., 2008; Merceret al., 2008; Lin et al., 2009).Several studies
have been performed regarding patient satisfaction and its correlates in various countries (Rahmqvist,
2001; Margolis et al., 2003;Bronfman-Pertzovskyet al., 2003). Only two studies have been conducted to
dateregarding the concept of patient satisfaction in Kuwait (Bo Hamra and Al-Zaid, 1999;Al-Doghaitheret
al., 2000). They found significant relationship of age, gender,nationality, marital status; education,
occupation, and income with patient satisfaction.
Dependent
Variable
Satisfied
Customers
Independent
Variable
Quality Control
Availability of
Medicines &
other suport staff
Patient Safety
Caring Staff
Theoretical Framework:
Quality
control
Patient Safety
Caring Staff
Dependent
variable
Avalability of
Medicines &
other suport
staff
Hypothesis Development:
H1: Independent variable like Advertisement has relation to dependent variable like sales.
H2: Moderating variable like Income of people is between Dependent variable and independent
variable.
Limitations: Time constraints of the semester require less time than may be ideal for an ethnographic
study. By being in the organisation for only four hours a week for five weeks, there are bound to be
aspects of leadership practice, organisational culture and team communication that will not be revealed
during my observations. Being an outsider may also limit what is revealed to me. The team members
may be guarded in their conversations around me, especially in my initial observations.
Time period:
The time period required round about 2 week.
Factors affecting the climate of

hospital patient safety
A study of hospitals in Saudi Arabia
Stephen L. Walston
Health Administration and Policy, University of Oklahoma City,
Oklahoma City, Oklahoma, USA
Badran A. Al-Omar
King Saud University, Riyadh, Saudi Arabia, and
Faisal A. Al-Mutari
Saudi Ministry of Health, Riyadh, Saudi Arabia
Abstract
Purpose The purpose of this paper is to describe three organizational dimensions that influence
hospital patient safety climate, also showing and discussing differences between organizational types.
Design/methodology/approach Surveys were conducted in four types of Saudi Arabian
hospitals. Resultant information was analyzed using factor analysis and multiple-regression.
Findings Management support, a proper reporting system and adequate resources were found to
influence the hospital patient safety climate.
Research limitations/implications The cross-sectional hospital survey took place in a country
that is radically redesigning its healthcare system. Major changes including hospital privatisation and
healthcare insurance systems may have significant effects on hospital organizational climates.
Originality/value Improving a hospitals patient safety climate is critical for decreasing errors and
providing optimal services. Although much patient safety research has been published, the
organizational climate in non-Western countries has not been studied. The paper provides a unique
Saudi Arabian hospital perspective and suggests that three dimensions influence the patient safety
climate. Hospital managers are encouraged to improve these critical dimensions to positively develop
their patient safety climate.
Keywords Safety, Saudi Arabia, Hospitals
Paper type Research paper
Introduction
Hospitals continue to be a major source of risk to people. Instead of solely benefiting
patients, hospitals and medical interventions often harm them (Baker, 2004). However,
efforts are made across the globe to improve patient care and diminish harm. These
efforts include many changes, including clinical and organizational improvements to
provide proper, quality care and treatment. Patient safety and service quality have
joined evidence-based medicine to better meet patient needs and preferences (Kohn
et al., 1999; Parasuramanet al., 1985). To accomplish this, health care providers must
incorporate safety and quality into their organization to assure appropriate clinical and
administrative activities. Although organizational patient safety factors are critical,
they have been much less studied in healthcare research (Navehet al., 2005).
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0952-6862.htm
A study of
hospitals in
Saudi Arabia
35
Received 9 April 2008
Revised 29 May 2008
Accepted 7 July 2008
International Journal of Health Care
Quality Assurance
Vol. 23 No. 1, 2010
pp. 35-50
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526861011010668
Organizational climate has emerged as a major factor that can influence patient
safety. The absence of a proper safety climate can lead to greater risk to patients and
safety deterioration. Limited research has examined the effect of patient safety culture
factors on organizational outcomes in the USA and Europe (Hofmann and Mark, 2006;
Navehet al., 2005; Carr et al., 2003; Parker et al., 2003). However, no research has
examined the relevance of a safety climate in hospitals located in the Middle East. Our
purpose was to study the factors that create a patient safety climate in Saudi Arabian
hospitals, how they differ by ownership and their effect on the perceived overall
climate of patient safety.
Background
Patient safety, which has been defined as freedom from accidental injury during
medical care or from medical errors has become a critical topic in medicine (Kohn et al.,
1999). The desire to avoid harm has existed as a concern in medicine since the fourth
century BC when Hippocrates the Father of Medicine admonished medical
professionals to do no harm (Hippocrates, 2004). The healthcare industry is fraught
with dangers for both patients and employees (Yassi and Hancock, 2005). These
dangers are linked directly to the environment and culture that surrounds medical
professionals and patients with their distinctive norms, values and shared beliefs
(Stone et al., 2004). Although medical professionals have for years sought to improve
quality by standardizing good processes, it is not enough to just design better ways to
control errors. The organizational climate must also encourage information sharing
and support safety (Hofmann and Mark, 2006).
Creating a proper patient safety climate includes changing management
behaviours, safety systems and employee safety perceptions that directly influence
healthcare professionals to choose proper behaviours that enhance patient safety (Colla
et al., 2005; Fleming, 2005). However, many studies and safety interventions have not
addressed actual safety climate, but have focused on activities such as data collection,
reporting, reducing blame, involving leaders, or focusing on processes (Singer et al.,
2003). Climate consists of shared employee perceptions relating to the practices,
procedures and behaviours that get rewarded and supported in an organization
(Schneider et al., 1998). An organizational climate is gained by the experiences
employees have and how they perceive their environment. The climate influences how
organizational members behave by how they think and feel about their work
environment. Employees work environment perceptions cause them to interpret
events and develop attitudes, which dictate how they work (Bowen and Ostroff, 2004).
Although organizational climate perceptions are significant safety indicators, there
have been few organizational safety climate studies in hospitals and even less with an
international scope (Collaet al., 2005; Navehet al., 2005; Stone et al., 2004).
Many countries and international organizations created regulations and rules for
their medical sectors to improve patient safety. These efforts sought to create a patient
safety climate to improve healthcare processes and outcomes through regulatory
processes. Typically, regulatory efforts involve three safety dimensions:
(1) Safety policies and procedures (Caldwell, 1995; Sloan and Torpey, 1995).
(2) Disseminating safety information to employees (Reber and Wallin, 1984).
(3) Prioritising safety among leaders (Zohar, 2000; Roberts, 1990; Zbaracki, 1998).
IJHCQA
23,1
36
Saudi Arabian healthcare safety efforts
The Kingdom of Saudi Arabia like many other countries is investing significant efforts to
improve healthcare quality. Their Ministry of Health created a directorate in the early
2000s to take responsibility for educating, training and improving patient care throughout
the Kingdom. Specific patient safety and quality training programs educate healthcare
personnel. A set of hospital national standards has been developed and hospitals will in
the near future be required to be accredited by the national accreditation body. Hospitals
in the Kingdom are also pursuing external accreditation, including the Canadian Council
on Health Services Accreditation and the Joint Commission International.
The Saudi Arabian healthcare system is unique regarding professionals providing
care. The country has both public and private providers. About 75 percent of
healthcare is provided from governmental providers. However, public sector
healthcare is subdivided into the Ministry of Health, university hospitals, specialized
hospitals (such as the King Faisal Specialist Hospital) and military hospitals (e.g.
national guard and military systems) with unique funding, authority and management.
The Ministry of Health now provides about 62 percent of the Kingdoms inpatient care.
Also, a significant difference from other Western national healthcare systems is that
less than 20 percent of physicians and nurses working for the Ministry of Health are
Saudi citizens. The remainder come from all over the world. These expatriates who
provide care have a high turnover with an average tenure of less than two and a half
years. Also, a higher percentage of Saudis make up the governmental healthcare

workforce; for example, about 20 percent of Ministry of Health physicians are Saudis
compared to only five percent in the private sector (Walstonet al., 2008).
Creating a positive patient safety climate
Creating a positive patient safety climate inside an organization can only be
accomplished through managerial commitment, strong communication, dedicated
organizational resources and mutual trust shared by organizational members
(Fleming, 2005; Singer et al., 2003). A proper patient safety culture is built through
commitment from an organizational leadership that does not punish when errors are
shared. It promotes collaborative efforts and experiences across hierarchies and
involves both patients and families (Battles, 2004; Fleming, 2005; Nieva and Sorra,
2003). A positive safety climate involves manager and physician commitment and
effort, as both are dependent on each other for creating positive patient outcomes and
each share dual roles in supervising care provision.
The positive patient safety climate organizational dimensions have been
categorized into management engagement, reporting systems with proper policies
and procedures and organizational resources (Singer et al., 2003; Navehet al., 2005).
These organizational factors suggest a strong positive relationship with an
organizational climate that promotes patient safety and safe care. Studies suggest
that positive safety climates result when leaders are committed to safety activities and
behaviours, and when policies encourage proper behaviours (DeJoy, 1985; Zohar, 1980).
North American research shows the importance of organizational factors and hospital
climate, which include management perceptions, stress levels, job satisfaction and
working conditions (Pronovostet al., 2003; Huang et al., 2007). Figure 1 illustrates three
dimensions that influence patient safety, its relationship to an organizational climate
and resultant patient safety.
A study of
hospitals in
Saudi Arabia
37
Patient safety climate dimensions
Management support
A key positive patient safety climate dimension is managerial support and its ability to
direct staff to formulate proper strategic plans and priorities. Organizational climate is
linked to managerial behaviours (Schneider et al., 1998). Managerial and physician
support play significant roles in the success of any patient safety activity, as each
direct a portion of the organization and care provision (Cooper, 2000). Involving
managers and physicians is especially critical because they are ultimately responsible
for hospital policy and decisions that affect the whole organization (Nieva and Sorra,
2003).
Managers have overall responsibility for organizing hospital medical services to
assure basic safety patient outcomes. Patient safety is derived from combined
directives, behaviours and actions formulated by managers and often interpreted and
implemented by physicians, to improve service and erase obstacles that may impede
success and improvement. Manager and physician efforts, therefore, affect patient
safety climate (Nieva and Sorra, 2003; Fleming, 2005). Managers define employee
priorities by their actions, goals and focus. This motivates employees work pace,
establishes workloads, rewards, punishments and the resultant pressures for
production and safety. Leaders prioritise safety by emphasizing specific safety

behaviours and de-emphasizing others. Employees view safety often through the
leaders lens (Flinet al., 2000; Zohar, 2002). Employees working in organizations whose
supervisors are committed to safety reflect manager commitment and perceive safety
to be important (Hofmann and Stetzer, 1998). However, if managers allow
safety-related activities to be perceived as mere rhetoric or pretence then there will
be a poor safety climate (Navehet al., 2005).
Continuous motivation and clarification are important to achieve a positive safety
climate. Supervisor and manager information sharing and feedback behaviour
critically affects the safety environment (Bisognanoet al., 2005) with the supervisors
communication actions and efforts more important than senior executives (Pronovost
et al., 2003). A patient safety climate necessitates a continuous feedback flow and
access to safety information from various modes, including communication and
training. To effectively motivate and maintain the climate, feedback should be
Figure 1.
Patient safety climate
dimensions
IJHCQA
23,1
38
sufficiently clear and unambiguous. Organizations vary according to the feedback they
provide and the amount of safety information disseminated, depending on frequency
and routines (Hofmann and Stetzer, 1998). Safety information dissemination often
demonstrates staffs planned efforts to improve safety performance by augmenting
their knowledge (Ford et al., 1994). Clear feedback should decrease errors and cause
employees to be aware what it takes to assure safety (Erez, 1977). This awareness
increases the likelihood that employees will use information (Reber and Wallin, 1984).
Managers can direct employees attention toward safety when they distribute safety
information and provide training. This facilitates disseminating knowledge among
organizational members and reinforces shared perceptions regarding safety that
develops an appropriate safety climate (Navehet al., 2005).
Communication between workers in the medical field is critical for safety. Good
communication supports planning, decision-making, problem solving and goal setting,
and promotes shared responsibility for patient care. Cooperation and collaboration
through proper communication determines positive patient outcomes. Climate can
influence communication regarding patient safety. It is important to ensure that all
communication channels are used properly to create a patient safety climate for staff
and patients. A positive safety climate is founded on mutual trust through good
communication) Nieva and Sorra, 2003). Errors occur when communication problems
arise (Singer et al., 2003). Feedback from managers and physicians is a critical
dimension that promotes a patient safety climate. Many studies show its importance
for improving and developing safety. The organization with a strong patient safety
climate seeks to develop its services through robust feedback and learn from its errors
(Nieva and Sorra, 2003). Good feedback increases staff involvement and commitment
(Fleming, 2005). We propose:
H1. Management support has a positive effect on the organizational climate of
patient safety.
Reporting system
Proper reporting systems are a patient safety climate key facet. Improving patient
safety requires encouraging error reporting and improving systems to reduce

incidence (Tamuz and Thomas, 2006). Reporting systems should enhance patient
safety by allowing learning from past errors and determining risk patterns, which may
go unnoticed without a reporting system (McFadden et al., 2006). A patient safety
climate is facilitated by clear and direct rules, policies and procedures for all workers to
follow. Organizations often spend great time and effort developing and implementing
safety rules and procedures (Gaba, 2000). Procedures that instruct employees how to
implement new technologies have been suggested to create a positive implementation
climate (Klein et al., 2001). A work environment that does not contain clear work rules
may lead to an unsafe environment. Formal safety policies are written organizational
rules and routines that define how organizational requirements for safety will be met.
They exist to assure safety by reducing risk, managing uncertainty and risk present in
healthcare services (Navehet al., 2005; Brunsson and Jacobsson, 2000). Most hospitals
in industrialized countries have adopted written systems for patient safety to
standardize patient care practices (Al-Omar and Al-Fawzan, 2008). It is important to
establish and adhere to policies and procedures including patient and medical staff
rights and responsibilities, service scope, clinical privilege definitions and protocols
A study of
hospitals in
Saudi Arabia
39
and treatment plans. Safety procedures establish expectations and standards to
improve service quality. Organization staff increase their safety demands by creating
policies and procedures (Navehet al., 2005). We propose, therefore:
H2. Good reporting systems positively affect organizational climate for patient
safety.
Resource adequacy
Patient safety climates are also created by appropriate resources, including relevant
information technology and staff. Information technology is needed to adequately
communicate in todays complex healthcare organizations. Technologies such as
automated drug order, entry and reminder systems increase accurate communication
and decrease common medical errors (Menachemiet al., 2007). Medical information
technologies decrease human errors and help medical service providers to offer higher
quality services Workload can also affect an organizations climate. Overworked
employees tend to minimize communication flows and feedback, resulting in
resentment and cynicism. Inappropriate workloads diminish critical information
transmission leading to errors that negatively affects the organizations safety climate
(Firth-Cozens, 2001; Blegenet al., 2004). Thus:
H3. Adequate resources positively affect organizational climate for patient safety.
This descriptive and analytical study was derived primarily from a survey
conducted among Kingdom of Saudi Arabia hospital staff. The target population
included clinical staff, such as physicians, pharmacists, nurses, specialists and
technicians located in different hospitals in the Ministry of Health, the military
system, teaching hospitals and private hospitals in Riyadh, Saudi Arabia. A
structured questionnaire with a five-point Likert scale (strongly agree to strongly
disagree) was used to measure respondents patient safety perceptions and to
ascertain the respondents personal characteristics. The questionnaire was developed
after reviewing pertinent patient safety and climate literature. The questionnaire
contained 60 items: seven for personal information; 44 core questions on key

dimensions influencing patient safety climate and nine for developing a patient
safety climate index. The questions were then reviewed by healthcare professionals
and altered to reflect their suggestions. Finally, a pilot study among 35
professionals gathered their suggestions. The questionnaires were then distributed
to 800 healthcare professionals in four hospitals categories: Ministry of Health,
private, military and teaching facilities. The questionnaire was produced in English
and Arabic and administrated according to language preference. Of those
distributed, 496 or 62 percent were returned completed. Table I shows
respondents characteristics. A little over 60 percent were women, 30 percent
were Saudis and the overall average age was 35 years. Also, they had 10.6 years of
work experience, 57 percent had a bachelor degree, 30 percent were physicians and
27 percent nurses. Most respondents worked either for the Ministry of Health (36
percent) or for private hospitals (43 percent).
Analysis
Univariate and covariate properties were explored by compiling basic descriptive
statistics and comparing them among the organizational groups. Differences between
IJHCQA
23,1
40
respondent characteristics and the overall score were examined using chi-square tests.
Significant differences between gender, holding a degree, being a registered nurse and
a Ministry of Health and private hospital employee were found. The only variable not
significant was being a physician. Multiple regression analyses were then used to
estimate managerial behaviour effects, reporting system and adequate resources on the
patient safety climate index. In addition to compiling a correlation matrix, a variance
inflation factor (VIF) was included in the regressions to ascertain the absence of multi
co-linearity. No VIF exceeded 1.7, which is well under the accepted guidelines of less
than ten (Kennedy, 1992). All analyses and statistical modelling were conducted using
SAS v.9.
Independent variables
Survey responses were subjected to a principal component analysis using prior
communality estimates. This method is designed to identify conceptual domains in the
survey and provides an accepted means for identifying underlying constructs
(Hatcher, 1994). The principal axis method was applied to extract the components,
followed by a Varimax (orthogonal) rotation. Only the first three components displayed
Eigenvalues greater than one while scree tests suggested that only these three
components were meaningful. Therefore, only the first three components were retained
for rotation. Combined components one, two and three accounted for 54 percent of the
total variance. Questionnaire items and corresponding factor loadings are presented in
(%)
Gender
Male 38.40
Female 61.60
Nationality
Saudi 30.1
Arab (non-Saudi) 28.9
Other 39.0
Age 35.3
Years experience 10.6
Education
Postgraduate 20.3
Bachelor 56.9
Diploma or high school 22.8
Occupation
Physician 30.0
Pharmacist 9.3
Nurse 26.6
Technician/other 34.0
Work
Ministry of Health 35.8
Private 43.2
Military 16.6
Teaching 4.4
Table I.
Respondent
characteristics
A study of
hospitals in
Saudi Arabia
41
Table II. On the rotated factor pattern an item loads on a given component if the factor
loading is 0.40 or greater for that component and less than 0.40 for the other. Using
these criteria, nine questions were found to load on the first component, which was
subsequently labelled the managerial support component. Eight questions loaded on
the second component, which was labelled reporting system. The third factor
resource adequacy loaded four questions. We achieved reasonable coefficient alpha
reliability estimates: 0.86 for the first two factors and 0.69 for the third factor (Hatcher,
1994). Loading strengths are represented by the communalities h2 - the variance in an
observed variable that is accounted for by the common factors. These numbers seem
strong for the all three factors (Hatcher, 1994). After closely examining the questions,
we feel that they fairly represent the designated constructs.
Main variable means and correlations, including the three factors/dimensions
generated, are presented in Table III. No high inter-variable correlations were
observed. All three factors have the expected zero correlation with one another, since
an orthogonal rotation in principal component analysis creates this relationship
(Hatcher, 1994).
Control variables
Control variables, anticipated to have systematic effects on organizational climate were
entered into the model. The tendency toward a patient safety climate may be
differentially affected by characteristics such as profession, education and
organizational type. These factors may reflect differential resources, expertise and
other pressures. Control variables were drawn from the survey.
Statements
Management
support
Reporting
system Resource adequacy
0.57 Proper means to ask about patient safety
0.56 Top managers create suitable work environment
0.66 Medical staff discusses ways to prevent errors
0.48 Supervisor welcomes suggestions

0.7 Patient safety instructions are clear for medical staff
0.8 Medical staff take responsibility for patient safety
0.74 Medical staff follow guidelines that enhance patient safety
0.57 Medical staff trained about patient safety
0.45 Reporting not structured to punish
0.66 Reporting errors leads to positive change
0.73 Medical believe in the importance of reporting errors
0.78 Physicians believe in the importance of reporting near-misses
0.63 Information from reported errors is used to improve safety
0.68 Physicians are encouraged to report problems
0.59 Reporting system procedures are clear
0.45 There are enough staff for workload
0.68 Electronic reporting system
0.8 Computerized physician order system
0.8 Patient electronic medical record
0.69 0.86 0.86 Alpha
2.45 4.28 4.59 Variance explained by each factor
Table II.
Loadings and statements
making up patient safety
climate factors
IJHCQA
23,1
42
10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Mean n
1 0 378 Management
support
1 0 0 378 Reporting system
1 0 0 0 378 Resource
adequacy
1 20.088 20.171 * * * 20.072 0.369 578 Male
1 0.218 * * * 20.095 20.248 * * * 20.253 * * * 0.301 578 Saudi
1 0.132 * * 0.160 * * * 0.031 20.048 0.05 0.941 578 Graduate degree
1 0.063 20.008 0.366 * * * 20.034 20.039 20.007 0.223 578 Physician
1 20.413 * * * 0.116 * * 20.302 * * * 20.365 * * * 0.007 0.197 * * * 0.113 * 0.372 578 Nurse
1 20.104 * 0.002 0.141 * * * 0.256 * * * 0.085 * 20.129 * 20.256 * * * 20.145 * * 0.324 578 Ministry of
Health
hospital
1 20.556 * * * 0.121 * * 20.014 0.126 * * 20.281 * * * 20.049 0.150 * * 0.159 * * 0.251 * * * 0.393 578
Private hospital
Notes: *p , 0:5; * *p , 0:01; * * *p , 0:0
Table III.
Means and correlations
A study of
hospitals in
Saudi Arabia
43
Dependent variable
A patient safety culture index was constructed from nine statements reflecting overall
safety climate dimensions. These were established from an extensive literature review.
Various patient safety indexes have been published, including one of nine items (Zohar,
1980; Mueller et al., 1999), 13 items (Rybowiaket al., 1999), and three items (Hofmann
and Mark, 2006). The survey statements we used are shown in Table IV. Questions,
again, were on a five-point Likert scale from 1 strongly agree to 5 strongly
disagree. An overall patient safety climate index was created by averaging responses
from nine statements:
(1) Medical staff members receive continuous education about patient safety.
(2) My supervisors behaviour reflects that patient safety is a top priority.
(3) The quality department in this hospital cooperates with staff regarding patient
safety.
(4) This hospital has a reward system for reporting errors.
(5) Information obtained from reported errors is used to improve patient safety.
(6) Patient electronic medical records are used to improve patient safety.
(7) Senior manager behaviour demonstrates that patient safety is a top priority.
(8) Medical staff takes care to achieve high standards of patient safety in their
work.
(9) The workload is appropriate for the available staff.
The three factors relationship to patient safety climate was evaluated using multiple
regression analysis (Table IV). Controls were added in the model and having a degree
ultimately deleted as it added little to the analysis (only 0.003 was added to the
adjusted R-square).
The differences among organizational types for each question were then reviewed
using a Tukey HSD test, which compares group means and indicates significant
pair-wise differences. We categorized significant differences by hospital type (Table V).
Patient safety climate index
,0.0001 30.5 F-value /Pr. F
0.441 0.456 R sq/adjR sq
Pr. t S. error Coefficient
,0.0001 0.082 3.108 Intercept
0.687 0.067 20.027 Male
0.031 0.074 0.161 Saudi
0.639 0.079 20.037 Physician
0.973 0.072 20.002 RN
0.702 0.078 20.030 Ministry of Health
0.850 0.070 20.013 Private
,0.0001 0.029 0.319 Factor 1: management support
,0.0001 0.030 0.276 Factor 2: reporting system
,0.0001 0.028 0.197 Factor 3: resource adequacy
Table IV.
Regression analysis
IJHCQA
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44
Findings
A patient safety climate represents a composite of employees organizational
conditions, operations and demands (Navehet al., 2005). Safety culture reflects many
professionals including physicians, nurses and technicians (Kohn et al., 1999). Our
study indicates that the Saudi Arabian Ministry of Health may have a better patient
safety climate than the others. Overall, our analyses suggest that Ministry of Health
hospitals score consistently better on their patient safety climate questions than other
organizations. As shown in Table VI, MOH hospitals were better than other facilities in
28 from 44 questions. In 11 questions there was no difference and in no question was

any other organizational type better than the Ministry of Health. Relatively, therefore,
the MOH appears to have a better patient safety environment. However, if response
absolute values are examined then the Ministry of Health can improve hospitals that
may have potential patient safety problems. For example, scores on the statement that
The quality department in this hospital cooperates with staff regarding patient
safety, shown in Table VI, are statistically significant between the Ministry of Health
and private hospitals. Private hospitals have a mean negative score of 4.09
(5 strongly disagree). The Ministry of Health average is less negative, but with only
a mean of 3.34, which can at best be seen as neutral. As we saw in the other statements,
four of which are shown in Table VI, this pattern is repeated.
Our multiple regression analysis demonstrates that the patient safety climate is
positively and significantly influenced by all three factors, supporting all three
hypotheses. H1: that management support influences a climate of patient safety is
accepted with a positive and significant coefficient of 0.319. Likewise, H2: the
organizations reporting system has an effect on the patient safety climate is also
supported with a positive, significant coefficient of 0.276. Last, H3: adequate resources
positively affect the climate for patient safety is also accepted with a positive
coefficient of 0.197.
Discussion
An improved patient safety climate can lead to better outcomes. Research suggests
that an improved safety climate encourages error and problem discussions; on the
other hand, a poor safety climate causes problems to be covered-up and not freely
discussed (Hofmann and Stetzer, 1998; Frese and van Dyck, 1996; Edmondson, 1996).
Number significantly different Survey question
5 MOH better than private
8 MOH better than private and University
1 MOH better than military
6 MOH better than University
6 MOH better than all
2 MOH and military better than private and University
1 Private better than military
1 Military better than University
2 University better than all
1 University better than military
11 No difference
44 Total questions
Table V.
Significant differences by
organizational type
A study of
hospitals in
Saudi Arabia
45
Negative safety climates deter individuals from acting appropriately and ensuring
safety (Dobbins and Russell, 1986; Hofmann and Stetzer, 1998). Interestingly, in our
study, Saudi Arabian public services appear to perform better than private hospitals.
The Ministry of Health invested substantial money and effort in the past few years to
increase service quality and safety. They sponsored symposiums and training in all
hospitals and initiated licensure. These efforts seem to improve patient safety
perceptions. However, although they are relatively better than the other hospital types,
some absolute scores are at best neutral. This demonstrates that continued
improvements are required. Our findings that private hospitals have negative
ratings and score worse on their patient safety climate may have implications for the
proposed Saudi Arabian hospital privatization (Ghafour, 2007). If the patient safety
climate is currently worse in the private sector, then assurances are needed that:
. patient safety will be improved; and
. existing Ministry of Health hospital patient safety climate should not decline.
There may be organizational reasons for private hospitals lower patient safety climate
scores. Saudi Arabian private hospitals have a reputation for providing reasonable
quality but are primarily staffed by expatriates who often have financial incentives to
investigate patients unnecessarily. Saudi Arabian private hospitals primary
advantage is their accessibility. Instead of waiting months for tests and surgery,
investigations in private hospitals may be done quickly if financial arrangements are
Question 6: The quality department in this hospital cooperates with staff regarding patient safety
Different Mean
MOH vs private 3.34 MOH
F 20.0, p , 0.000 4.09 Private
3.49 Military
3.79 University
Question 13: Top managers create a suitable work environment to encourage patient safety
Different Mean
MOH vs private 3.40 MOH
F 16:75 4.02 Private
3.77 Military
3.74 University
5 Strongly disagree 1 Strongly agree
Question 20: My supervisor welcomes our suggestions about patient safety
Different Mean
MOH vs private, and MOH vs University 3.34 MOH
F 10.75, p 0.000 3.86 Private
Different 3.73 Military
4.00 University
5 Strongly disagree 1 Strongly agree
Question 27: Department rules are effective in preventing errors occurring
Different Mean
MOH vs private, MOH vs University, 3.42 MOH
Military vs private, and Military vs University 4.03 Private
F 16.47, p 0.000 3.63 Military
4.29 University
Table VI.
Organizational
differences
IJHCQA
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46
met. However, our findings suggest that private hospitals have much further to go to
improve their patient safety focus.
Practice implications
Our findings provide practice implications and suggest that three dimensions need
highlighting:
(1) Management support.
(2) Reporting systems.

(3) Resource adequacy significantly affect patient safety climates.
Patient safety is a critical component in the quality of patient care. Yet, many
organizations ignore the underlying factors that contribute to improved patient safety.
Healthcare organizations, especially hospitals, need to allocate the time and resources
to assure that these conditions exist in their facilities that create not only monitors to
measure quality but processes, encouragement, and resources that produce a climate
and eventually a culture that becomes self-regulating and promotes patient safety.
This transformation has occurred in other industries, but only after interventions and
sustained efforts to change their work environments and climate (Gaba, 2000).
Communication and executive support are needed. Executives must understand what
their clinical providers believe. Other research shows that top managers are often
oblivious to staffs true perceptions within their organization and frequently are much
more positive than their clinical staff (Walston and Chou, 2006). Hospital leaders
should take time to evaluate staff perceptions using interviews, discussions and
surveys to better comprehend employee perceptions and feelings. Such interventions
allow appropriate changes to policies and resource allocation that may improve
managers support for patient safety.
Study limitations and implications for further research
There are limitations in our study and further research is needed to understand patient
safety climates. Our study was conducted in a developing country that is extensively
modifying its healthcare system. The statistical systems in the country are limited or
unavailable. Our research also represents a cross-sectional survey of hospital
employees patient safety perceptions and involved only patient care providers. Also,
as with all survey research, this study is possibly subject to sampling and response
bias, although efforts were made to control potentialities. Further research is needed to
validate and provide greater information on patient safety climate. Longitudinal data
would strengthen this research. Also, including patient feedback would add to our
research. Patient safety research generally lacks the patients perspective. Additional
research including patients hospital climate perceptions could be enlightening.
Likewise, performing the survey in multiple countries would provide an interesting
cross-country perspective to evaluate the potency of these factors and how they affect
patient safety climate and its interaction with local/country culture.
Conclusion
Patient safety continues to be a critical healthcare factor in all countries. There is a
need to provide better and safer care. Our research provides an international
perspective on how staff can differ in their patient safety focus and demonstrates how
A study of
hospitals in
Saudi Arabia
47
managerial support, proper reporting systems and adequate resources can affect
hospital patient safety climate. Hospitals that address these issues are likely to provide
better and safer patient care.
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Corresponding author
Stephen Walston can be contacted at: swalston@ouhsc.edu
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Factors influencing patient

satisfaction in primary healthcare
clinics in Kuwait
Abdul MajeedAlhashem, HabibAlquraini and
Rafiqul I. Chowdhury
Department of Health Information Administration, Kuwait University,
Sulaibekhat, Kuwait
Abstract
Purpose To measure the quality of health care services patient satisfaction is used as one of the
most important indicators. The study aims to identify factors affecting patients satisfaction at
primary health care clinics.
Design/methodology/approach The data was collected during January 2007 and May 2007
through a randomly-distributed questionnaire. The questionnaires were distributed in primary
healthcare clinics that represent all heath care regions in Kuwait. A total of 426 completed
questionnaires, out of 500, were returned resulting in a response rate of 85.2 percent.
Findings The majority (87 percent) of the patients responded that the time for communication
between physician and patient was not enough. Seventy-nine-percent of the surveyed patients said
they would go to the emergency room of the hospital in future if needed instead of going to the primary
care clinic. Regarding the quality of the communication relationship between physician and patients
most of the patients responded negatively. Exploratory factor analysis identified six factors and
reliability of overall scale was found to be 0.61.
Research limitations/implications One limitation to this study was the exclusion of the private
sector.
Originality/value The authors hope that this study identifies areas of dissatisfaction that can be
quickly remedied and ensures enhancement in the areas of satisfaction with ongoing attention and
emphasis.
Keywords Patient care, Health services, Customer satisfaction, Kuwait
1. Introduction
Patient satisfaction can be defined as judgment made by a recipient of care as to
whether their expectations for care have been met or not (Palmer et al., 1991). The
modern view of quality of care looks to the degree to which health services meet
patients needs and expectations both as to technical and interpersonal care (Campbell
et al., 2000; Eschet al., 2008). Investigation of patient satisfaction has been used to meet
three main objectives in health care delivery industry (Ware et al., 1978; Patrick et al.,
1983; Al-Doghaither and Saeed, 2000). First, to determine how and to what extent
satisfaction influences patients seeking care in terms of complying with treatment and
continuing to use the care. Second, to use satisfaction as an indicator of the quality of
care; and third to help physicians and the health care organizations better understand
the patients point of view, and to use this feedback to increase accountability and to
improve the services provided.
Patient
satisfaction
249
Received 23 June 2009
Revised 26 October 2009
Accepted 2 November 2009
International Journal of Health Care
Quality Assurance
Vol. 24 No. 3, 2011
pp. 249-262
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526861111116688
Patient satisfaction with medical care is a multidimensional concept, with

dimension that corresponds to the major characteristics of providers and services
(Ware et al., 1983; Moretet al., 2008; Donahue et al., 2008). Patient satisfaction with
health care services is considered to be of paramount importance with respect to
quality improvement programs from the patients perspective, total quality
management, and the expected outcome of care (Vouri, 1991; Donabedian, 1992;
Aggarwal and Zairi, 1998; Brown and Bell, 2005). Within the health care industry,
patient satisfaction has emerged as an important component and measure of the
quality of care (Aharony and Strasser, 1993; Grogan et al., 2000; Salisbury et al., 2005).
Patient satisfaction plays an important role in continuity of service utilization
(Thomas, 1984). Satisfied patients are more likely to adhere to doctors
recommendations and medical regimens (Ross et al., 1981). Besides, dissatisfied
patients do not utilize primary health care services optimally and over-utilize the
emergency rooms in the general hospitals (Shah et al., 1996; Al-Hay et al., 1997).
The quality of the communication relationship between physician and patient
showed positive influence on patient satisfaction measure (Moretet al., 2008; Mercer
et al., 2008; Lin et al., 2009). Studies from Kuwait found that patients tend to bypass the
primary care level due to the perception that it provides inferior quality of care in
comparison to that provided in the emergency rooms (Shah et al., 1996; Al-Hay et al.,
1997). Several studies have been performed regarding patient satisfaction and its
correlates in various countries (Rahmqvist, 2001; Margolis et al., 2003;
Bronfman-Pertzovskyet al., 2003). Only two studies have been conducted to date
regarding the concept of patient satisfaction in Kuwait (Bo Hamra and Al-Zaid, 1999;
Al-Doghaitheret al., 2000). They found significant relationship of age, gender,
nationality, marital status; education, occupation, and income with patient satisfaction.
Although many studies have been done on patient satisfaction internationally but
limited studies were done on patient satisfaction in the Gulf region and in particular in
Kuwait. Identification of predictors of patient satisfaction (what aspects of care matter
the most to patients) enables policy makers at the Ministry of Health in Kuwait to focus
on these aspects and improve them. The correlates of socio-demographic
characteristics of patients with satisfaction allow the health care providers to cater
to the different needs of patients based on their socio-demographic characteristics.
This study aims at identifying predictors of patient satisfaction in the primary care
clinics of the Ministry of Health, Kuwait (factors leading to patient satisfaction or
dissatisfaction) and its socio-demographic correlates.
1.1 Background
Kuwait is a small oil rich Arab-Muslim country of 3.2 million people, only 37 percent of
whom are Kuwaiti nationals. Non-Kuwaitis are from over 100 countries; 28.7 percent of
them are Arabs and the rest (33.3 percent) are from various other Asian countries
(PACI, 2007). The health care delivery system in Kuwait has developed very rapidly.
The Ministry of Health (MoH) of the government of Kuwait provides about 90 percent
of the health care services through a three-tier health care delivery system, primary,
secondary and tertiary. While Kuwaiti nationals get all health care free of charge, while
expatriates have to pay a nominal fee, which was imposed in 1999.
The entry point for accessing services is through primary health care centres
(PHCs). For approximately every 30,000 people there is one PHC. Of these PHCs, 70 are
IJHCQA
24,3
250
for general health care, 25 for maternal care and 64 childcare. Secondary health care as
well as emergency care are provided through five general hospitals. Finally, there are
20 tertiary care hospitals and centers that offer specialized services. The health care
provision in Kuwait relies heavily on expatriate human resources, employing care
providers from a number of countries (Shah et al., 2001). Health care professionals in
Kuwait are from various countries with different cultural background.
2. Methodology
2.1 Sample
The study population consisted of the patients who came for services to the primary
health care centers covering all health regions in Kuwait. The PHCs were divided into
five groups in accordance with the Ministry of Health regions: Capital, Hawally,
Farwaniya, Jahra, and Ahmadi. At first phase, based on the alphabetical list of PHCCs,
a systematic sampling was used where every fifth PHCC was selected from each health
region. Then patients were selected randomly from the selected PHCs. By using the
standard formula (n z 2pq=d 2, n required sample size, z the standard normal
deviate, p proportion in the target population estimated to have a particular
characteristics, q 1 2 p, and d degree of accuracy desired) a sample of
approximately 400 was selected (Abdelhaket al., 1996). However, the sample size was
increased to 500 patients to cover those who may not return the survey of the study.
The data collection period spanned January 2007 to May 2007. Out of 500 distributed
questionnaires 426 completed questionnaires were returned, resulting in 85.2 percent
response rate. The anonymity of all respondents was preserved. In keeping with the
standard research protocol, necessary permission was obtained from the concerned
authorities of the Ministry of Health for data collection.
2.2 Instrument
This descriptive cross-sectional study used a questionnaire that consisted of 22
closed-ended questions and specific questions on background (gender, age, nationality,
marital status, occupation, education, and income) characteristics. The questionnaire
based on Ware et al. (1978) model, is divided into six dimensions of care. Each
dimension of care (interpersonal, technical, accessibility, convenience, availability, and
overall) has a number of statements that measure patients satisfaction (dependent
variable) which is an ultimate outcome in evaluating quality of medical care.

Interpersonal dimension measured the satisfaction to the amount of caring shown
towards the patients and communications between them. Technical dimension also
pertains to provider conduct, focuses on the competence of providers and their
adherence to high standards of diagnosis and treatment. Accessibility and convenience
dimension measures satisfaction related to time and effort required to get an
appointment, distance and proximity to site of care, convenience of location time to
reach, hours during which care can be obtained etc. Availability dimension focuses
whether there are enough physicians, nurses, and other providers, and such facilities as
clinics and hospitals in the area. Other similar studies have used different names for
the dimension and called them attributes (Otaniet al., 2005). Each dimension used in
this study and its specific attributes were found to have some correlations with patient
satisfaction in previous studies (Harrison, 1996; Al-Fariset al., 1996; Makhdoomet al.,
1997; Gross et al., 1998; Shelton, 2000; Saeedet al., 2001). To measure patient
Patient
satisfaction
251
satisfaction, interviews or open ended questions produce much detailed information
and allow for clarification of respondents views but are considered difficult to analyze
(Fitzpatrick, 1991a). More structured approaches such as multiple item questionnaires
with Likert scale response categories produce data that are easier to handle but require
particular attention to validity and reliability to use in a different cultural settings
(Fitzpatrick, 1991b; Rees, 1994). In different cultural settings before applying any
existing scale it need re-evaluation (Kinnersleyet al., 1996; Grogan et al., 2000).
The instrument used a modified five-point Likert scale as choices of answer,
ranging from very dissatisfied (0) to very satisfied (5). An additional choice, not
applicable, was added to allow respondents to choose in case of service not provided or
where a given item was not applicable. The majority of statements used in the
questionnaire, 17 out of 22, are positively phrased to avoid any confusion that might
result from using a mix of positive and negative phrasing. In addition, there were two
questions relating to the patients number of visits to the primary care service during
the past year and the patients perception of his/her own overall health status. The
questionnaire was translated into Arabic and translated back into English by an
independent professional to check the validity. Prior to the actual administration, the
questionnaire was piloted in a small group of patients to validate the language, content
and flow of information aimed at appropriate rapport to make necessary changes. By
summing 11 positive questions on different aspect of satisfactions we computed an
overall satisfaction score. The overall satisfaction score ranges from 0 to 44. The lowest
possible score of 22 was considered as the lowest level of satisfaction. Cronbachs alpha
(reliability coefficient) was used to determine the internal consistency of the
instrument. The value of the alpha of the overall scale was 0.61. The construct validity
was assessed by factor analysis using factor loadings; these ranged from 0.41 to 0.76.
2.3 Statistical analysis
Descriptive statistics (frequency distribution, mean, and standard deviation) were used
to describe the data. Analysis of variance (ANOVA) and the t-test were used to see
whether the mean satisfaction score differed significantly between different categories
of the socio-demographic factors. Exploratory factor analysis was used to identify the
underlying factors and Cronbachs alpha was used to measure the internal consistency
of the scale and subscales.

3. Results
Distribution of the background characteristics of the patients are presented in Table I.
Regarding gender, 43.3 percent (183) were males, while 56.7 percent (240) were females.
The majority of patients were young. The age groups of 18-29 and 30-39 comprised
48.5 percent (206) and 29.2 percent (124) of the total sample surveyed, respectively.
Those 50 years and older constituted only 6.1 percent (26) of the total sample. While
majority of the responders were married 54.5 percent (232), single patients constituted
42.4 percent (180) of the sample and divorced and widowed represented 3.1 percent (13).
Regarding nationality, 60.7 percent (256) of the sample were Kuwaitis and 39.2 percent
(165) were non-Kuwaitis.
In terms of employment, government employees were 17.8 percent (68) of the
sample. Government employee in Kuwait refers to all those who work for the
government in jobs that are mainly clerical in nature; however, it also includes
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Characteristics Number %
Age (in years)
18-29 206 48.5
29-39 124 29.2
40-49 69 16.2
50-59 26 6.1
Gender
Male 183 43.3
Female 240 56.7
Marital status
Married 232 54.5
Single 180 42.4
Divorced 11 2.6
Widowed 2 0.5
Nationality
Kuwaiti 256 60.7
Arab 125 29.7
Asian 23 5.5
Bedoon 5 1.2
Other 12 2.9
Occupation
Student 111 29.1
Government employee 68 17.8
Military 6 1.6
Housewife 6 1.6
Retired 9 2.4
Teacher 46 12.1
Technical 32 8.4
Other 103 27.0
Education
Up to intermediate 20 4.8
secondary 136 32.4
diploma 101 24.0
Baccalaureate 129 30.7
Masters and above 34 8.1
Monthly income (in KD)
1-100 78 22
101-300 67 18.8
301-500 80 22.5
501-800 66 18.5
801-1,100 25 7
1,101-1,400 21 5.9
1,401 19 5.3
(continued)
Table I.
Distribution of
background
characteristics of the
patients
Patient
satisfaction
253
supervisors and managers. When analyzing the educational background, it was found
that 32.4 percent (136) had a secondary degree, which means they completed 12th
grade. Those with baccalaureate and diplomas (community college) comprised 30.7
percent (129) and 24.0 percent (101), respectively. In terms of income, 22.5 percent (80)
of the sample had an income between KD 301-500 (1 KD 3:75$), and 22.0 percent (78)
of the sample had an income between KD 1-100, while the high income group (KD
1,401 ) constituted only 5.3 percent (19) of the sample.
When asked about the number of health care visits during the previous year, 25.5
percent (108) of the patients surveyed indicated five visits or more, while 8.5 percent
(36) had visited four times, 17.2 percent (73) had visited three times, and 17.2 percent
(73) reported they had visited two times. In other words, 51.2 percent (217) of the
patients had visited the primary health care clinics 3 times or more. The majority of
patients surveyed had a good self-perception of their overall health status.
Eighty-five-percent (361) of the sample rated their health status to be between
excellent and good. As far as satisfaction with life, 30.2 percent (128) stated that they
were mainly satisfied with their lives, while 27.6 percent (117) reported that they were
mainly dissatisfied with life.
Table II presents the mean and standard deviation of overall satisfaction score by
different socio-demographic characteristics. Three statistically significant differences
were found. These categories were nationality, overall health status, and satisfaction
with life. Distribution of the responses of the patients regarding the survey is presented
in Table III.
The majority of the patients (89.1 percent) said that there is a need for specialized
doctors in the primary health care clinic. Also, majority of the patients (87 percent) said
Characteristics Number %
Visits to clinic in past year
1 63 14.9
2 73 17.2
3 73 17.2
4 36 8.5
5 or more 108 25.5
Not sure 71 16.7
Overall health status
Excellent 95 22.4
Very good 171 40.2
Good 95 22.4
Average 54 12.7
Poor 10 2.3
Satisfaction with life
Very satisfied 44 10.4
Mainly satisfied 128 30.2
Somewhat satisfied 89 21.0
Mainly dissatisfied 117 27.6
Table I. Very dissatisfied 43 10.8
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Characteristics Mean SD p-value
Age (in years)
18-29 34.39 7.83
29-39 34.91 7.97 p . 0.05
40-49 34.26 9.19
50 33.00 10.73
Gender
Male 34.12 8.89 p . 0.05
Female 34.63 7.78
Marital status
Married 34.58 8.68
Single 34.17 7.57 p . 0.05
Divorced 36.00 11.71
Widowed 36.50 .71
Nationality
Kuwaiti 34.51 8.02
Arab 33.98 8.80
Asian 32.43 7.91 p , 0.05
Bedoon 36.80 9.09
Other 40.91 5.68
Occupation
Student 34.47 6.89
Government employee 34.79 8.08
Military 40.50 3.56
Housewife 33.16 3.31 p . 0.05
Retired 32.00 16.79
Teacher 35.19 6.27
Technical 36.93 8.53
Other 33.79 9.36
Education
Up to intermediate 34.00 8.03
Secondary 33.94 7.87
Diploma 33.78 8.58 p . 0.05
Baccalaureate 35.06 8.54
Masters and above 37.08 7.86
Monthly income (in KD)
1-100 33.25 7.04
101-300 33.50 9.80
301-500 34.98 8.76 p . 0.05
501-800 35.53 8.35
801-1,100 34.16 9.67
1,101-1,400 33.90 8.72
1,401 36.15 7.63
(continued)
Table II.
Descriptive statistics of
total score by
background
characteristics
Patient
satisfaction
255
the doctor in the clinic did not allow enough time me to ask questions related to health
status. Seventy nine percent of the patients said that if they had a choice, they will go to
the emergency room in the future instead of going to the clinic. Majority of the patients
(86.3 percent) said the doctor did not suggest any diet that they should consider given
their medical conditions. Two-hundred-ninety (68.8 percent) of the participants said
that the working hours in the clinics were not suitable for most people.
Two-hundred-seventy-four (64.7 percent) of patients reported that the doctors in the
clinics were very skilled and experienced. Two-hundred-fifty-one (59.2 percent) of the
participants said that usually they waited for a long time to see the doctor in the clinic.
Two-hundred-forty-seven (58 percent) of the patients said the doctor showed respect
for them. Results of exploratory factor analysis and reliability analysis (Cronbachs
alpha) are presented in Table IV. Factor loadings which are used to measure construct
validity were high in general (above 0.54) except for two items which were 0.414 and
0.471. Internal consistency measure of scale (Cronbachs alpha) for overall was 0.61 and
varies from 0.471 to 0.746 for six factors identified by factor analysis. Factor six
included only one item and reliability coefficient was not possible to calculate.
4. Discussion
This study aimed to identify the factors that affect patient satisfaction in the primary
healthcare clinics in Kuwait. We found significant relationship of patient satisfaction
with nationality of the patients and overall health status. Our results show that
non-Kuwaitis, particularly Asians, showed lower mean satisfaction score in
comparison with Kuwaitis except for Bedoon and the other group. These results are
Characteristics Mean SD p-value
Visits to clinic in past year
1 33.61 7.19
2 35.75 8.32
3 34.84 9.19 p . 0.05
4 34.00 9.73
5 or more 35.37 7.56
Not sure 32.28 8.24
Overall health status
Excellent 32.93 8.33
Very good 34.89 6.89
Good 34.30 9.15 p , 0.05
Average 34.33 8.27
Poor 41.30 14.90
Satisfaction with life
Very satisfied 37.68 10.31
Mainly satisfied 34.65 8.31 p , 0.05
Somewhat satisfied 33.61 8.56
Mainly dissatisfied 34.35 5.72
Table II. Very dissatisfied 32.43 9.86
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Strongly
agree Agree Not sure Disagree

Strongly
disagree
Not
applicable
Characteristics n % n % n % n % n % n %
The doctor did not show any empathy 17 4.0 116 27.3 108 25.4 120 28.2 49 11.5 15 3.5
Doctors in the PHCC are very skilled and experienced 113 26.7 161 38.0 49 11.6 66 15.6 18 4.2 17 4.0
Usually, I wait for a long time to see the doctor in the
PHCC 112 26.4 139 32.8 53 12.5 70 16.5 20 4.7 30 7.1
The doctor did not suggest any diet that I should
consider given my medical conditions 171 40.3 195 46.0 18 4.2 20 4.7 15 3.5 5 1.2
This PHCC is conveniently located and easy to reach 34 8.0 81 19.1 127 30.0 93 21.9 69 16.3 20 4.7
The medical service in the PHCC is better than that in
the ER 30 7.0 66 15.5 68 16.0 122 28.6 114 26.8 26 6.1
I was encouraged to get a yearly medical exam 27 6.4 135 31.9 43 10.2 105 24.8 93 22.0 20 4.7
The doctor spent sufficient time explaining my
condition to me 51 12.1 180 42.9 46 11.0 79 18.8 48 11.4 16 3.8
The doctor listened to me carefully 113 26.8 105 24.9 82 19.4 67 15.9 26 6.2 29 6.9
The doctor did not check my medical record for previous
illness 22 5.2 92 21.7 87 20.5 116 27.4 92 21.7 15 3.5
There are enough doctors in this PHCC 69 16.4 105 24.9 96 22.7 96 22.7 40 9.5 16 3.8
Working hours in the PHCC are not suitable for most
people 80 19.0 210 49.8 59 14.0 38 9.0 20 4.7 15 3.6
The doctor showed respect for me 22 5.2 83 19.5 48 11.3 127 29.8 120 28.2 26 6.1
The doctor provided me with adequate information
regarding the side effects of the prescriptions 45 10.7 159 37.7 38 9.0 88 20.9 77 18.2 15 3.6
The environment in the waiting area is a comfortable 15 3.5 107 25.2 55 12.9 135 31.8 95 22.4 18 4.2
The doctor examined me thoroughly 78 18.4 145 34.2 47 11.1 112 26.4 29 6.8 13 3.1
The doctor did not allow enough time for me to ask
questions 259 61.2 110 26.0 30 7.1 10 2.4 10 2.4 4 .9
There is a need for specialized doctors in this clinic 255 60.1 123 29.0 29 6.8 12 2.8 4 .9 1 .2
The medical care in this clinic needs to be improved 105 24.9 106 25.1 86 20.4 65 15.4 39 9.2 21 5.0
If I have a choice, I will go to the ER in the future instead
of going to the PHCC 91 21.5 244 57.7 30 7.1 27 6.4 20 4.7 11 2.6
The doctor used simple and easy-to-understand
language 25 5.9 45 10.6 166 39.1 80 18.8 75 17.6 34 8.0
Table III.
Distribution of patients
responses regarding
various aspects of
satisfaction
Patient
satisfaction
257
consistent with a number of studies conducted in the Gulf regions where the
demographics are comparable. The relationship between patient satisfactions with
nationality showed mixed picture from different studies. The studies found that
expatriates from different countries showed a higher satisfaction rating in comparison
with nationals (Al-Shamekh, 1992; Abd Al Kareem et al., 1996; Al-Fariset al., 1996;
Makhdoomet al., 1997; Bo Hamra and Al-Zaid, 1999; Saeedet al., 2001). On the other
hand, two other studies found no significant difference between Saudis and non-Saudis
in terms of satisfaction (Mansour and Al-Osimy, 1993; Al-Doghaither and Saeed, 2000).
Kuwait government imposed the fees on expatriates for utilization of health care
services, while nationals continue to receive health care free of charge. This, we believe,
has lowered the expatriate patients satisfaction. Patients did not agree on a good
quality of communication between physician and them which may reduce the patients
satisfaction as found by some other studies (Mercer et al., 2008; Lin et al., 2009).
Patients with positive health perceptions have significantly higher satisfaction
score which is consistent with findings from other studies. The average patients
Factors Items descriptions Factor loadings Cronbachs alpha
1. If I have a choice, I will go to the ER in the future
instead of going to the PHCC
0.708 0.746
Working hours in the PHCC are not suitable for most
people
0.697
I was encouraged to get a yearly medical exam. 0.639
The doctor spent sufficient time explaining my
condition to me
0.562
The environment in the waiting area is a comfortable 0.472
2. The doctor did not check my medical record for
previous illness
0.679 0.692
The doctor did not show any empathy 0.644
The doctor showed respect for me 0.601
The medical service in the PHCC is better than that
in the ER
0.585
The doctor provided me with adequate information
regarding the side effects of the prescriptions
0.471
3. Usually, I wait for a long time to see the doctor in the
PHCC
0.721 0.572
The doctor listened to me carefully 0.599
The doctor examined me thoroughly 0.550
Doctors in the PHCC are very skilled and
experienced
0.414
4. The medical care in this clinic needs to be improved 0.739 0.471
This PHCC is conveniently located and easy to reach 0.697
The doctor used simple and easy-to-understand
language
0.540
5. The doctor did not allow enough time for me to ask
questions
0.757 0.474
There is a need for specialized doctors in this clinic 0.727
The doctor did not suggest any diet that I should
consider given my medical conditions
0.578
6. There are enough doctors in this PHCC 0.781
Overall 0.61
Table IV.
Results of factor analysis
and reliability coefficients
(Cronbachs alpha)
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258
satisfaction score for different categories of overall health status showed less average
score for the patients who believe that their health status is excellent, which is
unexpected. A number of studies have found that patients positive self-perception of
health is related to a higher level of satisfaction. Rahmqvist (2001) reported that Hall
et al. found that patients self-perceived overall health status predicts the level of
patient satisfaction. It was suggested that a positive relationship exists between
patients perception of their health and their satisfaction with health services (Weiss,
1988). For example, Linn et al. concluded that patients perception of their health status,
both physically and emotionally, has a significant effect on their rating of their doctors
behavior (Linn et al., 1984). In other words, when consumers perceive their well being
to be high, they tend to have a higher physician satisfaction rating regardless of the
actual nature of the physicians behavior. Similarly, Rahmqvist (2001) argued that poor
health and pain correlate negatively with patient satisfaction. Penchansky and
Thomas (1981) concluded that patients who perceived their health status to be low and
had more concerns about their health tended to be less satisfied than others. Similarly,
Patrick et al. (1983) found that patients who rated themselves to have fair-poor health
were significantly more likely to be dissatisfied with their doctors. Rahmqvist (2001)
reported that healthier patients tend to be more satisfied. On the other hand, Weiss
(1988) found only a marginal difference in satisfaction for those who rated their health
status and physical condition positively. More interestingly, Gross et al. (1998) reported
that patients who rated their health poorly were found to be less satisfied with the time
their physician spent with them.
5. Conclusion
This study has demonstrated the relationship between satisfaction and specific
socio-demographic attributes. The subject is important enough to recommend that the
Ministry of Health conduct patient satisfaction studies on a regular basis. This practice
will identify areas of dissatisfaction that can quickly be remedied and ensure
enhancement in satisfaction. More studies should be conducted in the primary care
setting to reexamine those variables examined in the current study which have not
proven to be significant and to validate the significant relationship found in this study.
Before using patients satisfaction questionnaire which was developed for different
cultural settings one should validate it in local context to measure the patient
satisfaction.
6. Recommendations
Additional studies should also include other aspects of the primary care setting, such
as nursing, pharmacy and clerical services and their effects on patient satisfaction,
which we have not studied. This is viewed as important in order to identify other
predictors of patient satisfaction that could not be determined in the present study. The
private sector is one plausible area of study.
7. Limitations of the study
One limitation to this study was the exclusion of the private sector. Examining patient
satisfaction in this sector could provide insight into reasons why patients prefer being
treated by doctors in private practice, where they have to pay out of pocket than by
Patient
satisfaction
259
those who are in public practice. Another limitation is that we did not validate the
questionnaire in local environment.

Another weakness was that some patients were reluctant to participate when they
learned that no incentive would be provided to compensate them for their time. While,
providing some kind of monetary incentive might convince participants to spend time
to complete the survey, this approach may, however, result in introducing a bias in the
form of favorable answers leading to a high but false patient satisfaction. We felt this
might be the case in this study and hence we avoided providing any compensation for
the participants.
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Evaluating Customer Relationship Dynamics in Healthcare Sector

through
Indoor Patients Judgement
INTRODUCTION
Research regarding service quality remains popular in the marketing literature. The sustained
effort to study service quality stems from its relationship with a number of key performance
measures such as customer satisfaction, customer loyalty, customer relationship management,
employee satisfaction, performance, word-of-mouth referral, price insensitivity, sales growth,
market share and productivity (Boulding, Kalra, Staelin, and Zeithaml 1993; Zeithaml, Berry &
Parasuraman, 1996; Santouridis and Trivellas 2010). In industries characterized by parity
products, very often it is service quality that distinguishes an organization from its competitors
(Kevork and Vrechopoulos, 2009). As businesses pursue long-term relationships with customers
to maximize their lifetime value, they need to be particularly concerned with how customers
view about the varied changes the concern makes over the time of the service offering. More
recently, with increasing focus on customer relationship management ( CRM), scholars have
begun to consider the importance of managing a firms portfolio of customers (Johnson and
Selnes, 2004). Such studies underscore the importance of dynamic service quality models of
service exchange relationships. Taking our lead from such researches, the present study
considers service quality ( composite of physical environment quality of organization and quality
of interaction with service providers) and its impact on satisfaction and loyalty, the two
significant CRM outcomes in context of credence services i.e. healthcare. In general parlance as
customer organization relationship extends, the impact of operational service quality results
into two significant changes. First, learning effects, by virtue of consistent and repeated
transactions of customers with an organization, results in customer satisfaction and customer

loyalty (Zineldin, 2006, 2005). This experiential model of learning supports the notion that an
individuals knowledge and evaluation reflects upon positive actions such as consistent care,
2
confidence in the services, their relatives and friends, and customer retention (loyalty) and better
long-term relationships with the firm (Gwinner, Gremler, and Bitner 1998). Second, the learning
effect also results in escalation in the size and complexity of the transactions between the
customer and organisation (Reinartz and Kumar, 2003). Besides satisfaction and loyalty, the
long-term customer organization relationship also brings additional benefits for customers that
include increased confidence in the services, trust on service providers, commitment, social
engagement, and improved opportunities for customization (Vesel and Zabkar, 2010).. Further,
long-term relationship with the firm enables customers to know their service provider on a
personal level, and can expect preferential treatment as the firm gets to know their preferences
better and above all, have less anxiety about service performance. In this context, the study
makes an attempt to understand the relative importance of CRM dynamics in general ( Figures
1a & 1b) and service quality components namely physical environment quality and interaction
quality and their impact on customer satisfaction and loyalty ( Figure 2) in particular.
This research paper is constructed in the following way. At the beginning, paper discusses about
the research significance and provides some background on CRM dimensions. The next section
provides discussion on hypotheses and depicts relationships between the variables within the
hypothesized research model. The methodology section describes the sampling approach and the
data collection procedure and discusses the psychometric properties of the measures used. After
presenting the results, the study concludes with discussion focusing on significant relationship
marketing strategies to maximize customer retention followed by implications for management.
Next, study limitations and directions for future research are highlighted.
CRM DYNAMICS
The development of successful, long-term, mutually beneficial relationships has attracted the
attention of researchers for the past few decades (Athanasopoulou, 2009). A close inspection of
some influential relationship concepts yield words such as maintenance (Morgan and Hunt,
1994), development, collaboration and cooperation (Sheth and Parvatiyar, 1995), one to one
marketing ( Peppers and Rogers 1999), relationship marketing and global account management
(Bohling et.al. 2006), all of which evoke the temporal nature of customer relationship concept.
Understanding the nature of these relational concepts is of critical importance to the success of
3
any organization as they help in understanding the way in which customer attitudes and
preferences are evolved during the term of their relationship with the organization. Indeed,
customer attitude and behaviour is the most important factor influencing the uptake of customer
relationship management (CRM) systems. CRM, in turn, is one of the most significant strategies
for the organization to retain customers vis--vis to achieve its goal of higher profitability
through delivering continuous qualitative services. It allows organizations to better acquire,
manage, serve, and extract value from their customers while improving operational efficiency
that is critical in todays economy ( Microsoft 2009). The practice of CRM is described as the
process for achieving a continuing dialogue with customers across all available touch points to
offer them customized treatment, based on their expected response to available marketing
initiatives, such that the contribution from each customer to overall profitability is maximized
(Bohling et.al. 2006). According to Ngai, Xiu and Chau, (2009), CRM is an enterprise approach
to understand and influence customer behaviour through meaningful communications to improve

customer acquisition, customer retention, customer loyalty, and customer profitability. Sumathy
and Tamilselvan ( 2008) consider CRM as a strategy to manage customer relationship and to
optimize customer satisfaction & loyalty in an organized way (Maruthamuther and Kavitha,
2008). An important contribution on the dynamics of marketing relationships was made by
Dwyer, Schurr, and Oh (1987) who view relationships as ever-changing phenomena that require
continuous adjustments to the service offerings to meet the changing needs of customers. As
customer-organization relationships develop, customers become increasingly entrenched to
relationship-specific investments (Jones et al., 2000). As their expertise and experience with both
the firm and the service category grow, they become better at evaluating alternative product
offerings and make specific investments in the relationship as relationships mature. The extent of
such investments is a function of time and the stage of such relationship development.
Relationship-specific experience increases customers perceptions of the costs of switching
between providers. The notion that expectations of customer-organization relationships change
as the relationship matures is supported by various studies on customer life-cycle variables and
relationship strength. Choi et.al. (2005), for example, reveal that age has a direct effect on
customer satisfaction while Chahal& Sharma (1995) show that life-cycle demographics (e.g.,
age, marital status, education) influence the relationship between satisfaction and loyalty.
4
Though research on CRM in marketing literature is attracting significant attention from
last two decades, however comprehensive tool to evaluate credence services in terms of quality,
satisfaction and loyalty in public healthcare service sector of developing countries is given a
limited focus in the literature (Chahal, 2009). As such there is a need to integrate the role of
service quality with customer satisfaction and customer loyalty to facilitate the development of a
CRM model for relationship building(Kevork and Vrechopoulos, 2008). Further, since
patients decision of going to a particular hospital is affected by their experience, demographic
characteristics and expertise in evaluating the healthcare service, a separate and special focus on
interaction quality to evaluate healthcare service quality is required, which is still missing in the
literature. Furthermore, as a high involvement healthcare product, physical environment along
with interaction quality (elements of service quality), that feature prominently in customers
evaluation, require special insight to understand CRM dynamics. This particularly becomes more
important for countries dominated by public or public-private mix economy structures. Although
regular paradigm shift in technology, competition, customer awareness etc. make CRM
implementation a challenging task but at the same time research that integrates the role of service
quality with other service marketing variables such as customer satisfaction and customer loyalty
is called for to facilitate the development of a CRM model for relationship building ((Rasila,
2010Wahlberg, Strandberg, Sundberg. and Sandberg, 2009). The researchers have also remarked
that customer centric research represent a crucial step in the general development of CRM. As
such the study examines the role of CRM dynamics ( Figure 1a) viz; service quality, customer
satisfaction and loyalty in healthcare sector. Specifically, it aims to investigate physical
environment and interaction quality aspects of the service offerings valued by customers, which
lead to customer satisfaction and loyalty.
HYPOTHESES DEVELOPMENT
Service quality as a significant tenet of CRM dynamics plays valuable role in building strong
relationship with customers through satisfaction & loyalty. The study proposes service quality to
be the one and most significant platform to achieve CRM objectives of providing optimum
5
satisfaction to customers to retain them. As such two components of service quality i.e physical
environment quality ( PEQ) (ambient condition, tangibles and social factor) and interaction
quality (IQ) (attitude & behavior, expertise and process quality) as antecedents to outcome
service quality ( OSQ) (Brady & Cronin, 2001) that leads to customer satisfaction and ultimately
to loyalty (see Figure 1b) are considered. The perceived outcome service quality of the
organization is proposed to moderate the relative strength of the relationships between service
quality (physical environment and interaction quality) and customer satisfaction and customer
loyalty. The following text offers operationalisation of CRM through service quality (physical
environment quality & interaction quality) and provides rationale for the proposed relationships
between three CRM dynamics i.e perceived service quality, customer satisfaction and customer
loyalty.
Ambient Condition, Tangibles, Social Factor and Physical Environment Quality
A subsequent review of the literature reveal support relationship of three factors namely ambient
condition, social factor and tangibles with physical environment quality (Dagger, Sweeney and
Johnson 2007, Parasuraman, Zeithaml& Berry 1985, Bitner 1992, Rust & Oliver 1994 and
Brady & Cronin 2001). Ambient conditions relate to non visual aspects, such as temperature,
scent, music (Bitner, 1990) peaceful, tranquil and maintenance services (Brady & Cronin, 2001),
and natural light and fresh air (Chahal& Sharma, 2004). Second important sub dimension of
physical environment quality is social factor, which refers to the nature, number and type of
people availing services and their behaviour (Bitner, 1990). Further, it also includes transparency
and ethics in decisions, acceptance of legal and statutory framework, integrity and honesty in
practices, focus on societal needs, pollution control and hygienic life styles (Sardana, 2003).
Another sub dimension of physical environment quality is tangible. It includes physical facilities,
equipment and personnel appearance (Conway &Willcocks, 1997), waiting room and amenities
(Choi et. al., 2005), technical services (Chahal& Sharma, 2004), and sitting arrangements (Kang
& Jeffrey, 2004). The aforementioned review paves way for the development of following
hypothesis .
Hypothesis 1 Perception about ambient conditions, social factor and tangibility positively
influence physical environment quality.
Attitude &Behaviour, Expertise, Process Quality and Interaction Quality
6
Services are intangible and inseparable in nature (Lovelock, 1981). The interaction that takes
place during service delivery has greatest effect on service quality perceptions of the customers
and ultimately on CRM outcomes (satisfaction & loyalty) (Brady & Cronin, 2001). Attitude &
behavior is one of the important dimensions of interaction quality authenticated by researchers
such as Brady & Cronin, 2001 and Chahal& Sharma, 2004. Bitner (1992) empirically
demonstrated that attitude is a super ordinate concept of satisfaction. In this context Cheng,
Yang & Chiang (2003), Hughes ( 2003) and Sardana (2003) stated that patients judge the
performance neither through the clinical cure nor through the technology employed but reach
conclusions on the basis of behavioral attitudes and communication skills of the doctors and
attending staff. The attitude &behaviour of staff (doctors, nurses, supporting staff) can be
assessed through functional dimensions of service quality dimensions such as friendliness,
helpfulness, ability to clear patient queries, honesty, support, care which also directly affect
interaction quality. The another important dimension that affects interaction quality is expertise
of the staff (Qin, Zhao and Yi, 2009). Expertise basically relates to correct diagnosis and
adequate knowledge about the respective fields. The third important factor which affects
interaction quality is process quality. A hospital is a complex system which incorporates
personnel, drawn from various disciplines such as medical, paramedical and administration that
are all required to work as a team. It also has diverse support service infrastructure in areas of
dietary service, sanitation, supplies, laundry and housekeeping. In addition management of
values such as customer focus, convenient procedure and performance orientation also contribute
in building process quality (Sardana, 2003). The patients perceptions about these dimensions are
subsequently combined to evaluate the overall interaction quality and finally outcome quality.
On the basis of the reviewed literature another set of hypothesis and objective are constructed.
Hypothesis 2 Attitude & behavior of staff, expertise skills and process quality directly and
positively influence the quality of service interaction quality.
Physical Environment Quality, Interaction Quality and Perceived Service Quality
Customers form service quality perception on the basis of evaluation of organizations
performance at multiple levels and they combine these evaluations ultimately to arrive at an
overall service quality perception (Brady and Cronin, 2001). Number of studies viewed that the
overall perception of service quality is based on the customers evaluation of two dimensions of
7
the service encounter, namely physical environment quality and interaction quality (Rust &
Oliver 1994; Brady & Cronin 2001). The surrounding physical environment can have a
significant influence on perceptions about the overall quality of the service encounters in the
service industries such as hospitals (Bitner, 1992) as services being intangibles, often require the
patients to be present during the process. The second important dimension of evaluating service
quality is interpersonal interaction that takes place during service delivery and often has the
greatest effect on service quality perceptions (Bitner 1990, Newman &Pyne 1996; Gronroos
1982). Dedeke (2003) have identified three kinds of interaction viz; customer to staff (social
interaction), customer to technology (technology interaction), third customer to product (product
interaction). Brady & Cronin had used interaction quality as one of important third dimensions
of service quality in their hierarchical approach, which comprised three sub dimensions namely
attitude, behavior and expertise. Both dimensions directly affect overall service quality of the
organization. In other words, physical environment and interaction quality are important
ingredients of overall service quality. Based on this the following hypothesis and objective of the
study are framed:
Hypothesis 3 - Physical environment quality and interaction quality contribute positively to
perceived service quality
Perceived Service Quality , Customer Satisfaction and Customer loyalty
Physical environment and interaction quality have the potential to contribute differentially to
customer attitudes and behaviors. Positive perceptions about service quality are likely to be
positively associated with customers attitudes toward the organization and their likelihood of
remaining associated with the organization. The empirical support to this assertion is
wellestablished
in the literature (Yim, Anderson and Swaminathan 2005, Bloemer, Ruyter and
Wetzels 1999, Choi. et. al. 2002, Cronin, Brady &Hult 2000 and Zeithaml et al. 1996) which
later results in customer satisfaction and customer loyalty, Customers evaluate these service
outcomes after service delivery (Gronroos 1982, Rust & Oliver 1994 and Brady & Cronin
2001). Satisfaction is the basic tenet of CRM outcome. Satisfaction is perceptual difference
between prior expectations and post performance of the product (Tse and Wilton, 1988). It is the
satisfaction level only which propels patients to choose the same hospital next time (Sardana,
2003) and transforms patient satisfaction into patient loyalty. A number of dimensions, such as
8
physician care, nursing care, supporting staff behavior, convenient visiting hours, availability of
emergency aid (Sardana, 2003) and food, room characteristics & treatment (Raftopoulous, 2005),
all related to service quality have been suggested in literature that influence patient satisfaction.
Overall, doctors, nurses, management, facilities and cleanliness are the major factors which
affect satisfaction (Chahal& Sharma, 2004). Customer loyalty is another important outcome of
service quality; it is a consumers intent to remain associated with an organization (Zeithaml et
al., 1996). It represents a commitment by the customer to purchase more and varied products
from the organization and to help it where possible and to recommend it to others (e.g., through
word-of-mouth recommendations). Besides, use of behavioral intentions perspective also helps
in recognizing spurious loyal who have a low relative attitude toward the organization but are
constrained to repeat purchase (Ruyter et. al., 1998). CRM as an enterprise approach to
understanding and influencing customer behaviour through meaningful communications in order
to improve customer acquisition, customer retention, customer loyalty, and customer
profitability (Ngai, Xiu and Chau, 2009).
To the extent that both physical environment and interaction service quality contribute to
customer satisfaction & loyalty through perceived service quality, the study hypothesized that:
Hypothesis 4 - Perceived Service Quality positively influence customer satisfaction and
customer loyalty.
Socio Demographic Factors
Gender, education, age, income, profession are important factors for studying the perception of
consumers as health needs vary according to these factors and also because of their intensity in
moderating the relationship between satisfaction and loyalty (Choi et al. 2005 and Sharma &
Chahal, 1995). Accordingly customers assign different weights to different quality dimensions of
healthcare services such as doctors, nurses, medical assistants, management, sanitation,
cleanliness and other supportive medical facilities, The gender is considered as significant factor
to influence the level of perceived service quality (Parasuraman, Zeithaml& Berry, 1985) and is
considered as a strong discriminating factor. Number of studies found that the females are more
satisfied than males with regard to healthcare services (Sharma &Chahal, 1995). The second
demographic characteristics, education, also plays vital role in determining the utilization pattern
9
of health services. The researchers found that the low educational status of the patients restrict
their thinking and deprive them from gaining knowledge about what they ought to be provided at
the hospitals for their welfare. Thus, they can be easily be satisfied with whatever they are
provided in the hospitals. On the other hand the better educated class is quite conscious of its
rights and expects good quality care services. Degree of healthcare satisfaction would be high
among those who have lower educational status (Sharma &Chahal, 1995). Similarly, income
also affects level of satisfaction of patients. Lower income customers generally learns to live
with their illness rather than use their small stock of financial resources for recovery. Such
persons would be satisfied with healthcare services even if they are of poor quality, while higher
income group customers because of their better standards of living prefer quality healthcare
services. Further, attitude of customers toward healthcare service is also affected by nature of
occupation. Sharma &Chahal (1995) found business class customers to be more satisfied than
service class customers in Indian settings as business customers availing public healthcare
services are generally less educated and less awared and hence comparatively more satisfied than
service customers. Besides, age is another factor that influences patient satisfaction and loyalty.
Choi et.al. (2005) found that older patient tend to be more satisfied with healthcare services than
younger customers. The older patients valued continuity (i.e. see the same doctor on every
visit) while the younger ones want healthcare that is technically proficient. This led to the
development of the following hypothesis:
Hypothesis 5 The demographic characteristics of the patients affect their level of
satisfaction
and loyalty.
RESEARCH METHODOLOGY
Sample - The study on CRM dynamics vis a vis and service quality, satisfaction and loyalty
is based on primary data collected from indoor patients of Udhampur District Hospital admitted.
The pre testing ( 35 respondents) was conducted initially for two reasons. First, to check face
and content validity of the items for the four different constructs. Secondly to determine sample
size for final data collection. The study used following formula for final sample size
determination (Malhotra 2002, pp.375):
n = (1 ) z2 /D2
where,
10
n = sample size, CL = confidence level (95 %), = population proportion (0.32),
D = Level of precision (p - = + 0.05) and Z = 1.96.
This resulted in the sample size of 380 for the study which was rounded off to 400 for the final
survey. The survey was conducted between May to August 2007 and patients associated with the
hospital for more than three years and present more than 4-5 stay in six departments namely
general medicine, pediatrics, general surgery, gynecology, ENT and orthopedics were contacted.
The proportionate stratified random sampling was used for final data collection. This efforts
resulted in selection of 74 patients from general medicine, 74 from paediatrics,88 from general
surgery, 74 patients from gynecology, 30 patients from ENT, 60 from orthopedics department
thereby making total sample equal to 400.
Measures - All measures PEQ, IQ and OQ used in the study were extracted from existing
scales
on service quality, satisfaction and loyalty (Brady & Cronin 2001, Gronroos 1982, Chahal&
Sharma 2004, Choi.et.al. 2004). The wordings of scale items were adapted to suit the public
healthcaresector. All constructs used a 5-point likert-type scale, with anchors of strongly agree
(5) and strongly disagree (1). Perceived Service Quality was measured through 77 statements
related to PEQ and IQ . The PEQ relates to the visual aspects related elements of service
delivery (e.g., ambient condition, tangibles and social factor) and contains 39 items. Further, IQ
relates to interaction with service provider related aspects of the service (e.g., attitude &
behaviour, expertise and process quality) and contains 38 items.. OQ comprises customer
satisfaction and customer loyalty. Customer Satisfaction, defined as psychological satisfaction of
consumer, is measured with help of 13 items taken from Bloemer studies such as Sardana
2003; Chahal& Sharma 2004 and Choi.et.al. 2004 whereas customer loyalty, defined as
customers intentions to stay with and level of commitment to the organization, is measured
using 15 items scale derived from the works of Corbin et.al. 2001; Ruyter, Amine 1998 and
Wetzels&1998.
Data Purification
Exploratory factor analysis is conducted for data reduction and summarizations to delete items
from the initial battery of items based on statistical and theoretical grounds. Before initiating
exploratory factor analysis, response scores for negative items were changed and all items were
checked for normal distribution. Later, from a statistical standpoint, the item to total correlation
11
coefficient was considered, and values that were well below other item-total correlations (less
than .03) were targeted for deletion. This also checked the significance of inter-correlation
among items as required for effective factor structure identification. The study used principal
component analysis with varimax rotation for factor analysis. Varimax rotation being the best
rotation procedure as it maximises the number of items with high loadings on one factor, thereby
enhancing the interpretability of the factors (Malhotra 2002, p.595). The eigen value equal to or
more than 1 criterion is used to determine number of factors to be extracted and Kaiser Meyer
Olkin (KMO) value equal to and greater than 0.50 is used to find out relevancy of data
reduction and grouping for factor analysis. Further Bartlett test of Sphericity is used to identify
the significance of correlation coefficients among the variables and degree of correlation
coefficient equal to or greater than 0.30 is used as criterion for selection of items (Hair. et. al.
1995). The pre testing efforts resulted in modifying the schedule with the deletion of seven
items viz four from PEQ i.e. tangibles (3 items ), social factor (1 item) and three from IQ i.e.
attitude & behavior (1 item), expertise (1 item), and process quality (1 item), and patient
satisfaction (1 item). We also then verified that the deletion of these items do not change or harm
the intended meaning of the constructs of which they were a part.
Reliability & Validity
Reliability of the scale is checked to know the extent to which scale produces consistent results
of measurements repeatedly (Hair et. al. 1985). The internal consistency using split half method
is used to assess the reliability of the scale (Malhotra 2002, Hair et. al. 1995 and Tull and
Hawkin 1988). The overall Cronbach alpha value for the sample is found to 0.951 for perceived
service quality scale. Further the Cronbach alpha values for PEQ and IQ are arrived at 0.883 and
0.922 respectively indicating the internal consistency and reliability of the sample. The reliability
of the data was also examined by dividing the respondents into two equal halves to examine if
the variation in both the halves is within the range of sampling. Overall, the results ( alpha values
greater than .7 ) indicate internal consistency in the responses of the respondents of the two half
samples (Table 1).
The face and content validity of the scales were, duly assessed through review of literature and
deliberations with the subject experts, doctors and patients for the selection of items in the
schedule at the time of pretesting. The KMO, measure of sampling adequacy, variance explained
12
and communalities values are examined to check the construct validity of the scales (Hair et. al.
1995). All values are found acceptable which support construct validity of the scales ( Tables 1).
Further, convergent validity of the construct was checked by examining the conceptual and
empirical criteria among the items used (Parasuraman et. al., 1998), The degree of correlation
coefficient values between respective overall sub-dimensions of PEQ and IQ and overall PEQ
and IQ, ranged between 0.780 to 0.907 indicating high degree of convergent validity (Table 1).
Discriminant validity of the constructs was also assessed. The degree of correlation coefficient
values among unassociated components of PEQ and IQ ranged between 0.146 to 0.323 (Table
1) which indicated discriminant validity.
Demographic Profile
The sample of indoor patients from tertiary public referral hospital ( Udhampur, North India )
consisted of 66.5 % females and 33.5 % males. Majority of the inpatients were high school pass
outs ( 77%) where as only 13% were graduates and post graduates and rest were illiterates.
Majority of the inpatients were young whose age fell between 20 years to 40 years ( 67%) and
about 26% aged between 40 years to 60 years. Further majority of respondents ( 65%) were
dependents i.e housewives, students, etc. and this was followed by service class respondents
(23%) and rest belonged to business class and professional groups. Income wise, majority of
respondents ( 66%) belong to income group second with income between Rs 5000 to Rs 10,000.
DATA ANALYSIS
As per reliability, convergent, and discriminant validity results, all scales met the psychometric
property requirements. Factor analysis with principal component method and varimax rotation,
was once again applied on all sub dimensions of four constructs viz. PEQ, IQ, CS and CL to
identify significant factors structure. Both KMO and inter-item correlation values for the four
constructs were well above the threshold criteria. The detailed analysis for PEQ, IQ, OQ CS
and CL is explained in the following sections (Table 2).
Physical Environment Quality (PEQ)
Ambient Condition, first sub dimension of PEQ explained about 62.70 percent of variance. The
specific items of first factor of Ambient Condition include natural light (0.58), cleanliness of
13
hospital (0.70), internal atmosphere (0.67), peaceful wards (0.81) and cleanliness of wards
(0.80). However only single item i.e proper placement of beds with high positive factor loading
value of 0.91 is found in second factor. Similarly two factors of sub dimension tangibles are
emerged. The first factor include items namely telephone facilities (0.81), availability of
oxygen services (0.75), cleaned bed sheets (0.80) and drinking water facilities (0.81). This
factor explained 40.15 percent of variance out of 64.52. And the factor two is found to be the
function of well equipped operation theatre (0.81) and good technical services (0.85) items.
The third sub dimension of PEQ i.esocial factor also comprises two factors. The first factor
include equitable treatment to patients (0.83), hygienically life style (0.70), special services
to needy (0.79) and societal commitment (0.55) whereas integrity and honesty in medical
practices (0.75) and overall impression (0.77), employee role towards social responsibility
(0.50) are found to be ingredients of second factor . Both factors explained variance about 57.83
percent.
Interaction Quality
The first sub dimension of interaction quality i.e attitude & behavior is found to be function of
four factors which explained about 73.19 % of variance. The first factor include items on nurses
and these include nurses behavior with friends and relatives (0.79), explaination about
technical treatment (0.73), attitude & behavior (0.84), helpful & supportive (0.57) caring
(0.78), answer queries satisfactorily (0.83), and listening ability (0.83). The second factor
contains four items on doctor and these include communication with staff (0.76), helpful &
supportive (0.83), attitude (0.75) and patient involvement (0.726). The statements regarding
supportive staff availability (0.78), attitude & behavior (0.84), friendly & helpful (0.76) fall
under factor 3. However two items namely professional values (0.64) and answer queries
satisfactory (0.71) , relating to doctors fall under factor 4. The second sub dimension of
interaction quality i.e. expertise comprise of two factors that explained 48.96% of variance. Eight
items namely physician expertise (0.81), operational competence (0.69), technical staffs
expertise (0.71), correct diagnosis (0.79), nursing expertise (0.82), technical knowledge
(0.71) and explain logically (0.64) are more significant and fall under factor one. By applying
factor analysis only one statement namely overall competent (0.95) came under factor 2. The
third sub dimension process quality comprises two factors. The first factor include good
housekeeping services ( 0.81), listening ability of supportive staff (0.77), interaction with
14
frontline staff (0.70) and grievances handling system (0.82) items that explained 31.89 percent
of variance out of total variance of 56.49 percent. The second factor include items namely
administrative function (0.71), laboratory services (0.65) (Sharma &Chahal 2003) and blood
bank services (0.84).
Outcome Quality (OQ)
The application of factor analysis resulted in two factors of customer satisfaction sub-dimension
of service outcome quality. The first factor comprises five items viz up to date healthcare
techniques (0.67), good technical facilities (0.76), indoor services (0.85), consciousness
towards patient satisfaction (0.73) and suggestion scheme (0.64) that explained 34.70 percent
of variance out of 58.82. Its second factor comprises three items namely visit for all treatments
(0.77), satisfaction regard supportive staff (0.76) and satisfaction regard to doctors (0.63).
The second sub-dimension customer loyalty is function of three factors which explained 29.66%
of variance. Factor one include items i.e satisfied from hospital (0.87), physician (0.88),
price effectiveness (0.65) and trust (0.62) whereas two items namely emotional attachment
(0.83) and quality of care (0.75) are part of factor 2 and two items namely preferences over
other private hospitals (0.81) and positive perception (0.81) are part of factor three.
RELATIONSHIP AMONG CRM DYNAMICS: PERCEIVED SERVICE QUALITY,
CUSTOMER SATISFACTION AND CUSTOMER LOYALTY
Impact of ambient condition, tangibles and social factor on physical environment quality;
attitude &behaviour, expertise, process quality on interaction quality and the combined impact
of physical environment quality and interaction quality on perceived service quality are assessed
using structural educational modeling (SEM) using AMOS 5 (Figure 2 and Table 3). In addition,
the impact of perceived service quality on customer satisfaction and customer loyalty is also
assessed. The impact of ambient condition and social factor on physical environment quality;
attitude &behaviour and process quality on interaction quality are found to be significant as the
CR values are found to be above 1.96. This led to the acceptance of hypotheses 1 and 2. Further
physical environment quality explained about 70% variance with regard to interaction quality.
Similarly, the CR values of physical environment quality and interaction quality revealed
15
significant and positive combined effect on perceived service quality, and thus supported the
hypothesis 3. In addition, as expected, results supported that perceived service quality leads to
customer satisfaction and customer loyalty (Hypothesis 4). As such all the hypothesis are
accepted. Moreover model fit values were also considered P (CMIN) (.000), CMIN/DF (11.399,
NFI (0.720), RFI (0.651), IFI (0.738), TLI (0.671), CFI (0.736), RMSEA (0.161). The above
values showed that only NFI, RFI, IFI, TLI, CFI reflects accepted fit whereas CMIN/DF, P
(CMIN), RMSEA showed poor fit but on the whole the overall model fit can be considered as
below fit.
To examine the impact of socio demographic factors on customer satisfaction and
customer loyalty, t test for gender and F test (ANOVA one way) for age, education, income,
profession were applied. The results of t-test indicate that both male and female respondents
have significant differences in their perceptions about customer satisfaction and customer loyalty
measures ( Table 4). In the age wise comparison the results of F test revealed that with respect to
customer satisfaction and customer loyalty there is significant differences among perception of
SAG and TAG, TAG and FAG. On the other hand FAG and SAG have similar perceptions. The
same results were observed by Choi et. al., 2005. Further education groups viz, SEG and TEG,
TEG and FEG have different perception but FEG and SEG have similar perceptions. Similarly
income groups FIG and SIG, TIG and FIG have significance difference in their perception. In
contrary SIG and TIG showed similarity in there perception about customer loyalty but
significant perceptual difference with regard to customer satisfaction. Further in profession wise
analysis Business and Service showed similarity in there perception, Service and Professional
have significant difference and the Professional and Business showed similar perception about
customer satisfaction and different perception about customer loyalty. Overall results indicate
that there is significant difference in the perception of demographic groups (Sharma and Chahal,
2003) namely male & female, education groupS (SEG & TEG, TEG & FEG), income groups (
FIG & SIG, TIG & FIG) and profession based gropus (Service & Professional, Professional &
Business ) with respect to customer satisfaction and customer loyalty.
DISCUSSION
16
Overall we find support for all the five hypothesized relationships. The finding of positive and
significant main effects of physical environment and interaction quality on service quality are as
per service researchers perceptions (Brady & Cronin et al. 2001 and Chahal& Sharma 2003).
Physical Environment Quality: Among three physical environment quality sub-dimensions,
customers are quite appreciative about the tangible facilities of the hospital, both technical as
well as supportive, followed by overall ambient condition and social responsibility in general.
The results indicate that items relating to ambience of the hospital such as proper arrangement
for natural light, overall cleanliness of hospital, good internal atmosphere, peaceful wards, and
hygienically clean wards are significant items with average scores. This is followed by somewhat
less significant item i.e. proper placement of beds which scored below average mean score.
Further in tangibles availability of oxygen services, telephone services, clean bed sheets and
continuous pure drinking water facility with above average mean score are comparatively more
significant followed by well equipped operation theatre and good technical services with average
mean score values. Lastly equitable treatment to patients, hygienic life style, special services to
poor and needy patients, societal commitment are important first factors items followed by factor
second items namely integrity and honesty in medical practices, overall impression and
employee role towards social responsibility with below average mean score under social factor
sub-dimension of PEQ. Overall results indicate that there is a need to given more consideration
to the aforesaid items to make physical environment quality competitive and to contribute more
to customer satisfaction and loyalty.
Interaction Quality: The antecedent of service quality is interaction quality. The result indicate
that expertise of staff is somewhat more significant in terms of degree of service quality followed
by attitude &behaviour and process quality. The staff expertise is found to be the function of
items namely physician expertise, operation competence, technical staff expertise, correct
diagnosis of diseases , nursing expertise, technical knowledge and explaining logically the
ailment and treatment procedure to patients. All items are contributing averagely to service
quality. The second sub-dimension attitude &behaviour is found to be function of four factors
viz; nurses, doctors attitude, technical & supportive staff and doctors behaviour. The mean score
values of attitude & behavior show average level of patient satisfaction for doctors, technical and
supportive staff and dissatisfaction with respect to nurses. The results suggests that there is a
need for hospital administration to organize training programme that can inculcate positive
17
attitudinal and behavioral response of staff with respect to characteristics such as helpful,
supportive and caring nature, satisfactory answers to patients. queries , listening ability ,
explanation about technical treatment etc. to enhance patient satisfaction for nurses. Further,
Lastly housekeeping services, listening ability of supportive staff, interaction with frontline staff
and grievances handling system are important factors followed by comparatively less significant
factor second items namely supportive facilities included administrative function, laboratory
services and blood bank services which reflect satisfactory process quality. Overall process
quality is perceived to have below average contribution to service quality.
Customer Satisfaction: Further the study finds that service quality leads to patient satisfaction
and patient loyalty. Consumer satisfaction, an outcome of service quality, is function of up to
date healthcaretechniques, good technical facilities, indoor services, consciousness towards
patient participation ( all with below average mean score values) followed by less important
factor items namely visit for all treatment, satisfaction regard to supporting staff and satisfaction
regard to doctors.
Customer Loyalty: With respect to loyalty patient prefer public hospital over other private
hospitals because of trust, price effectiveness and well known doctors. However overall quality
of care and overall negative perception contribute negatively to. loyalty dimension. The
satisfaction and loyalty when examined individually reflected near to average mean score,
indicating the need of service provider to look concretely into the service quality dimensions
visavis need to improve CRM dynamics in the public healthcare to accomplish CRM objectives:
The overall composite impact of sub dimensions of physical environment quality and interaction
quality on respective overall physical environment quality and overall interaction quality indicate
their significant positive contribution as all CR values are above threshold value of 1.96 at 95%
level of significance. In terms of relative strength of squared multiple correlation and regression
weights, tangible variable followed by ambient condition and social factor contribute quite
significantly to physical environment quality. However relationship between physical
environment quality & perceived service quality and interaction quality & perceived service
quality though significant is weak for perceived service quality and process quality and very
strong for interaction quality and perceived service quality. Further perceived service quality and
customer satisfaction and perceived service quality relationship are also found to be significant
in terms of critical ratio, regression weights and square multiple correlation values. The overall
18
mean score is below average for customer satisfaction and above average for patient loyalty. The
somewhat higher value of customer loyalty in relation to customer satisfaction indicate presence
of some moderating factors like customer value which need to be examined to know the real
impact of service quality on customer satisfaction & loyalty.
IMPLICATIONS FOR MANAGEMENT
Managerial Implications: Several managerial implications emerge from this study to
operationalise CRM strategy. First, and perhaps most important, services firms must pay
attention to both the physical environment and interaction quality in their service offering to
attain customer satisfaction and retain customers loyalty. As customer are demanding much
more than only medical treatment of ailments such as good ambient condition and interaction
with doctors and nurses adequate efforts should be made by hospital on additional benefits to be
given to customers to sustain stiff competition prevailing in healthcare sector. While providing
value added customer services, superior returns though remains a primary goal but at the same
time service provider also need to recognize that elements of the service process can create loyal
and committed customers. Further, encouraging and enabling service personnel are required to
be engaged with customers in a friendly manner, to communicate openly, and to retain a sense of
empathy for situations which will lead to increased loyalty and patronage. Furthermore,
management should also understand the overall service impact and kept in mind that over a
series of transactions, customers may build switching costs through the development of personal
relationships and the accumulation of organization benefits in terms of technology and good
ambience and as such will remain associated with the hospital . This consequently breeds
complacency within organizations because of the fact that long-term customers will continue to
be loyal despite fluctuations in service quality. The study suggest, that both physical
environment and interaction quality of the service will remain consistently important even as
switching costs increase with the development of relationships. Thus, understanding how
customers prioritize the importance of physical environment and interaction quality of service
quality will lead to building positive image in eyes of customer and leads to satisfaction of
patients and help in building long term relationship with firms. To the extent that organization
image develops overtime, providers must continually change the emphasis in their service
interactions with customer according to their changing requirements.
19
Research Implication : There are several implications for further research. The most obvious
extension is to re-investigate the interrelationships between service quality and other service
constructs i.e. satisfaction and loyalty to manage customer relationship. The marketing literature
has made great strides in understanding service quality relationship with satisfaction and loyalty.
Determining whether our conceptualization can help overcome the customer problem should be
of great interest to researchers. Moreover, any improvement in the ability to capture service
quality perceptions will enhance the understanding of customer relationship. Specifically, the
physical environment quality and interaction quality are important attributes of service quality it
is what a customer gets from a service experience. Given the interest in investigating service
quality our conceptualization could be extended to analyze service quality from an employee
perspective in different settings will comw out with new and useful findings.
STUDY LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH
The foregoing recommendations should be considered in the light of some of the limitations of
this study. The study took a snapshot of customers and unable to follow individual customers
over time. Clearly cross-sectional research design does not offer nearly the same insight into the
dynamics of customer relationships with a firm as a longitudinal design. As such a longitudinal
design would afford greater insight into this in the future. The studys focus on a single
healthcare unit may also limit the extent to which the findings can be generalized. Another
limitation of our sample is that our findings cannot be generalized to business-to-business
relationships where there is likely to be an even greater emphasis on technical service quality as
a determinant of customer loyalty. Further, it is plausible that the nature of the observed
relationships would change with services that are higher or lower in credence properties (e.g.,
higher education and airline services, respectively) as the potential for customers building
expectation is likely to vary significantly across these industries and thus requires different path
to operationalise CRM, which need to be studied in the future. In addition, the relative
importance of the role of service personnel in the delivery of physical environment and
20
interaction quality is also likely to vary between such industries. Nonetheless, study recognizes
the need for future replication of our model in alternative service industries. Further, the research
model has omitted certain antecedents of satisfaction and loyalty that could help and explain
customer perception more concretely as the major focus of the was on the physical environment
and interaction quality provided by the unit to understand impact of service quality on CRM
outcomes. Furthermore, future studies may consider broader organization image typologies and
measures in understanding CRM dynamics such as organizational excellence and customer
value. This would also allow researchers to consider and analyze moderation effects between
service quality and customer satisfaction and loyalty and image. Despite these limitations, this
study provides some important insights for CRM theory and practice. There is strong support for
the view that customers change the way they evaluate a firms service as switching costs and
image vary. An understanding of service quality, customer satisfaction and loyalty dynamics is a
first step toward effective service management and the retention of customers in the long term.
The impact of service climate and

service provider
personality
employees
customer-oriented behavior in a
high-contact setting
on
PanisaMechinda
Department of Marketing, Faculty of Business Administration, Rajarnangala

University of Technology, Thanyaburi , Thailand, and
Paul G. Patterson
Department of Marketing, Australia School of Business, University of New South

Wales Sydney Australia
Abstract
Purpose The purpose of this study is to empirically test and extend knowledge of
the determinants of customer-oriented behavior (COB) of service
providers in an affective, high contact service setting (healthcare).
Design/methodology/approach The authors examine the relative effects of
dispositional variables (e.g. personality of service provider), as well as
service climate and job satisfaction on five dimensions of customer-oriented
behavior. The research hypotheses are tested using self-report data
collected from 270 nurses in five hospitals (public and private). Qualitative work,
including three focus groups with nurses and a series of depth
interviews with patients, was conducted to test the applicability of the scales.
Findings Results support the role of personality, job satisfaction and service
climate on employees COB, but do not support interaction effects.
Various personality traits have differing effects on different types of customeroriented behaviors. Service climate has effects on both technical and
interpersonal behaviors whereas job satisfaction impacts only technical behavior.
Research limitations/implications This study was conducted in an affective, high
contact and high emotional labor setting, i.e. healthcare, and in
an Eastern collectivist culture (Thailand). As a result, the generalizability of the
findings into other service settings and cultures needs to be undertaken
with care.
Practical implications For service employees to display customer-oriented
behaviors, the organization must first recruit individuals with high levels
of conscientiousness, agreeableness, extraversion and emotional stability. Second,
the organization must create a climate for service that supports,
encourages and motivates service employees to better serve their customers. This
service climate at the unit/branch level includes inspirational
leadership, providing appropriate tools and technology, training, and commitment
from senior management to a truly customer (patient) centric
organization. Finally, when the organization is successful in creating satisfaction
among employees, then employees are more inclined to offer a better
technical performance.
Originality/value This is one of only a few studies that have examined the impact
of personality and organizational variables on front-line employee
performance.
Keywords Health services, Services marketing, Individual behaviour, Personality,
Employee attitudes, Thailand
An executive summary for managers and executive
readers can be found at the end of this article.
Introduction
Services may be characterized along three dimensions:

1 the degree of emotional labor expended in delivering the
service;
2 proximity (degree of close physical and intimate contact
with the customer); and
3 extended duration (the length of time and frequency of
the service encounter) (Price et al., 1995).
Services high on each dimension place an especially high
burden on the skill and emotional labor (i.e. the display of
expected emotions by a service provider during a service
encounter) (Erickson and Grove, 2008) of front-line
employees. Health services, especially in-patient hospital
services, are one such service. They are characterized by
close, frequent and extended interactions between employees
(nurses) and customers (patients). Furthermore, they are
customized, high involvement, high in emotion and anxiety,
Journal of Services Marketing
25/2 (2011) 101113
q Emerald Group Publishing Limited [ISSN 0887-6045]
[DOI 10.1108/08876041111119822]
Received October 2008

Revised May 2009
Accepted August 2009
101
and associated with considerable patient perceived risk.
Further, because it is often difficult for patients to
confidently evaluate the technical outcome of the service,
the pro-social behavior of nurses or how the service is
delivered, including the processes and personal interactions,
plays a central role in patient satisfaction evaluations (Hall
et al. 2002; Hausman, 2004).
The central role of interpersonal interactions in the
customers (patients) evaluation process is supported by
social cognition theory (Janz and Becker, 1984), meaning that
patients rely heavily on social information in their service
evaluations. When patients at the Mayo Clinic were asked to

describe their best and worst experiences, virtually all
mentioned the physicians behavior (bedside manner)
rather than the physicians technical expertise (Berry and
Bendapudi, 2007). Furthermore, as noted by Hausman
(2004), patient involvement, communication and education
are critical to patient compliance (comply with physicians
instructions concerning medication, exercise, diet, etc.). Thus
the pro-social, customer oriented behaviors of front-line
medical personnel such as nurses and physicians are front and
center for both the hospital fa determinant of patient
satisfaction and loyalty) and the patient (successful medical
outcomes). Thus it is important to examine and understand
what drives of this pro-social, customer-oriented behavior
why do some nurses consistently exhibit such desired
behaviors and others not so consistently? Understanding the
extent to which the organizational environment (service
climate) and the innate personality of individual nurses drive
behavior in this unique service setting can only benefit all
parties the patient (customer), employees and the
organization (hospital).
Scholarly research in both marketing and organizational
psychology suggests that three categories of factors affect the
performance of service personnel organizational factors;
individuals satisfaction with their job; and dispositional
variables (Liao and Chuang, 2004). Organizational factors
refer to characteristics of the organization that reward and
facilitate excellent customer service at the branch level of
analysis. These include; organizational culture and climate
(Gounaris, 2008; Schneider et al., 2000), leadership (Gibson
and Birkinshaw, 2004), job design (Bettencourt and Brown,
2003), empowerment (Bowen and Lawler, 1992) and
management support and commitment (Reeves and Hoy,
1993). Job satisfaction is defined by Locke et al. (1970, p. 136)
as the pleasurable emotional slate resulting from the
appraisal of ones job. Personality (disposition) represents
the innate characteristics of an individual and has been shown
to be correlated with employee performance in a range of job
contexts (Barrick and Mount, 1993; Bove and Mitzifiris,

2007; Tettet al., 1991). One of the contributions of this study
is that we include all three categories of factors to explain
front-line employees (nurses) customer oriented behavior.
Unlike other studies that have attempted to model aggregate
COB, a further contribution of this study is that we model the
antecedents of five dimensions of COB (congeniality,
anticipation, courtesy, attentiveness, capability). This is
important because as noted earlier, patients evaluate their
overall experience along two general dimensions how
(congeniality, courtesy) the service is delivered, and what is
delivered (capability, attentiveness, anticipation).
Finally, as service scholars (Lovelock et al., 1999; Patterson,
2004, 2006) have long noted, all services are not the same.
Rather, different types of services may be categorized
according to various characteristics. Medical services are
different from other services, even other professional services,
in that they are characterized by the extended duration of the
service encounter, the emotional nature of the service, and the
close physical contact between provider and customer (Price
et al., 1995). In these circumstances, how the service is
delivered i.e. perceptions of the interactions while an
inpatient, takes on added importance in overall patient
satisfaction, quality and value judgment. This is one of the
few studies that has attempted to model employee
performance for a service with such characteristics.
Theoretical background
It is generally accepted that some people are able to succeed

in a range of occupational and general life endeavors by virtue
of their basic personality (Cran, 1994). Healthcare managers
have noted that some employees have varying degrees of
intrinsic service orientation (or service.mind) (Daniel and
Darby, 1997). However, research linking personality and
employee (and consumer) behaviors has shown personality
typically accounts for only a small percentage (between 3-20
per cent) of variance in performance (Liao and Chuang,
2004; Hurley, 1998), It might be expected that research
would have focused on issues beyond whether people are
consistent and whether situations or persons are more

important (Hurley, 1998). However, the literature to date
attempting to examine person-situation effects is minimal.
Situational factors have been used extensively to explain
various aspects of consumer behavior and, as rationalized by
Organ (1994), attitudes predict behavior only to the extent
that behavior is not bound by situational constraints.
Therefore we include two other variables known to impact
front-line employee service performance. The first is service
climate (Schneider et al., 1996), an organizational factor that
is known to effect front-line employees attitudes and behavior
towards customers. If an organization is seriously committed
to delivering excellent customer service then it must establish
practices that encourage and reward such service a climate
for service if you like. Service climate reflects the service
quality activities, policies and work unit behaviors that
employees sense and experience around them on a daily basis
that make up the general tone, atmosphere or work climate
(Schneider et al., 2000). The second variable is job
satisfaction which has been shown in numerous works to be
a key antecedent of employees work attitude and
performance (Avilla and Tadepalli, 1999; Franke and Park,
2006; Iaffaldano and Muchinsky, 1985).
Recent research has simultaneously examined the impact of
individual characteristics (personality) and organizational
factors (service climate, FIRM practices) and found both
were significantly associated with service performance in a
restaurant chain setting (Liao and Chuang, 2004). Our study
extends this work by focusing on a health care setting where,
as previously noted, the interaction between employee (nurse)
and customer (patient) has more impact on service
evaluations.
In the following section we first discuss the key constructs
in the study in more detail, and then present a series of
general hypotheses for testing.
The impact of service climate and service provider personality
PanisaMechinda and Paul G. Patterson
Volume 25 Number 2 2011 101113
102
Dependent variable: customer-oriented behavior

(COB)
Customer orientation at the firm level is a set of beliefs that
put the customers interests first, while not excluding those of
all other stakeholders, in order to develop a long-term
profitable enterprise (Hartline et al., 2000). At an individual
level, Saxe and Weitz (1982) and others defined customer
orientation as the willingness of individual service providers to
customize their service delivery according to the customers
situation (e.g. needs, problems, special circumstances). The
term customer-oriented behavior (COB) refers to specific
behaviors displayed by service personnel during service
delivery such behaviors that lead to satisfied customers
(Winsted, 2000a, b).
In her study of the USA and Japanese students, Winsted
(2000 a, b) found several dimensions of COB but noted there
were some differences across the two countries. Three
dimensions were common to both countries. First, the
concern dimension combined elements of empathy, assurance
and responsiveness (Parasuramanet al., 1985, 1988), as well
as authenticity, listening and dedication. The second
dimension, civility, included all behaviors that service
personnel should avoid in order to provide adequate service
(Parasuramanet al., 1991) and to protect against
dissatisfaction (Winsted, 2000a, b). Example of such
behaviors included not acting arrogantly, getting annoyed
with or ignoring customers. The final dimension,
congeniality, related to behaviors such as smiling, being
happy, cheerful and enthusiastic. In addition, in the US
sample, attentiveness was shown to be an additional COB
dimension, while for Japanese courtesy was a priority. More
recent work in a medical setting found patient satisfaction was
positively associated with doctors and nurses ability to
consistently enact the following key behaviors:
communication skills, courtesy, attentiveness to patient
needs, personalization, sensitivity as well as a capability
(competency) dimension (Hasinet al., 2001).
Personality
Personality characterizes an individual and distinguishes him
or her from others (Costa and McCrae, 1992). There is
considerable consensus regarding the big five personality
dimensions (John and Srivasta, 1999; McCrae and Costa,
1996, 1999) which comprise extraversion, emotional stability,
conscientiousness, openness to experience and agreeableness.
The five-factor model is not based on a single theory of
personality but incorporates a number of theoretical
perspectives and has similarities with the prominent MyersBriggs Type Indicator (McCrae and Costa, 1989). They are
considered universal, having been validated in diverse cultures
such as North America, Europe and Asia and remain stable
over time (Costa and McCrae, 1992). Logic would seem to
dictate that in a service setting (medical) characterized by
high emotion, intimacy and prolonged interaction with the
customer, a persons fundamental personality will impact on
their level of performance (as perceived by patients). Each
personality trait is now briefly discussed.
Extraversion refers to a persons propensity to be sociable
and assertive (Salgado, 1997). Jung (1971) drew a central
distinction between introverted and extraverted attitudes
which represent fundamentally different orientations to the
world. Jung described extraverts as open, sociable, jovial, or
at least friendly and approachable characters (Jung, 1971,
p. 333) but also morally conventional and tough minded.
Introverted attitudes on the other hand tend to manifest
themselves for the most part, negatively (Jung, 1971, p. 387).
Individuals who score high on emotional stability are typically
unworried, have a sense of security and arc generally relaxed
and less likely to experience negative emotions. Conscientious
individuals are more likely to thoroughly and correctly
perform work tasks, to remain committed to work
performance, and to comply with policies. They tend to be
responsible, dependable and persistent. This construct is
related to performance across jobs (Salgado, 1997; Barrick
and Mount, 2003) and is valid predictor of success at work
(Judge et al., 1997). Next, the dimension of agreeableness is
characterized by kindness and being good-natured, trusting

and cooperative. Agreeable individuals tend to be successful
in occupations where teamwork and customer service is
important (Barrick and Mount, 2003). Given the nature of a
nurses role providing emotional support in stressful
situations, while remaining calm, confident and possessing
of high technical competencies it seems logical that
extraversion, emotional stability, conscientiousness and
agreeableness would all impact their propensity and ability
to provide excellent patient service. The final dimension,
openness to experience, is characterized by curiosity,
imaginativeness, need for variety and a willingness to
discover and be creative. Based on our qualitative interviews
this trait was not seen as relevant in a Thai (a hierarchical
society) nursing context. Nurses indicated they needed to
strictly follow protocol, should not be creative and should
strictly followed physicians orders. Further, they did not wish
to be empowered to make discretionary decisions.
Thus our first general hypothesis is:
H1. Personality traits (extraversion, emotional stability,
conscientiousness, agreeahleness) will be positively
correlated with dimensions of customer-oriented
behavior (COB).
Climate for service
It is generally agreed that an organization should possess two

major ingredients for service personnel to deliver excellent
service: a concern for customers (all practices and policies
should be customer-oriented), and concern for employees
(how employees are treated and supported by management).
Consumers are better served if service organizations are
structured to meet and satisfy the needs of their employees.
When employees feel their organization is not truly customeroriented,
both employees and customers report less positive
experiences (Bendapudi and Bendapudi, 2005; Schneider and
Bowen, 1995). Schneider and colleagues defined climate for
service as employees perceptions of practices, procedures
and behaviors that get rewarded, supported and expected
with regard to customer service and service quality
(Schneider et al., 1998, p. 15). Service climate is a specific

subset of organizational climate i.e. employees shared
perceptions of what is truly important in their organization.
This notion (service and organizational climate) builds on the
notion that, in interpreting their work environment,
employees integrate their day-to-day perceptions of
workplace events with macro-perceptions of climates which
103
capture the important themes in their work environment.
When excellent service is an important theme in an
organization, then a positive service climate exists (Dietz
et al., 2004).
While considerable service climate research has emerged
over the past decade, empirical studies typically have not
specified boundary conditions i.e. when or under what
conditions service climate is likely to have a significant (or
lesser) impact on employee and customer attitudes and
behaviors. Contact between employees and customers is at
center stage when understanding the nature of service
products. Schneider and Bowen (1995, p. 424) asserted
. . .key element underlying the link between employees and
customer perceptions is the physical and psychological
closeness of employees and customers. As boundary
spanners, front-line service employees, be they nurses or
receptionists at the JW Marriot hotel, are sensitive to servicerelated
practices and their impact on customers. Social
network theorists (e.g. Krackhardt, 1992, p. 218) recognize
that . . . interaction creates the opportunity for the exchange
of information... and frequent contact leads to vicarious
experiences of each others behaviors, opinions and attitudes.
High and prolonged contact frequency means more
opportunities for employees to understand and appreciate
customers needs and to compare these with the service
culture that exists in the organizational work unit, be it a
hotel, hospital or bank. Under these conditions a strong
service culture should be strongly, positively correlated with

dimensions of COB. As noted earlier, in-patient services
involve frequent and prolonged contact between nurse and
patient. Hence, the next general hypothesis is:
H2. Employee perceptions of positive service climate will
exert a positive influence on their customer-oriented
behavior (COB).
Job satisfaction
Job satisfaction is defined as a general pleasurable or positive

emotional state resulting from the appraisal of ones job or job
experiences (Locke, 1976, p. 1300). It is also seen as the
general emotional evaluation of service providers of their job
situation and experiences (Brown and Peterson, 1994;
Karatepeet al., 2007). Operationally, job satisfaction
consists of several facets, including satisfaction with the
supervisor, work, pay, advancement opportunities, coworkers,
and customers (Brown and Peterson, 1994).
Hoffman and Ingram (1992) have summarized two
conceptual foundations which support the relationship
between job satisfaction and customer-oriented behaviors.
First, social exchange theory proposes that individuals will
engage in reciprocal behaviors and support those from whom
they benefit. Thus, for employees who benefit extrinsically
(pay) and intrinsically (other job facets) from taking care of
customers, then customer-oriented behaviors can be
expected. Second, a series of psychological studies support
the role of an individuals mood on helping behaviors. That is,
pro-social behavior is most likely to occur when the individual
is experiencing a positive affect. On the other hand, when
employees are unhappy and disgruntled about some aspect of
their job, it is very difficult for them to serve customers well
(Atkins et al., 1996; Karatepeet al., 2007). There is an
abundance of empirical evidence linking employee job
satisfaction with customer satisfaction (Rogers et al., 1994),
customer orientation (Gounaris, 2008; Hoffman and Ingram,
1992), and role-prescribed customer service of employee (Lee
et al., 2006). Hence our next hypothesis is largely a replication
hypothesis.
H3. Job satisfaction is positively associated with all

dimensions of COB.
Behaviorists in psychology assume that people are almost
infinitely plastic and can adapt to virtually any organizational
arrangement (Hogan, 2004, p. 4). In this model
organizational structures and tasks are driven by the
financial, logistic and communication imperatives of the
organization. On the other hand, personality psychologists
claim there are limits to human adaptability, and that different
people (with differing personalities) find certain operational
and contextual situations more conducive to working to high
performance standards. (Schneider and Smith, 2004). This
suggests an interaction effect between personality traits and
organizational factors (e.g. service climate). Accordingly H4
is:
H4. The interaction of personality traits and service climate
will have a significant, positive impact on COB.
Methodology
Stage 1
This comprised three focus groups, each containing seven to
eight nurses from both private and public hospitals. In
addition, a series of in-depth interviews was also conducted
with five hospital administrators and nursing directors, as well
as with 12 patients. The purpose was first to test the face
validity of our model and, second, to examine whether the
measures of COB and service climate made sense in the study
context (i.e. a hospital setting in an Eastern collectivist
culture) - Thailand (Hambleton, 1993). All interviews were
conducted in Thai by one of the authors who is bilingual. The
interviews were recorded and later transcribed. This stage
generally confirmed the face validity of the model and
accompanying measures. However, it did result in some scale
modifications as discussed later in the Measures section.
Following Stage 1, the instrument was pre-tested to assess the
applicability and meaning of the scales. Interviews were
conducted with 52 nurses from public and private hospitals.
This resulted in no modifications to the measures of
personality traits but minor modifications were made to
service climate and COB measures. The details are reported

in the Measures section.
Study 2
Following pilot testing, the questionnaire was modified and
administered. The questionnaire was first translated from the
source language (English) into Thai by a bilingual Thai
translator. This version was then translated back into English
by a bilingual native speaker of English. The author then
compared the back-translated versions with the original
English.
Sample
A non-probability convenience sampling procedure was
employed where all nurses working on a particular shift in
general hospital wards (excluding intensive care) were asked
104
to participate. Three private and two public hospitals agreed
to participate. An incentive (e.g. a pen, a towel) was offered
for participation in the study. The average agreement rate
across all five hospitals was 71 per cent yielding two hundred
and seventy usable questionnaires for the final analysis. There
was minimal variance of response rates between private and
public hospitals.
Measures
Personality was treated as a formative indicator and captured

using the 32-item, nine-point Mini-Marker scale developed
by Saucier (1994). For job satisfaction the scale from Singh
et al. (1996) was used. For service climate the scale was
adapted from Schneider (1990) and was the first time this
scale had been used in a healthcare context. Instead often
dimensions, eight dimensions were employed in the final
analysis. The leadership empowerment dimensions were
dropped. From our qualitative phase, it was apparent that
nurses perceived leadership practice as any behavior
conducted by management or physicians. Furthermore,
nurses strongly indicated that, since their jobs literally deal

with matters of life and death, they are more comfortable
when strictly following physicians instructions and were not
comfortable being empowered or being imaginative or
creative. This is typical behavior in a hierarchical culture
like Thailand. Hence the empowerment dimension was
dropped, as was the openness to experience personality
dimension.
For the dependent variable (COB) we employed Winsteds
seven-point Likert scale containing 32 items (2000a, b). As
noted above, a qualitative phase was undertaken to assess the
relevance and meaning of the dimensions. As a result, the
scale developed by Winsted (2000b) was used (with minor
modification) in order to suit a healthcare context. Further, as
a result of the qualitative phase, a capability dimension was
included as a dimension of COB. This is logical since nurses
technical competence is a crucial aspect of their performance.
All questions are shown in the Appendix (Table AI). Since it
was not possible to match individual patients to one nurse,
customer-oriented behavior (COB) was captured by asking
nurses to report their perceptions of actual behavior towards
their patients. There is considerable support for this approach
(Singh, 2000; Schneider and Bowen, 1995). This issue is
further discussed in the Limitations section.
Control variables
To control for any extraneous effects of hospital type (public
versus private), or nurses experience and education levels, we
included these as control variables to provide a more robust
test of our hypotheses.
Scale evaluations
For scale evaluation, confirmatory factor analysis was
performed using AMOS version 4,01 (Arbuckle and
Wothke, 1999). All constructs were subjected to scale
purification except for personality traits which, consistent
with studies in psychology, are treated as formative scales
(Saucier, 1994). Consistent with previous works (Lytle et al.,
1998) higher-order factor analysis for service climate was
undertaken. After the removal of two items, the model fit was
acceptable (x2=df 1:72, p 0:00 level, GF1 0:90,

AGFI 0:86, RMR 0:03, RVISEA 0:05). There were
no standardized residual covariances greater than ^2.58 in
the final model. Consistent with previous studies (Brown et al.,
2002), an index score (Diamantopoulos and Winklhofer,
2001) was created for each set of items which served as
indicators for the service climate construct in the
measurement model.
For customer oriented behavior (COB), confirmatory
factor analysis indicated dimensions that were at slight
variance with Winsteds (2000a, b) work. In the current study
two additional dimensions emerged, namely, attentiveness
and anticipation. Attentiveness and anticipation are specific to
the healthcare context as noted by Hasinet al. (2001). They
reported that Asian patients expect nurses to make an effort
to understand patients problems. Since Thai patients
typically shy away from openly talking about their
conditions, a customer-oriented nurse should be attentive
and able to anticipate a patients needs. The items for these
dimensions also emerged in the focus groups and seem highly
relevant in an Eastern healthcare context.
Higher-order factor analysis for COB was then performed.
After two items were removed due to the lower-than threshold
value of squared multiple correlation, the model fit was
acceptable (x2=df 2:43, p 0:00 level, GFI 0:90,
AGFI 0:86, RMR 0:04, RMSEA 0:07). There was
no standardized residual covariance greater than ^2.58 in the
final model. Finally, an index score was created for each of the
five COB dimensions (congeniality, courtesy, anticipation,
attentiveness, capability) which then served as dependent
variables in the regression analysis.
Assessing validity
To determine whether the constructs (job satisfaction, service
climate and dimensions of COB) are conceptually distinct
from each other, the procedure described by Fornell and
Larcker (1981) was used. As an indication of convergent and
discriminant validity, the average variance extracted (AVE) for
each construct should be higher than the squared correlation
between that construct and any other construct (Patterson

and Spreng, 1997). No squared correlation value was greater
than the AVE of each construct. Thus, it can be concluded
that the constructs are discriminant. A correlation matrix of
all variables is shown in Table I.
Results of regression analysis
Overall, the variance explained across the five COB
dimensions ranges from 19 per cent to 26.5 per cent
indicating the combination of predictor variables do a
reasonable job of explaining the drivers of COB. The
detailed results will now be discussed in line with the
hypotheses developed earlier.
H1 posited a positive association between the personality
traits of extra version, emotional stability, conscientiousness,
agreeableness and all five dimensions of COB. The pattern of
regression results in Table II show that various personality
traits differentially impact the five dimensions of COB.
Perhaps the first thing to note is that, in a sense, the five
dimensions might be grouped into technical behaviors
(capability, attentiveness, anticipation) and interpersonal
behaviors (congeniality and courtesy). The former relate to
what is delivered, i.e. nurses anticipating patient needs,
listening attentively to patient requests, and performing a
range of health care related tasks with accuracy and reliability.
The latter is how it is delivered, i.e. that they are cheerful,
105
friendly and respectful when meeting patient technical
needs (Lovelock and Wirtz, 2007). It is equivalent to a
doctors bedside manner.
Perhaps it is not surprising, then, that personality traits of
extraversion (a propensity to be sociable), emotional stability
(unworried, a sense of security and generally relaxed, and less
likely to experience negative emotions), and agreeableness
(exhibits kindness and is good-natured, and cooperative) are
significant predictors (refer Table II) of congeniality and
courtesy behaviors. On the other hand, it is agreeableness and

conscientiousness that are generally significant predictors of the
technical aspects of COB (anticipating customer needs, being
attentive and capable). After all, conscientious individuals are
more likely to thoroughly and correctly performwork tasks and
remain committed to work performance. In fact, the highest
beta coefficients for any of the personality traits are for
conscientiousness (p 0:24, p , 0:00 with attentiveness; and
b 0:26, p , 0:00 with capability).
H2 asserted that employee perceptions of service climate
would be positively, strongly associated with customeroriented
behaviors. This is, by and large, supported by the
data in Table II. Service climate is significant (at p , :00) for
four of the five COB dimensions indicating the potency of a
customer centric service culture in a service organization.
Table I Correlations matrix and AVE results
Y1 Y2 Y3 Y4 Y5 XI X2 X3 X4 X5 X6
Congeniality (Yl) 0.78
Anticipation (Y2) 0.66 * * * 0.71
Courtesy (Y3) 0.62 * * * 0.63 * * * 0.78
Attentiveness(Y4) 0.55 * * * 0.60 * * * 0.62 * * * 0.84
CapabiIity(Y3) 0.29 * * * 0.37 * * * 0.28 * * * 0.51 * * * 0.81
Service climate (XI) 0.31 * * * 0.32 * * * 0.33 * * * 0.25 * * * 0.12 * 0.68
Job satisfaction (X2) 0.18 * * 0.25 * * * 0.15 * * 0.31 * * * 0.28 * * * 0.18 * * * 0.70
Extraversion(X3) 0.26 * * * ns 0.18 * * * ns 0.11 * 0.15 * * ns
Emotional stability (X4) 0.25 * * * 0.23 * * * 0.17 * * * 0.13 * * 0.21 * * * ns 0.14 * *
0.17 * * *
Conscientiousness (X5) 0.23 * * * 0.23 * * * 0.11 * 0.36 * * * 0.41 * * * 0.17 * * * 0.26 *
* * 0.18 * * * 0.26 * * *
Agreeableness(X6) 0.35 * * * 0.18 * * * 0.26 * * * 0.23 * * * 0.31 * * * 0.14 * * 0.17 * * *
0.24 * * * 0.29 * * * 37 * * *
Notes: * Correlation is significant at the 0.10 level; * * correlaton is significant at
the 0.05 level (two-tailed); * * * correlation is significant at the 0.01 level
(two-tailed); ns indicates no significant corrlation; n 281, square root of AVEs
are reported in italic and on the diagonal; Y indicates dependent variable
whereas X indicates independent variable; the value of AVE for personality traits
constructs (extraversion, emotional stability, conscientiousness, agreeableness)
are not reported because they are formative indicators
Table II Regression results

Dependent variables (COB dimensions)
Congeniality Courtesy Anticipation Attentiveness Capability
b Sig. b Sig. b Sig. b Sig. b Sig.
R2 (%) 26.5 19.0 20.0 25.2 24.3
F 7.39 4.78 0.5.09 0.6.92 0.6.57
Independent variables
Main effects
Service climate 0.21 0.00 0.27 0.00 0.26 0.00 0.18 0.00 ns
Job satisfaction ns ns 0.15 0.01 0.19 0.00 0.16 0.00
Extraversion 0.14 0.01 ns nsnsns
Emotional stability 0.13 0.01 0.10 0.0.05 0.13 0.01 ns ns
Conscientiousness ns ns 0.10 0.06 0.24 0.00 0.26 0.00
Agreeablencss0.23 0.00 0.18 0.0.00 ns 0.10 0.05 0.15 0.01
Interaction effects
Climate *Extraversion ns nsns 0.09 0.06 ns
Climate *Emotional stability 20.13 0.02 ns nsnsns
Climate *Conscientiousness ns nsnsnsns
Climate *Agreeableness ns ns20.09 0.06 ns ns
Control variables
Hospital type ns nsnsnsns
Experience ns nsns 0.09 0.06 0.11 0.03
Education 20.11 0.02 ns ns 0.08 0.05 0.09 0.05
Notes: Experience was measured in years as a nurse; education measured as years
of secondary and university education; variables used in interactions were
mean centered; one tail test of significance used
106
H3 posited that job satisfaction is positively associated with
all dimensions of COB. The data in Table II only partially
supports this. Interestingly, job satisfaction is statistically
significantly associated with the three technical aspects
(anticipation (p 0:15, p , 0:01); attentiveness (p 0:19
p , 0:00); capability (p 0:16 p , 0:01) of COB, but not so
with the interpersonal aspects.
H4 addressed the impact of the interaction effects between
service climate and personality traits on COB. While there

might be theoretical support for this hypothesis, the data
cannot support this, with only three of the 20 associations in
Table II having statistically significant effects. Thus H4 is
rejected.
While not hypothesized, education and years of experience
exhibited small, but significant, effects on two of the technical
aspects of COB (attentiveness and capability).
Limitations
First, since this study was conducted in the healthcare
context, where there is high degree of interpersonal contact as
well as high emotional labor, care needs to be exercised in
generalizing the findings to other service settings with
differing service characteristics. Second, the use of selfreported
measures is criticized by some scholars for being
susceptible to a social desirability bias. However, Singh
(2000) based on several studies and meta-analyses found thai
self-rating measures are more likely to bias the mean values
(upward) but less likely to bias their correlations with other
constructs. It is therefore a reasonable approach for this study
because we aimed at investigating the correlations. Among a
set of independent and dependent variables. Moreover,
Churchill et al. (1985) have found that self-reported
measures have less restriction of range and less error than
several purportedly objective measures. Also, evidence is
accumulating that these biases are substantially reduced and
that the validity of self-reported performance is enhanced if
respondents are anonymous. In so doing, the motivation for
self-presentation is curtailed (Schneider et al., 1996). Finally,
in a series of studies conducted by Schneider and Bowen
(1995), it was found that employees self-rating of the service
quality they provided was strongly associated (correlation
coefficient of 0.73) with customers ratings of the same
service. That is, when employees report that they deliver highquality
service, customers report the same; when employees
report that they deliver poor-quality service, their customers
say so too.
Conclusion and discussion
Figure 1 illustrates graphically the results of the study (as per

Table II). Our results suggest that COB can be grouped into
two major categories; technical and interpersonal behavior.
Furthermore, as depicted in Figure 1, different personality
traits have differing impacts on each COB behavior.
Therefore, both recruitment and training policies are
important. In terms of personality, the most important trait
influencing technical behaviors is conscientiousness (high
standardized beta coefficients in Table II). Conscientious
employees are more likely to thoroughly perform work tasks,
to remain committed to work performance and take initiative
in solving problems (Barrick and Mount, 2003). Empirical
research has shown that conscientiousness has a relationship
with the reliability dimension of service quality (Lin et al.,
2001), service performance (Frei and McDaniel, 1998) and
role-prescribed behavior (Williams and Sanchez, 1998). In a
medical setting this is obviously an important trait to possess.
Agreeableness, on the other hand, influences both technical
and interpersonal behavior. Individuals high in agreeableness
are gentle, sympathetic, courteous and helpful (Kassin,
2003). Research has revealed that there is link between
agreeableness and empathy and assurance (Lin et al., 2001),
and customer orientation (Brown et al., 2002). Extraversion
and emotional stability only impact on interpersonal behavior.
The extroverts are sociable, friendly and cheerful, by their
very nature (Kassin, 2003), while the emotionally stable are
less likely to experience negative emotions such as anxiety,
fear, depression or irritability (Sulset al., 1998). Empirical
research has shown that responsiveness (Lin et al., 2001),
service performance (Hurley, 1998) and pro-social behavior
(Williams and Sanchez, 1998) are all related to extraversion.
As noted earlier, Berry and Bendapudis (2007) study of
patients at the Mayo Clinic highlighted the importance of
physicians and nurses bedside manner (i.e. interpersonal
behaviors) in patients evaluations of their overall hospital
experience. While the ability to enact high quality technical
behaviors is a given in a medical context, renewed emphasis
must be placed on employing staff that have the innate
personality traits (agreeableness, extraversion, emotional

stability) to relate to and empathize with people. These soft
people skills are often overlooked, but are critical in
emotionally charged, high-contact contexts such as medical
services.
Interestingly, as per Figure 1, job satisfaction influences
technical behavior. That is, when service employees are happy
about their jobs, they are willing to put in extra effort and go
the extra mile for their customer. This results in behavior
which demonstrates they are paying attention to the
customers needs, and are adjusting their service offering
and delivery accordingly. They are more willing, and more
inclined, to be attentive to customers requests and to perform
their nursing duties professionally. Interpersonal behavior
(congeniality, courtesy), however, seems linked to ones
intrinsic personality as well as to climate for service. Climate
for service influences both technical and interpersonal
behavior. A close examination of Table II reveals that
service climate has, overall, a greater positive impact on the
customer oriented behaviors (COB) of nurses than any other
variable in the study. Employees are more likely to deliver
excellent service when the organization provides them with
the resources, has an appropriate reward structure as well as
customer-centric policies, procedures and practices that
enhance their capability, and desire to deliver excellent
service.
The findings are especially relevant for managers
responsible for designing and implementing service delivery
systems in service industries characterized by intimate,
prolonged contact and emotionally charged service
environments (e.g. medical, legal, financial counseling,
psychological counseling or personal fitness services). Our
results permit a comparison of the impact of personality and
organizational variables (service climate, job satisfaction).
The results emphasize the important role of human resource
management in terms of personnel recruitment on the basis of
personality type. Basic personality traits are strong predictors
of nurses customer-oriented behavior. Apart from guiding
recruitment decisions, it also provides managers with

107
guidance on how to enhance customer-oriented behavior
among their service personnel. For example, improving the
service climate in a work unit (e.g. providing staff with the
latest tools and technology, having customer satisfaction
tracking and complaints management systems in place,
inspirational service leadership, and appropriate rewards
systems) can assist in achieving desirable staff behaviors.
In summary, for service employees to display customeroriented
behavior, the organization must:
. Recruit individuals with the personality traits that match
the demands of the job. The results also reinforce the
adage hire for attitude and train for skill.
. Develop a climate for service including resources,
practices and procedures that support employees and,
importantly, signal the importance of a customer-centric
culture.
. Motivate and retain the right employees through rewards
systems and by treating them the same way the
organization would like them to treat customers.
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110
Appendix
Table AI Summary of constructs and their measurement properties

Construct CSPaConstruct reliabilitybAVEc
Endogenous construct
Customer-oriented behavior congenialityd0.87 0.62
NCOB29: Happy and cheerful 0.87
NCOB27: Smiles a lot 0.78
NCOB30: Sincere facial expression 0.82
NCOB28: Enthusiastic 0.69
Customer-oriented behavior anticipationd0.83 0.51
NCOB19: Considers what patients have to say 0.61
NCOB18: Very understanding 0.81
NCOB17: Interested in patients needs 0.70
NCOB16: Anticipates patients needs 0.82
NCOB23: Acts in a personal way 0.61
Customer-oriented behavior courtesyd0.83 0.62
NCOB11: Very courteous 0.93
NCOB10: Respects patients 0.77
NCOB12: Talk with patients 0.65
Customer-oriented behavior attentivenessd0.87 0.70
NCOB6: Takes time to perform nursing services 0.72
NCOB7: Very helpful 0.92
NCOB8: Very attentive 0.87
NCOB9: Readily available when patients need me 0.7
Customer-oriented behavior capabilityd0.85 0.66
NCOB3: Very intelligent 0.70
NCOB2: Very capable 0.90

NCOB4: Behaves in a professional manner 0.76
Exogenous construct
Job satisfactiond0.75 0.50
JS1. This job is pleasant for me 0.73
JS3. This job is better than most jobs 0.69
JS5. Im contented with this job 0.89
Service climate: leadership practice 0.86 0.56
SVC28: Management constantly measuring service quality 0.71
SVC29: Management show care about service quality by giving of themselves 0.81
SVC30: Management provides resources not just lip services to enhance ability to
give service 0.83
SVC31: Management constantly measuring service quality 0.77
SVC32: Management is responsive to nurses request for help and guidance 0.64
Service climate: standard communication 0.79 0.57
SVC20: Every nurse understand all of the service standard 0.65
SVC21: We have developed chain of objectives linking every branch to support
corporate vision 0.84
SVC22: Service performance measures are communicated openly with all nurses
regardless of position
or function 0.77
Service climate: service recovery 0.84 0.64
SVC15: We have an excellent patient complaint handling system for service followup 0.72
SVC16: We have established problem-solving groups to enhance our ability to
resolve service
breakdowns 0.84
SVC17: We provide follow-up service calls to confirm tha our services are being
provided properly 0.85
Service climate: human resource practice 0.88 0.65
SVC34: This hospital noticeably recognizes excellent services 0.63
SVC35: In this hospital,nurse receives recognition and reward for the delivery of
superior work and
service 0.64
SVC36: Every nurse in this hospital receives personal skill, training that enhances
her ability to deliver
high quality service 0.89
(continued)

111
Paul G. Patterson can be contacted at: p.patterson@
unsw.edu.au
Executive summary and implications for

managers and executives
This summary has been provided to allow managers and executives

a rapid appreciation of the content of this article. Those with a
particular interest in the topic covered may then read the article in
tototo take advantage of the more comprehensive description of the
research undertaken and its results to get the full benefits of the
material present.
Sounds simple, but it needs to be said again and again, that
one of the best ways of keeping your customers happy is
keeping your front-line employees happy and providing them
with the facilities and equipment to do their jobs well. Sounds
simple but, like most things in life, its harder to achieve than
say. Employees, just like the customers, are individuals with
their own particular personalities. If you are a customer, who
would you prefer to deal with? A friendly, courteous person
who seemed happy in their work and eager to help, or an illtempered
sort who gives you the impression they would rather
be anywhere else than at work helping you?
Theres not a lot you can do about your customers
personality traits, but you can make efforts to hire pleasant
people who are likely to be happy in their jobs and eager to do
their best for your customers. You want them to be capable,
but also courteous and attentive and well-blessed with
communication skills. Especially so if your business involves
prolonged contact with customers in an emotionally-charged
environment for instance, medial, legal, financial or
psychological counselling, or personal fitness services.
Doctors and nurses are often graded by patients for their
so-called bedside manner. While physicians and medical
staff need the skills to enact high-quality technical behaviors,

they also need innate personality traits such as agreeableness,
extraversion and emotional stability in order to relate to and
emphasize with the patient. These soft people skills are
often overlooked, but are critical in emotionally-charged,
high-contact contexts such as medical services.
Additionally, improving the service climate in a work unit
(e.g. providing staff with the latest tools and technology,
having customer satisfaction tracking and complaints
management systems in place, inspirational service
leadership, and appropriate reward systems) can assist in
achieving desirable staff behaviors.
For service employees to display customer-oriented
behavior, the organization must:
Table AI
Construct CSPaConstruct reliabilitybAVEc
SVC37: During training session, we work through exercises to identify and improve
attitudes toward
patients 0.77
Service climate: service technology 0.89 0.73
SVC9: We enhance our service capabilities through the use of state of the art
technology 0.79
SVC10: We use high levels of technology to support the effort of women on the
frontline 0.91
SVC11: Technology is used to build and develop higher levels of service quality 0.86
Service climate: customer treatment 0.81 0.59
SVC1: Nurses care for patients as they would like to be cared for 0.84
SVC2: Nurses go the extra mile for patients 0.86
SVC3: We are noticeably more friendly and courteous than competitors 0.59
Service climate: service failure prevention 0.77 0.53
SVC12: We go out of our way to prevent patients problems 0.84
SVC13: We go out of our way to head off patient problems rather than reacting to
problems once they
occur 0.75
Service climate: participation 0.88 0.78
SVC7: Nurses in this hospital participates in changing or developing service
procedures 0.81
SVC8: Nurses in this hospital participates in planning and implementing service

systems 0.96
Overall service climated0.85 0.46
Leadership practice (Index score of SVC28-32) 0.76
Service standard communication (Index score of SVC20-22) 0.64
Service failure recovery (Index score of SVC15-17) 0.73
Human resource practice (Index score of SVC34-37) 0.77
Service technology (Index score of SVC9-11) 0.60
Customer treatment (Index score of SVC1-3) 0.63
Participation (Index score of SVC7-8) 0.62
Note: a Completely standardized parameter. Square multiple correlatins for each
measure can be obtained by squaring the completely standardized parameter
for the item (factor loadings); b Construct reliability computed as (Pstanardized
loading)2 4 {Pstandardized loading)2+P1j }; c Average variance extracted,
which is the proportion of variance in the construct that is not due to
measurement error (Fornell and Larcker, 1981); d Constructs employed in the
structural
model
112
. Recruit individuals with the personality traits that match
the demands of the job (hire for attitude and train for
skill).
. Develop a climate for service, including resources,
practices and procedures that support employees and,
importantly, signal the importance of a customer-centric
culture.
. Motivate and retain the right employees through rewards
systems and by treating them the same way the
organization would like them to treat customers.
In The impact of service climate and service provider
personality on employees customer-oriented behavior in a
high-contact setting PanisaMechinda and Paul G. Patterson
say that, in terms of personality, the most important trait
influencing technical behaviors is conscientiousness.
Conscientious employees are more likely to perform work
tasks, to remain committed to work performance and take

initiative in solving problems. Conscientiousness has a
relationship with the reliability dimension of service quality,
service performance and role-prescribed behavior.
In a medical setting the authors study is based on
healthcare in Thailand this is obviously an important trait
to possess. Agreeableness, on the other hand, influences both
technical and interpersonal behavior. Individuals high in
agreeableness are gentle, sympathetic, courteous and helpful.
There is a link between agreeableness and empathy and
assurance, and customer orientation. Extraversion and
emotional stability only impact on interpersonal behavior.
The extroverts are sociable, friendly and cheerful, by their
very nature, while the emotionally stable are less likely to
experience negative emotions such as anxiety, fear, depression
or irritability. Responsiveness, service performance, and prosocial
behavior are all related to extraversion.
Interestingly, job satisfaction influences technical behavior.
That is, when service employees are happy about their jobs,
they are willing to put in extra effort and go the extra mile for
their customer. This results in behavior which demonstrates
they are paying attention to customers needs, and are
adjusting their service offering and delivery accordingly. They
are more willing, and more inclined, to be attentive to
customers requests and to perform their duties professionally.
Interpersonal behavior (congeniality, courtesy), however,
seems linked to ones intrinsic personality as well as to climate
for service. Climate for service influences both technical and
interpersonal behavior. Service climate has, overall, a greater
positive impact on the customer oriented behaviors of nurses
than any other variable in the study. Employees are more
likely to deliver excellent service when the organization
provides them with the resources, has an appropriate reward
structure as well as customer-centric policies, procedures and
practices that enhance their capability, and desire to deliver
excellent service.
The results emphasize the important role of human
resource management in terms of personnel recruitment on
the basis of personality type. Basic personality traits are strong

predictors of nurses customer-oriented behavior.
(A precis of the article The impact of service climate and service
provider personality on employees customer-oriented behavior in a
high-contact setting. Supplied by Marketing Consultants for
Emerald.)
Examining Quality and Efficiency of the U.S. Healthcare System

Sameer Kumar1, Neha S. Ghildayal2 and Ronak N. Shah3
1, 3Opus College of Business
University of St. Thomas
1000 LaSalle Avenue
Minneapolis, MN 55403-2005
USA
Email: skumar@stthomas.edu
2School of Public Health
Division of Health Services Research, Policy and Administration
University of Minnesota
Minneapolis, MN 55455
USA
Biographical Sketches
Sameer Kumar is a Professor of Decision Sciences and Qwest Chair in Global Communications
and Technology Management at Opus College of Business, University of St. Thomas. Major
research interest include optimization concepts applied to design and operational management of
production and service systems where issues relating to various aspects of global supply chain
management, product and process innovation, and capital investment justification decisions are
considered.
Neha S. Ghildayal is currently pursuing Ph.D. in Health Services Research, Policy and
Administration in the School of Public Health, University of Minnesota, Minneapolis. Prior to
joining doctoral program, Neha graduated from Carlson School of Management, University of
Minnesota with a B.S. in Business Administration majoring in Finance and Risk Management
and Insurance.
Ronak Shah is pursuing an MBA at Opus College of Business and holds engineering position
with a start- up medical device company. He is a seasoned development engineer worked on a
numerous leading medical devices in cardiovascular and endovascular area and successfully
brought to the market. He worked for Fortune 500, midsize and start-up companies Boston
Scientific, Accellent Inc., Black and Decker and AclaraBioSciences in various engineering
capacities and has earned M.S. from the University of Massachusetts Lowell in Plastics
Engineering.
1
Examining Quality and Efficiency of the U.S. Healthcare System

Abstract
Purpose - The fundamental concern of this research study is to learn the quality and efficiency
of U.S. healthcare services. The impact of quality and efficiency is examined on various
stakeholders to achieve the best value for each dollar spent for healthcare. The study offers
insights on quality reformation efforts, contemporary healthcare policy and a forthcoming change
shaped by the Federal healthcare fiscal policy and recommends the improvement objective by
comparing the U.S. healthcare system with other developed nations.
Methodology The U.S. healthcare system is examined utilizing various data on recent trends
in: spending, budgetary implications, economic indicators i.e. GDP, inflation, wage and
population growth. Process maps, cause and effect diagrams and descriptive data statistics are
utilized to understand the various drivers that influence the rising healthcare cost. A proposed
cause and effect diagram is presented to offer potential solutions, for significant improvement in
U.S. healthcare.
Findings At present, the U.S. healthcare system is of vital interest to the nations economy
and
government policy (spending). The U.S. healthcare system is characterized as the worlds most
expensive yet least effective as compared to other nations. Growing healthcare costs have made
millions of citizens vulnerable. Major drivers of the healthcare costs are institutionalized medical
practices and reimbursement policies, technology induced costs and consumer behavior.
Practical Implications Reviewing many articles, congressional reports, internet websites
and
related material, a simplified process map of the U.S. healthcare system is presented. The
financial process map is also created to further understand the overall process that connects the
stakeholders in the healthcare system. Factors impacting healthcare are presented by a cause and
2
effect diagram to further simplify the complexities of healthcare. This tool can also be used as a
guide to improve efficiency by removing the waste from the system. Trend analyses are
presented that display the crucial relationship between economic growth and healthcare
spending.
Limitations The scope of the study is broad and intended to touch on information at the
macro
level. The U.S. is a very diverse country with geographical variation, races and genetic
construction, hereditary borne diseases, socioeconomic standards and varied income levels. One
can study further by implementing the advanced correlation and regression analysis to further
establish various trends between healthcare costs and social and economical factors.
Originality / Value - There are many articles and reports published on the U.S. healthcare
system. However, very few articles have explored, in a comprehensive manner, the links
between the economic indicators and measures of the healthcare system and how to reform this
system. As a result of the U.S. healthcare systems complex structure, process map and
causeeffect
diagrams are utilized to simplify, address and understand. This study linked top level
factors i.e. the societal, government policies, healthcare system comparison, potential
reformation solutions and the enormity of the recent trends by presenting serious issues
associated with the U.S. healthcare.
Keywords: PCP- primary care physicians, GDP- Gross domestic product, HIT- Healthcare
Information Technology, CRS Congressional research service, WHO-World Health
Organization, CBO-Congressional Budget Overview and OECD-Organization of Common
Economic Development.
Type of Paper General Review / Viewpoint
3
Introduction
The total expenditure of the U.S healthcare surpassed $2.26 trillion in 2007, as compared to
$714 billion and $253 billion in 1990 and 1980 respectively. U.S. healthcare spending was about
$ 7,439 per person and accounted for 16.3% of the nations Gross Domestic Product (GDP) in
2007 and will trend upward reaching 19.5% of GDP in 2017. As compared to other OECD
countries, U.S. healthcare spending per capita continuously leads by huge margins. In recent
years, the sociopolitical culture of the U.S. shifted from a welfare society to an ownership society
resulting in significant increases in employee sponsored healthcare premium by 87%.
Government assisted public healthcare insurance programs such as Medicare and Medicaid also
increased by 18.7% accounting for nearly 40% of the total national health spending. Despite its
top ranked emergency responsiveness, advanced medical care, new drugs and ultramodern
medical devices, the U.S. healthcare system ranked by the World Health Organization (WHO)
37th in overall performance and 72nd by overall level of health (among 191 member nations
included in the study) (World Health Organization, 2007). Although Americans benefit from the
investment cost in healthcare services, recent rapid cost growth coupled with an economic
slowdown and growing federal fiscal deficit, will influence the financial well being of the U.S.
healthcare system significantly in coming years.
Several questions have been researched through literature and answered in a simplified manner
to address the contemporary issues with the U.S. healthcare system. The questions researched
are:
(1) How do stakeholders influence quality in healthcare services?
(2) Do quality considerations lead to the overuse or underuse of services by various
4
healthcare system stakeholders?

(3) What factors impact the variation of services geographically?
(4) What factors contribute to the disparities in the quality service provided?
(5) What role does technology play in quality of healthcare?
(6) What tools or strategies can be used to promote increased quality in the healthcare
system?
(7) What is the prevalence of medical errors in the healthcare system and what is its
effect on costs?
(8) What lessons can be learned from the experience of healthcare systems of other
countries about the role of quality?
The quality and efficiency of the U.S. healthcare system is studied by utilizing various Operation
Management tools. The U.S. healthcare system, role of government and finance of the overall
healthcare system is studied via process maps. The contemporary issues of the healthcare system
are studied in order to address the research questions. Literature overview, analytical framework,
limitations, research findings, managerial implications and conclusions are presented in a
chronological order throughout the paper.
Literature Overview
Several papers, internet web-sites and congressional reports were reviewed to understand the
current state of the U.S. healthcare system and the present issues associated with it. Internet
websites were found to be useful in data collection and information for the proposed study. The
National healthcare expenditure report (2008) was used to analyze the past and projected data to
establish various trends associated with healthcare expenditure. Healthcare in United States
5
(2008) provided great insights on payment system, regulatory environment, role of government,
healthcare efficiencies and inequities and costs drivers associated with the healthcare system.
This report presented a very analytical and practical viewpoint of the present issues. The U.S.
Healthcare Spending In An International Context (Reinhardt, Hussey, Anderson, 2004) and The
Critical Condition: Healthcare in America (Colliver, 2005) shed light on soaring healthcare
costs and aligning it with the state of the fiscal and economical conditions. Inflation rate, GDP
growth rate, wage increase rate and many others indicated that the state of the U.S. healthcare is
very gloomy and constructive actions are required otherwise the system could become bankrupt.
Many articles discussed the various costs drivers. The U.S. Healthcare System: Just Best in the
World or Just the Most Expensive? (Hellander and Bailey, 2001) and Nothing Short of a
Complete Overhaul will cure Americas Healthcare System ( 2007) argued that the United
States has the most expensive healthcare system in the world. It is the only developed country,
besides South Africa, that does not provide healthcare for all its citizens. The article provided a
glimpse of the U.S. standing among other countries in terms of percent GDP spend, infant
mortality rate, disability adjusted life expectancy, fairness of financial contribution,
responsiveness of health system and overall system performance. It is understood from the
article that people without insurance live sicker and die younger. This also causes expense to
taxpayers and causes cost shifting considerations for hospital and other emergency care.
Understanding Healthcare Cost Drivers (Moroney, 2003) explained a vast array of a complex
healthcare cost problem and yet there is no common consensus to resolve this problem. The
cursory review of this article also concludes the limitless horizon of the problem and other
significant factors contributing to rising health care costs that should be addressed include: aging
6
population, system delivery capacity, the rising cost and increasing use of medical devices and
hospital operations and the overall system of health care delivery and the impact of prevention
on costs.
To define quality of healthcare, WHO provides a brief internet guideline. As per BMJ published
WHO guidelines, WHO recommends the emphasis on primary healthcare and shift the focus
from acute to chronic healthcare in all developed countries. Numerous articles touch on
healthcare disparities, geographic variations and overall impact on healthcare quality. The social
case for reducing health disparities should be treated just as the business case (Lurie et al, 2008).
Few commercial web-sites were explored to research healthcare system of various developed
nations and OECD countries. Advantages and disadvantages of single payer systems of U.K.,
Canada and Germany compared with that of U.S. The debatable issue over healthcare is less a
pure macroeconomic issue than an exercise in the political economy of sharing (Reinhardt,
Hussey and Anderson, 2004, Peterson and Burton, 2007).
Analytical Framework
This section is divided into the following three subsections Descriptive Data Analysis, Process
Map Analysis, and Cause and Effect Diagrams.
Descriptive Data Analysis
In this section, various trends are presented that cover the socioeconomic standpoint and how it
directly impacts the U.S. healthcare system. Several graphs are presented to analyze the recent
and projected trends of the U.S. healthcare. The relationship between economic indicators and
healthcare spending are also trended. This relationship helps to determine the current fiscal
health and its sustainability of the system.
7
Figure 1 shows per capita U.S. healthcare expenditure from 2002 to 2017; whereas 2008-2017
expenditure is projected. In 2007, the U.S. spent $ 7,439 per person on average. It is projected
that in 2017, the per capita U.S. healthcare spending will rise to $13,101, a higher amount than
any other nation in the world. It can be observed from the graph that the healthcare expense is
growing at a steady rate between 6-7% and increases by nearly 33% every five years. If the
spending trend continues, then it will be almost doubled in the next 10 years which poses serious
threats to the overall economy and welfare of the United States.
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
14000
12000
10000
8000
6000
4000
2000
0
Year
Healthcare Expense per capita (000')
13101
12369
11684
11043
10439
9862
9322
8816
8329
7868
7439
7026
6649
6301
5952
5560
Figure 1. Per Capita U.S. Healthcare Expenditure 2002-2017 ($000)

(Source: Center for Medicare and Medicaid Services, 2008)
Figure 2 shows the U.S. healthcare spending as a percent of GDP. In 2007, the U.S. spent 16.3%
of its GDP on healthcare. The current growth of healthcare spending is even higher than the GDP
8
growth rate. If the trend continues then it is expected that the U.S. will spend almost one fifth of
its GDP on healthcare. In other words, of every $5 spent, $1 is contributed to healthcare.
Despite this relatively high level of spending, the U.S. does not appear to provide substantially
greater health resources to its citizens, or achieve substantially better health benchmarks,
compared to other developed countries. This growing gap between health spending in the U.S.
and that of other developed countries should encourage policymakers to look more closely at
what people in the U.S. are getting for their far higher and faster growing spending on
healthcare.
Figure 2. U.S Healthcare Spending Trend in percent of GDP from year 2002-2017
(Source: National Health Expenditure Projection 2007-2017)
Figure 3 shows that the U.S. GDP spending remains ranked highest among the OECD countries.
In 2006, U.S. spent 15.3% of its GDP in healthcare. Switzerland ranked second, spending 11.6%
of its GDP in healthcare. All other OECD countries have a less complex healthcare structure and
delivery system. However, rising cost drivers, diverse population and geographical related
disparities, government regulations, emphasis on quality delivery and innovative drugs, and
9
device culture set the economic model of the U.S. healthcare to contribute the higher percent
GDP.
Figure 3. Healthcare Spending Among Several Top OECD Nations Based as Percent of GDP in
2006 (Source: Peterson and Burton, 2007)
As described in Figure 4, the U.S. ranked highest among all the OECD countries in the world
spending $6,401 per capita on healthcare followed by Switzerland, France, Germany and
Canada. The healthcare spending growth rate for the U.S. is assumed to remain constant at nearly
6% which is almost one third more than Switzerlands healthcare spending growth rate. This is a
massive amount and the rising trend in healthcare expenditure will be expected to create a
serious deficit for government budget and spending.
10
Figure 4. U.S. Dollar Per Capita Healthcare Spending Among Top Several OECD Nations in
2006 (Source: Peterson and Burton, 2007)
As shown in the Figure 5, the healthcare cost drivers have increased significantly in the past few
years. Among all the healthcare cost drivers, personal healthcare, health service and supplies
tend to increase or remain at a steady growth rate of 6-8%. Physician and clinical services tend to
increase by 5.7 to 8.1%. All the cost drivers are expected to rise more than the GDP growth rate
and inflation growth rate also contributing to push the growth in the national healthcare cost by
6.3% on average. Medical technology is expected to rise by 20% with the highest growth rate
among all the other cost drivers.
11
Healthcare Cost Driver Trend (2004-2008*)
0
500
1000
1500
2000
2500
2004 2005 2006 2007 2008
Cost Drivers Expense ($ Billions)
Health Service & Supplies Expenditure Personal Healthcare Expenditure
Hospital Care Expenditure Physician and Clinical Services
Prescription Drug Expenditure Durable Medical Equipment Expenditure
Nursing Home Care Expenditure Private Health Insurance
Total U.S. Healthcare Expense U.S. Population
2008* is a projected trend.
Figure 5. Various Cost Driver Trends in Recent Years (2004-2008*)

(Source: National Health Expenditure Projection 2007-2017)
As shown in Figure 6, healthcare premiums have continuously grown faster than inflation or
workers earning in recent years. Between 2002 and 2004, the cumulative growth of health
insurance was 78% compared to the cumulative inflation of 17% and cumulative wage growth of
19%. Although the share of the total premium that workers pay has remained fairly stable (28%
for family coverage/16% for single) over the recent past, the rapid growth in overall premium
levels mean that the workers are paying much higher amounts than they did several years ago.
The average cost of the healthcare cost paid out-of-pocket increased by 34% in 2004. One
percent of people with the health spending account in 2004 paid 6% of their out-of-pocket cost
(Trends in Healthcare Cost and Spending, 2007).
12
Figure 6. Relationship between Insurance Premium, Inflation and Wage Growth (19882007) (Source: Trends in Healthcare Cost and Spending, 2007).
Data Tables 1 to 5 associated with Figures 1 to 6 are included in the Appendix.
Process Map Analysis
In this section the U.S. healthcare system will be analyzed using the process map analysis. Figure
7 represents the financial service blueprint of the U.S. healthcare system. The U.S has adopted a
hybrid healthcare service approach provided by private sector and the federal government.
Among all the OECD countries, besides South Africa, the U.S. is the only country that does not
have a universal healthcare delivery system.
13
Figure 7. The Financial Process Map of the U.S. Healthcare System

Various elements of Figure 7 are described as follows.
Individuals and businesses
Both individuals and businesses pay income taxes to the government. In addition, there is a
payroll tax on employers and employees to finance Medicare. Employers pay all or most of the
premium for employer-based insurance for employees, and employees pay the remainder. On the
individual market, individuals pay for all premiums out of pocket. Employer-based insurance
premiums and individual insurance premiums are collected by private insurers. There is another
component, called direct or out-of-pocket payments, is a direct payment to a provider for health
care services (e.g. a co-payment).
14
Government
The government uses money generated from taxes to reimburse providers who care for patients
enrolled in Medicare, Medicaid, S-CHIP and the VA programs. Public employees health
insurance premiums are paid to private insurers by the government from tax dollars. There is a
tax subsidy of employer-based insurance that represents a major cost to the government
(approximately of $100 billion). Employees receive health insurance benefits as tax-free

compensation, and employers are able to deduct health insurance benefits as a cost of doing
business. (Since employers are only taxed on profits, defined as any income above the cost of
doing business, being able to deduct health insurance benefits as a cost of doing business is a tax
subsidy for employers).
Private insurers
Private insurers accept premiums from individuals, businesses, and the government. In turn, they
reimburse providers for taking care of patients with private insurance.
Health service providers
Providers (doctors, allied health professionals, hospitals, and other health care facilities) provide
care for individuals. They are reimbursed for their services by private insurers and the
government.
Figure 8, illustrates the employer-based or a private healthcare delivery system. Employers
collaborated with the private insurance companies and provide the healthcare benefit to their
employees. Participating employees bear a deduction from their paycheck for the stipulated
healthcare plans and services. Employers also bear a percent of their share for the employee
insurance.
15
When healthcare service is requested by an employee, a co-pay is paid by the employee to the
service provider and any amount exceeding the co-pay is the burden of the insurance provider.
However, any disputed amount that is not subjected to coverage in the selected healthcare
insurance plan is also paid by employee.
Figure 8. Process Map of Employer Based Healthcare Delivery System
As described in Figure 9, the Government provides insurance to all its Federal employees and
also individuals eligible for the Government assisted Medicare and Medicaid plans. Both, the
Medicare and Medicaid veterans have to register with the Government for their eligibility in
order to receive healthcare benefits. Medicaid assists lower income citizens and seniors whereas
16
Medicaid is offered to war veterans and disabled citizens. The Federal government bears the cost
of the healthcare benefits.
According to the Institute of Sciences and the National Academy of Sciences, the U.S. is the
only wealthy and industrialized nation that does not have universal healthcare. In the United
States, around 84.7% of citizens have some form of health insurance; either through their
employer (59.3%), purchased individually (8.9%), or provided by government programs
(27.8%); there is some overlap in these figures. Certain publicly funded programs help to provide
for the elderly, disabled, children, veterans, and the poor, and federal law mandates public access
to emergency services regardless of ability to pay. U.S. government programs accounted for over
45% of health care expenditures, making the U.S. government the largest insurer in the nation.
Americans without health insurance coverage at some time during 2007 totaled about 15.3% of
the population, or 45.7 million people. Health insurance costs are rising faster than wages or
inflation, and "medical causes" were cited by about half of those filing bankruptcy in the United
States in 2001 (Healthcare in the United States, 2008).
17
Figure 9. Process Map of the Government Sponsored Healthcare Delivery System

Cause and Effect Diagrams
The factors influencing healthcare costs will be presented and explained by the fishbone
diagram tool. Healthcare costs enhanced by way of various factors will be presented and
learned. The proposed solution can also be explained via Cause-Effect diagram that can help
create a better healthcare system. The proposed Cause-Effect diagram will address the
demographics, flawed healthcare management, medical technology, administrative costs,
government regulations, healthcare facilities and supply side of economics will be discussed that
impact the quality of U.S. healthcare system.
The U.S. Healthcare costs represent a vast array of complex economic factors. Cost drivers can
fit into three categories (i) price of the goods and services, (ii) quantity of goods & services
18
being delivered and, (iii) healthcare delivery system itself. The cause and effect diagram in
Figure 4 displays the categorical cost drivers and sub-drivers of cost drivers that affect the
overall healthcare cost growth and total dollar spent. The major U.S. healthcare cost drivers
distributed in six different categories are (1) Provider costs, (2) Hospital costs, (3) Technology
costs, (4) Provider costs, (5) Insurance costs, (6) Consumer behavior and (6) Flawed
management.
Figure 10. Various Sub-drivers of the Major Costs Drivers of the U.S. Healthcare Costs
19
Various elements (or sub-drivers) that impact the cost drivers shown in Figure 10 are described
as follows.
Provider Costs
In 2006, physician service consumed 21% of total healthcare expenditure. Annual average
growth rate of total provider costs was 6.5%. Cost drivers for provider costs can be distributed in
three different categories physician compensation, malpractice premiums and supply and
demand characteristics. Physician compensation in 2007 increased by 5.8%, which is more than
the rate of inflation, whereas overall increase in healthcare cost were 6.6%. Malpractice
premiums are also a huge cost driver. As a result of the judicial systems threat of litigation,
healthcare providers are forced to practice defensive medicine. In 2007, malpractice premiums
increased by 11%. Research suggests that the more providers in a given area results in utilization
of more medical technologies and services. Researchers have found that for each 1% growth in
GDP per capita results in a 0.75 increase in physicians per capita. However, the last 50 years in
U.S. there are more super-specialist and sub-specialists have been produced than the primary
care physicians. Physicians are also considered as gatekeepers that controls the demand side of
the healthcare economy. Pushing for better and earlier diagnostics fosters greater use of the
physician services.
Hospital Costs
Hospital costs will continue to rise by 6.6%-6.7% each year from 2007 to 2017. Such cost rise in
U.S. is a combination of price and quantity as a result of increasing inpatient, outpatient and
emergency services. In 2006, 37%, 38.5% and 14% of hospital costs were nearly absorbed by
private insurance companies, Medicare and Medicaid respectively (American Medical
Association, 2006). Other hospital cost drivers are (1) Wage pressure and physician charge, (2)
20
the 3Cs (consolidation, competition and construction), (3) Technology acquisition and use, (4)
Government payment levels and (5) Hospital support system. Nursing shortages spurred
significant increases in wages forced hospital administrators to offer higher salaries, signing
bonuses, more flex time and also results in hiring more temporary staff. Hospital technology
usage also increased in terms of more modern technologies and applications i.e. MRI,
catheterization and other diagnostic services. Hospital costs also increased due to competition to
utilize more sophisticated equipment and capital intensive services. Consolidations also
occurred to gain efficiency and reduce excess capacity and transactional cost, but, does not
always save money. Facility expansion also required in the area of cardiology, neurology and
orthopedic as a result of an increase in an aging population.
Technology and Pharmaceuticals are major drivers of healthcare cost
In the past five years medical technology spending comprised about 20% of the growth in
healthcare costs and now exceeds $200 billion annually. There is substantial evidence that
overutilization and misuse of technology leads to spending that exceeds its value for patients.
Diagnostic imaging technology increased nearly to a $100 billion business (Beever, Bums and
Karbe, 2004). According to Pharmaceutical Technology Sourcing and Management, in 2006,
$637 billion global pharmaceutical market was dominated by the United States. Though, U.S.
pharmaceutical growth is expected to grow by only 1-2% in coming years, the emerging market
growth will continue to push the medicine costs upward due to R&D expenditure on the new
drugs in pipeline. Direct-to-consumer advertising also increased due to FDA approved
guidelines for drug ads on radio that do not require warning labels. In 2002, pharmaceutical
industry spent almost $2.5 billion overall advertising directly to consumers.
21
Consumer behavior impact on price and delivery

The public has been increasingly demanding specialty care and that demand is a main reason
why managed care failed. Patient demand for the latest technology along with more advanced
diagnostics, more costly drugs, new and higher cost vaccine and regulatory environment
mandates are some of the real causes of rising medical costs.
Insurance costs
In recent years, the U.S. shifted into an ownership society away from a welfare society.
Insurance premium cost increased by 42% in the last five years from 2002-2007 (National Health
Expenditure Report, 2008). Premiums for employer-based health insurance rose by 6.1% in
2007. Administrative cost also contributes to higher premiums. The U.S. spent roughly 31%
administrative costs or $1000 per person in 2007 which is significantly more than double as
compared to Canadas costs.
Figure 11 describes the potential reformation drivers proposed by authors that may contribute to
a better U.S. healthcare system. They are grouped into six different categories: (1) Universal
coverage, (2) Prudent purchase promotion, (3) Healthcare-IT promotion, (4) U.S. Policy to
support for primary care, (5) Aligned payment system, (6) Increased use of medical technology
and pharmaceutical research.
22
Figure 11. Proposed Cause and Effect Diagram with Potential to Contribute to
Better U.S. Healthcare System
Various elements (or sub-drivers) that impact the potential reformation drivers are shown in
Figure 11 are described as follows.
Universal coverage It significantly reduces the administrative costs, expedites the
deliverability and by providing legal guarantees to the coverage, government can deliver more
incentives instead of relying on private sector.
23
Prudent purchase promotion Prudent purchase allow consumers to take ownership of

their
own healthcare management. Consumers can make own decisions and select a plan that allows
them to pay based on their income level instead of pursuing a forced plan that requires them to
pay a higher amount of healthcare expenses.
Healthcare IT Promotion In recent years there has been a huge push to reduce healthcare
costs, especially administrative costs. Many OECD countries have adopted the electronic data
enterprise system for various purposes such as billing, record tracking, insurance claim
processing etc. Utilizing healthcare IT administrative costs can be reduced significantly, which
also increase customer satisfaction and system efficiency.
U.S. Policy for PCP support - There are over 100 million citizens in the U.S. suffering from
chronic illness. WHO has recommended shifting healthcare focus from acute to chronic
healthcare. U.S. has produced more specialists than PCPs. The Federal Government can change
policies and increase the training of more PCPs to boost the care of chronic illness and also
reduce many costs implication associated with chronic illness.
Aligned payment system Presently, the U.S. healthcare payment system is a scattered and
non
aligned system. The payment methodology is not based on performance or achieving a service
objective, but rather it is based on the volume that is requested against the healthcare service
delivery. Geographic variation exists in the payment system and sometimes reporting of the
payment creates dysfunctionality. This can be avoided by creating an aligned payment system. It
will also boost incentives for quality improvement.
24
Reverting to Research Questions

Questions posed in the beginning of this paper are addressed next.
How does quality impact the use of healthcare services for consumers, providers
and other
stakeholders?
According to WHO guidelines, the quality of the U.S. healthcare system is defined based upon
good health measures, responsiveness and fairness in financing. Good health is making the
health status of an entire population as good as possible over the whole life cycle.
Responsiveness is characterized as a response to peoples expectation of respectful treatment and
client orientation by health providers. Fairness in financing is ensuring financial protection for
everyone with cost distribution according to ones ability to pay.
Rising medical technology cost, defensive medicine practice enhanced diagnostic costs;
prescription drug cost caused the U.S. consumer to face the ordeal of paying a higher insurance
premium, out-of-pocket and prescription drug expense in recent years. There are 42 million
people in the U.S. without insurance and every year more than one million file for bankruptcy
because of an inability to cover medical costs. Consumer-driven health plans offer more
transparency, encourage consumers to take ownership of their own healthcare and become more
prudent with healthcare money (U.S. Healthcare Background and Brief, 2008). As consumers
benefiting from the tax favored Health Reimbursement Arrangement (HRA) accounts contract,
the healthcare service providers have to cover the portion of the healthcare costs increase by
pushing low income earners to pay more for the services rendered. Administrative costs have
increased as the overall healthcare model shift from a non-profit to a profit bearing base.
25
Does quality consideration lead to the overuse of services by various healthcare

system
stakeholders?
Quality considerations will lead to the overuse of services by various healthcare system
stakeholders. WHO calls for the countries to shift from acute to chronic care because increased
longevity, urbanization and unhealthy lifestyles require reacting to prevalent chronic conditions
(WHO calls for countries to shift from acute to chronic care, 2008). Research suggested that over
100 million U.S. citizens are suffering from at least one or more chronic conditions that costs
more than $679 billion in healthcare and $233 billion in lost productivity in 2000. Overuse of the
services can be expected in terms of diagnostic tests, preventive medical treatments, radiological
imaging i.e. MRI and PET scan, frequent visits to PCPs, recommendations of sophisticated
medical devices, minimally invasive surgery procedures and modern drugs to prevent and cure
such disease conditions.
What factors impact the variation of services geographically?
There are several factors that can contribute to variation of services geographically. The main
contributors are: Prices paid for medical services, health and illness status of residents of a given
region, regional preferences about the use of health care services and the determinants of those
preferences, such as income (Geographic Variation in Health Care Spending, 2008).
Demographic factors such as, race, gender and age can have an impact on the service level.
However, only 5% of variation can be explained by the demographics. Differences among
regions in the prices of medical services and in the populations health status explain some of the
observed geographic variation in Medicare spending. The amount of variation explained by those
factors is most likely less than half of total variation, as in some areas the physician services,
26
hospital supplies differ in cost from those in others. Variation in health status can also be
explained by education attainment, income level and dual policy holdership.
What factors contribute to the disparities in the quality of services provided?
The term health disparities is broadly defined as observed clinically and statistically
significant differences in health outcomes or healthcare use between socially distinct vulnerable
and less vulnerable populations that are not explained by the effects of selection bias (Kilbourne
et al., 2006, p. 12). Health disparities are apparent in the data on health outcomes, socioeconomic
status, and access to health/insurance and health care provider selection effects (Kilbourne et al.,
2006). Societal factors such as, income level, insurance status, access to healthcare,
culturalcommunication
and language barriers and partnership in decision making are the major
contributors to the healthcare service disparities. Ethnic factors also contribute to the healthcare
disparities that are influenced by the socioeconomic factors (Kilbourne et al., 2006).
What role does technology play in the quality of healthcare?
Healthcare costs are increasing at an annual rate of 7% per year. If sustained, this will bankrupt
the Medicare program in 9 years and also increase the nations overall healthcare bill to $4
trillion in 10 years. New or increased use of medical technology contributes 4050% to annual
cost increases, and controlling this technology is the most important factor in reducing them. The
average age of the population in the U.S., Japan and Europe continues to increase. By the middle
of this century, the worldwide proportion of people under age 15 will decrease to approximately
20 percent. This demographic change creates enormous pressure on the ability to finance the
U.S. healthcare system. Considerable potential for improvement can be foreseen through the use
of minimally-invasive technologies, for example in surgery, cardiology, stomach or colon
endoscopy. In medicine, minimally-invasive technologies include diagnostic and therapeutic
27
measures that lead to the least possible surgical strain for the patient. These technologies allow
for a more gentle treatment of the patient, as well as, a reduction in pain. The use of
minimallyinvasive
technologies leads to quicker recovery times and to considerably shorter hospitalization
(Biotechnology and Life Sciences in Baden-Wrttemberg, 2009).

What tools or strategies can be used to promote the increased quality of the
healthcare
system?
Many experts agree, the real problem with healthcare is not a lack of money, technology,
information or even people, but the lack of an integrated system connecting these resources, that
deliver a more cost effective care. There are several tools and strategies to promote increased
quality.
Overcoming cultural barriers: Established procedures in the healthcare system can be
improved by cost reduction efforts. Systems such as electronic medical records (EMR) can help
physicians and clinicians to communicate.
Reducing barriers to integrate health system development: Unreasonable pricing
practices
can be reduced and the quality of healthcare can be increased by utilizing EMR in a newly
created, large, integrated, multi-specialty physician network.
Enhancing healthcare performance measurements: Removing the resistance of
hospitals and
physicians to expand price and quality transparency by creating a central nationwide system to
record and access the performance measures.
Creating financial incentives for healthcare quality and value: Government and
private
sector can promote such programs like P4P pay for performance reimbursement. This will
significantly increase the quality of healthcare, the extent of financial incentives, and
performance measures.
28
What is the prevalence of medical errors in the healthcare system and its effect
on costs?
There are four types of medical errors that result in medical inefficiency of a healthcare system.
Diagnostic errors: Error or delay in diagnostic, failure to employ indicated tests, use of
outmoded test therapy, or failure to act on results of monitoring or testing.
Treatment errors: Error in performance of an operation, procedure or test in administrating
the
treatment, error in dose or method of using a drug, avoidable delay in treatment or in responding
to an abnormal test, inappropriate care.
Preventive: Failure to provide prophylactic treatment, inadequate monitoring or follow-up
treatment.
Other: Failure of communication, equipment failure, other system failure. The total national
medical cost of medical errors was $37.4 billion annually
In 1999, the Institute of Medicine released a report entitled To Err is Human that found
medical errors to be the eighth leading cause of death in the United States, with as many as
98,000 people dying each year as a result of medical errors. Studies have shown the
inconsistency of the medical liability system in determining negligence and compensating
patients, and doctors struggle to pay soaring medical liability premiums. The report indicated
that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors.
The Institute of Medicine report estimates that medical errors cost the nation approximately
$37.6 billion each year; about $17 billion of those costs are associated with preventable errors.
About half of the expenditures for preventable medical errors are for direct health care costs
(Migdail, 2000).
29
What lessons can be learned from the experience of healthcare systems of other
countries
about the role of quality?
The U.S. can learn by studying what works well in other countries and by applying the best
practices to the U.S. in terms of distinctive political systems, values and culture. However, no
single system studied is perfect and each has trade-offs. In general, single payer systems have
lower administrative costs, high quality, and satisfaction. However, cost controls may create
shortages and delays. On the other hand, pluralistic systems can be designed to achieve universal
coverage with individual freedom to purchase additional services, but are less equitable and have
higher administrative costs.
Primary care is the foundation of high performing delivery systems: In France,
Germany and
U.K, societal investment in medical education has achieved a well trained workforce with the
right proportion of primary care physicians and specialists and is large enough to assure access.
Investment in primary and preventive care can result in better health outcomes, can result in
reduced costs, and help assure an adequate supply of primary care physicians. Federal
government should intervene to avert the impending catastrophic shortage of primary care
physicians. The U.S. should set specific targets for producing generalists and specialists to boost
the level of healthcare available to masses.
All high performing systems have universal coverage: The OECD countries have
adopted the
universal coverage system either by a single payer (i.e. Governments of U.K, Canada, Japan) or
by a pluralistic - mixer of both private and public system (in Australia, France, Germany,
Switzerland). Guarantee by law that all people within the United States have equitable access to
appropriate health care without unreasonable financial barriers. Both systems have tradeoffs that
the public will need to weigh in making a choice. Fiscal budgets and price controls can restrain
30
costs but can have negative consequences and do not improve efficiency unless the budget is
reasonable and the target region is small enough to motivate individual providers. Price controls
can restrain costs, but may lead to cost- delays for elective procedures, cost shifting and creation
of a parallel private sector.
U.S. should align payments to physicians with quality and care coordination: In
the United
States there is need for a policy to provide incentives for physicians to achieve evidence-based
performance standards. U.S. needs to revise existing volume based payment systems used by
Medicare and most private insurers to create care coordination payments for primary care
physicians working with health care teams to manage care (Patient-Centered Medical Home).
High performing systems invest in Healthcare IT, have uniform billing, and lower
administrative costs: Germany, U.K., Canada, Taiwan and many other countries have
adopted
a uniform billing and electronic processing of claims which improves efficiency and reduces
administrative expenses. An inter-decision operable health information infrastructure can enable
physicians to obtain instantaneous information at the point of medical decision-making and
enhance electronic communications among health professionals. The U.S. should reduce the
costs of health care administration and invest in HIT infrastructure to assist physicians in
delivering evidence based healthcare. HIT will also help create uniform billing and credentialing
systems across all payers.
Findings
The analysis provides a macro model of the current U.S. healthcare system and identifies major
drivers of the countrys escalating healthcare costs. Some of the identified cost drivers include
healthcare service providers costs, hospital costs, consumer behavior, new technologies, health
insurance costs, and flawed management (e.g., medical errors, recording errors). Increasing
healthcare costs in the U.S. have made millions of citizens financially vulnerable, resulting in
31
personal bankruptcies, a lack of healthcare delivery access, and an overall lack of consumer
confidence in the U.S. healthcare system. A number of solutions to improve the current system
are then described, including universal health coverage, prudent health insurance plan purchase
option for consumers, healthcare-IT promotion (such as, Electronic Medical Records), federal
government policy to support primary care as a foundation, aligned payment systems and the
continued promotion of growth in medical technology and pharmaceutical research.
Limitations of the Study
The U.S. healthcare system is very diverse and complex as compared to other nations. The
quality and efficiency measures are also very diverse to achieve a universal healthcare policy.
The entire healthcare model is institutionalized around the corporate culture such that there are
many complex areas required to analyze. The healthcare reform proposals include restructuring
the private health insurance market, employer "pay or play" requirements, premium subsidies to
help individuals purchase health insurance, increased use of health information technology,
research and incentives to improve medical decision-making, reduced high risk behavioral
factors, reforming the payment of providers to encourage efficiency, limiting the federal tax
exemption for health insurance premiums, and reforming several market changes such as
resetting the benchmark rates for government sponsored plans and allowing the Federal agencies
to negotiate drug prices.
A fundamental problem in evaluating reform proposals is the difficulty in estimating their cost
and potential impact. Proposals often differ in many important details, therefore, it is difficult to
provide meaningful side-by-side cost comparisons. The empirical data and theory underlying
cost
estimates in this area are limited and subject to debate, increasing the variation between
estimates
32
and limiting their accuracy. Any healthcare reform solution that potentially impacts the
healthcare
model of the U.S. needs to be aligned with the new healthcare practice. This subject is beyond
the
scope of this study, yet needs to be addressed and studied in subsequent research.
Managerial Implications
In order to curb rapidly rising U.S. healthcare costs, decision makers in the U.S. government,
insurance companies, and hospitals should be proactive in implementing policies which could be
effective in removing inefficiencies from the U.S. healthcare delivery system. For instance,
decision makers should insist on using acute care to prevent future chronic care, and the
physician
community should be given incentives to practice preventative medicine to avoid later

consequences. Also, healthcare decision makers should promote the pay for performance
model in order to support a culture that reduces defensive medical practices and litigations. To
further reduce hospital costs, hospital management should take actions to increase staff
efficiency
and reduce hospital contributed medical errors. In addition, hospital management should
increasingly utilize technologies such as Teleradiography in order to reduce diagnostic treatment
costs, and central IT systems to enhance record keeping and billing practices. Lastly,
management in private and government organizations should promote healthy lifestyles among
U.S. workers. In the past few years, U.S. society has increasingly developed into an ownership
society instead of a welfare society, and consumers should continue to make responsible lifestyle
choices and educated healthcare decisions.
Conclusions
Healthcare expenses are one of the largest portions of annual consumer spending in the U.S. The
U.S. GDP is growing at a rate of 2%, whereas the healthcare spending in the U.S. is increasing
much faster than the GDP growth (Healthcare in the United States, 2008). Therefore, close
scrutiny of the U.S. healthcare delivery system efficiency and effectiveness will be prudent. In
our
33
analysis, the state of U.S. healthcare delivery system is examined by utilizing various operational
management tools such as financial process maps and cause and effect diagrams. In the cause
and
effect diagrams, U.S. healthcare cost drivers and the various elemental causes of the cost drivers
are identified to explain the major sources contributing to U.S. healthcare system expenditures.
After pinpointing the major cost drivers, we determined that the focus of decision and policy
makers should be on various important measures of U.S. healthcare system performance, such as
treatment cost, access to healthcare, health and well being, responsiveness, fairness in financing,
and consumer satisfaction (Hellander and Bailey, 2001). There are several steps that can be taken
to reform the U.S. healthcare system by reducing the costs and increasing the quality and
efficiency. Computerized medical records, active promotion of primary care physician services,
pay for performance paradigm shift, universal healthcare coverage and many other solutions can
be applied to reform the U.S. healthcare system. The U.S. government policy makers, corporate
strategists and public welfare committee representatives should work jointly to revitalize the U.S.
healthcare system (Hellander and Bailey, 2008).
This study does not extensively examine the influence of the healthcare systems of other OECD
countries and their impact on the social and cultural factors on the U.S. Since the U.S. is such a
diverse country in terms of race, geographic variation, genetic implications on hereditary
diseases,
taxation differences in the government system towards healthcare spending and many others
the
lack of full scale comparison is a limiting factor of this study. Other tools can be used to study
the
cost drivers, such as, regression analysis to incorporate unemployment rate, lifestyles in various
34
age groups and economic standings, and so forth to further understand the effect of cost drivers
on
U.S. healthcare system efficiency and effectiveness.
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36
Appendix
Table 1. U.S. Healthcare Expenditure From 2002-2017* (2008-2017* projected)
Year
National Healthcare
Expenditure ($Billions)
Healthcare Expense
per capita ($)
U.S. Expense as
% GDP
2002 1603.4 5560 15.3
2003 1732.4 5952 15.8
2004 1852.3 6301 15.9
2005 1973.3 6649 15.9
2006 2105.5 7026 16
2007 2245.6 7439 16.3
2008 2394.3 7868 16.6
2009 2555.1 8329 16.9
2010 2725.8 8816 17.1
2011 2905.1 9322 17.4
2012 3097.8 9862 17.7
2013 3305 10439 18
2014 3523.6 11043 18.4
2015 3757 11684 18.8
2016 4007.8 12369 19.1
2017 4277.1 13101 19.6
Table 2. Healthcare Expenditure of Various OECD Countries in 2007

OCED
2007 Healthcare Expense
as % GDP Healthcare Expense
U.S. 15.3 $6,401.00
Switzerland 11.6 $4,177.00
France 11.1 $3,374.00
Germany 10.7 $3,287.00
Canada 9.8 $3,326.00
37
U.K. 8.3 $2,724.00
Spain 8.2 $2,255.00
Japan 8 $2,358.00
Table 3. Percent Growth of Various Economic Indicators (1988-2007)

Year Inflation Earnings growth Premium Growth
1988 3.9 3.1 12
1989 5.1 4.2 18
1990 4.7 3.9 14
1993 3.2 2.5 8.5
1996 2.9 3.3 0.8
1999 2.3 3.6 5.3
2000 3.1 4 8.2
2001 3.3 4 10.9
2003 1.6 2.6 12.9
2004 2.2 3 13.9
2006 2.3 2.1 11.2

2006 3.5 2.7 9.2
2007 3.5 3.8 7.7
Table 4. Healthcare Cost Distribution and U.S. Population Growth (2004-2008* projected)
HealthCare Costs Distribution 2004 2005 2006 2007 2008
Health Service & Supplies Expenditure 1499.4 1620.7 1966.2 2095.5 2234.5
Personal Healthcare Expenditure 1547.7 1653.7 1762 1877.6 1999.1
Hospital Care Expenditure 564.4 605.5 648.2 696.7 747.1
Physician and Clinical Services 393.6 422.6 447.6 473 501.7
Prescription Drug Expenditure 188.8 199.7 216.7 231.3 247
Durable Medical Equipment Expenditure 22.8 23.2 23.7 24.5 25.4
Nursing Home Care Expenditure 115.2 120.7 124.9 129.7 136.5
Private Health Insurance 1206 1284.2 1358 1445.8 1542
Total U.S. Healthcare Expense 1852.3 1973.3 2105.5 2245.6 2349.3
U.S. Population 288.4 291.1 294 296.8 299.7
38
Table 5. Economic Indicators (Wage Growth, Inflation, Population Growth), Healthcare

Premium Growth and Healthcare Expenditure Growth from Year 2003-2007
Year
Health
Insurance
Premium
Growth
(%)
Inflation Wage Growth
%U.S.
Population
Growth
% GDP
%
Expenditure
Growth of
U.S.
Healthcare
2003 13.9 2.2 2.2 0.9 2.5 8
2004 11.2 2.3 2.3 1 3.6 6.9
2005 9.2 3.5 3.5 1 3.1 6.5
2006 7.7 3.5 3.5 0.1 2.9 6.7
2007 6.1 2.6 2.6 0.7 2.1 6.7
Measurement of
Patient Satisfaction
Guidelines
Health Strategy
Implementation Project
2003
Measurement of
Patient Satisfaction
Guidelines
Health Strategy Implementation Project 2003
Measurement of Patient Satisfaction - 2
Table of Contents
1. Introduction 7
2. Purpose of this Document 8
3. Why are we now Measuring Patient/Client Satisfaction Perception 9
4. Guide to Measuring Patient Satisfaction 13
5. Conclusion 23
6. Appendix One 26
7. Bibliography 27
Foreword
These guidelines have been produced in response to a specific commitment in the National
Health Strategy: Quality and Fairness - A Health System for You that a national standardised
approach to the measurement of patients satisfaction will be introduced (Action 48).
The need to capture the voice of the patient/client using a more structured approach is an
essential element of policy planning. The Prospectus Report (audit of structures) highlighted that
clear and visible accountability to the user of health services is underdeveloped. It also recognised
that some inroads are being made:
A very welcome development in recent years has been the National Patient/Client Survey in Irish
Hospitals by the Irish Society for Quality & Safety in Healthcare in collaboration with the
hospitals themselves.
This document can be used by all health service providers to ensure that the principle of
peoplecenteredness,
which is at the heart of the Strategy, becomes an increasingly important feature of
how we plan and deliver health services.
These guidelines follow on from the series produced in 2002 which cover a range of actions set
out in the Strategy. They were produced by a team of people drawn from across the health
service and have been adopted by the Chief Executive Officers of health boards.
The guidelines are not intended to be prescriptive rather they should act as a reference or guide
to people working within the system, supporting the overall commitment to delivering better
quality health services.
The development of these guidelines was greatly assisted by the publication of The Measurement
of Patient Satisfaction with Acute Services in Ireland Irish Patient Satisfaction Literature
Review and Scoping Exercise (HSNPF/ISQSH, 2003).
Finally, I would like to thank the project team which included nominees from HeBE, the Irish
Society for Quality and Safety in Healthcare and the Health Services National Partnership Forum,
who, in consultation with a wide range of people, produced these guidelines.
Denis Doherty
Director
The Health Boards Executive
Introduction
One of the significant trends in the development of modern healthcare is the involvement of
patient / clients in the management of their care and treatment. This is recognised in current
health strategies both in Ireland and in other jurisdictions.
The Health Strategy Quality and Fairness (DOHC 2001) makes a particular reference to the
inclusion of patient/clients in both the principles and the National Goals.
To support this development it is important to acknowledge that the experiences of
patients/clients of health care vary considerably. Some may have an occasional intervention while
others have a more permanent and long-term relationship with a service provider depending on
the nature and extent of their need.
Person centred health care respects the dignity and value of each person. It is entirely desirable
and proper that the views of patient/clients should be sought on their experiences and
expectations of health care.
This document is designed to provide both a helpful and supportive guide to patient satisfaction
for service providers. The guidelines explain what is involved in establishing a measure of
patient/users satisfaction and the various methods available. A detailed guide to support staff
involved in this work is also included.
Purpose of this Document

Action 48 of the National Health Strategy: Quality and Fairness - a Health System for you (DoHC,
2001) identifies the need for a national standardised approach to the measurement of patient
satisfaction. It is consistent with Objective 1 of the Strategy that the patient/client is at the
centre in the delivery of care.
A people centred health system:
identifies and responds to the needs of individuals;
is planned and delivered in a coordinated way; and
helps individuals to participate in decision making to improve their health.
Feedback from patients/clients can influence the whole quality improvement agenda and provide
an opportunity for organisational learning and development. It provides crucial information on
what the patients/clients expectations are and how they perceive the quality of care, which may
be different from that of all staff providing that care. (Generally, this information is collected by
good management and good listening.)
Many healthcare organisations currently collect feedback but a study by the Irish Society for
Quality and Safety in Healthcare on behalf of the Health Services National Partnership Forum
showed that there was no structured method utilised. A structured framework to collect
information about patient/client satisfaction to ensure a systematic methodology that will
facilitate benchmarking and allow collected information to be fed back into the overall decision
making process.
The people-centred health care system of the future will have dynamic, integrated structures,
which can adapt to the diverse and changing health needs of society generally and of individuals
within it. These structures will empower people to be active participants in decisions relating to
their own health. (Quality and Fairness, DoHC, 2001)
Why are we now Measuring

Patient/Client
Satisfaction/Perception?
Consumer participation is increasingly being linked with improvements in the quality of health
care and improved health outcomes. There is an increasing impetus for shared decision making
and person centred care. Person centred care has become a central concept in healthcare as a
response to:
A general trend towards increasing attention to social inclusiveness and the needs of the
customer.
The rapidly increasing cost of healthcare and the imperative for effectiveness.
The focus on improvement of processes and outcomes of care (Al-Assaf, 1993, Lehr and
Shrosberg, 1991).
Increased access of patient/clients to information about healthcare treatments and options
(Lutz and Bowers, 2000).
There is a growing evidence of the links between consumer feedback and participation in
decision-making in individual care leads to improvements in health outcomes (England et al,
1992, Fallowfield et al, 1990) and stronger therapeutic alliances (Chambers, 1999). Effective
consumer feedback strategies
Lead to more accessible and effective health services (Draper and Hill, 1995).
Facilitate participation by those traditionally marginalized by mainstream health services
(Alexander and Hicks, 1998).
Make organisations more aware of significant areas of dissatisfaction with care and
services (Ovretveit, 1998).
Give staff new insights into how people perceive aspects of their care (Draper,1997) and
can increase consumer confidence (Chambers,1999).
As techniques to measure the quality of healthcare proliferate and improve, health professionals
are beginning to accept that patient/clients and their families hold unique vantage points as
expert witnesses of care (Delbanco, 1996) and that they should plan their services to reflect the
needs of patient/clients. Patient/client satisfaction is now a critical variable in any calculation of
quality or value and therefore in the assessment of corporate/individual accountability. It is a
legitimate and important measure of quality of care.
Patients/clients are rightly becoming more involved in their own healthcare and are being
encouraged to do so. The movement to include patient/client evaluations of care is growing as
more providers/organisations realize that patient/client satisfaction measurement is a cost
effective, non invasive indicator of quality of care. Giving the patient/client an opportunity to
voice their opinions about the care they receive can be seen as part of a broader commitment to
public and patient/client participation in healthcare service planning and delivery.
The Joint Commission of Accreditation of Health Care Organisations (JACHO, 1994) has embraced
patient/client satisfaction as a valid indicator and mandated in its 1994 standards for
accreditation that the organisation gathers, assesses, and takes appropriate action on
information that relates to patient/clients satisfaction with service provided.
The Irish Health Services Accreditation standards similarly seek evidence of a Client and
Community Focus and ask the question do we know what our patient/clients think of us. More
and more there is a recognition that quality healthcare must take account of the outcomes which
are important to people.
The increasing cost of the health services and the need for better use of available resources is a
concern for healthcare providers. Consequently, it is evident that there is a need to measure the
efficiency of health care to determine if proper use of available resources is being made.
According to Fitzpatrick (1991), patient satisfaction is an important and widely accepted measure
of care efficiency.
What is patient / client satisfaction?

Satisfaction, like many other psychological concepts, is easy to understand but hard to define. The
concept of satisfaction overlaps with similar themes such as happiness, contentment, and quality
of life. Satisfaction is not some pre-existing phenomenon waiting to be measured, but a
judgment people form over time as they reflect on their experience. A simple and practical
definition of satisfaction would be the degree to which desired goals have been achieved.
Patient /Client satisfaction is an attitude a persons general orientation towards a total
experience of health care. Satisfaction comprises both cognitive and emotional facets and relates
to previous experiences, expectations and social networks (Keegan et al, 2002). Meredith and
Wood (1995) have described patient satisfaction as emergent and fluid. It also has been
described as a particularly passive form of establishing consumers views (McIvor, 1992).

Satisfaction is achieved when the patient/clients perception of the quality of care and services
that they receive in healthcare setting has been positive, satisfying, and meets their expectations.
For the purpose of this document it is important to recognise that patient/clients range from
people who are in receipt of ongoing care, personal assistance services and other community
delivered supports to people admitted to hospital on a once off or episodic basis. The opinions of
the family, and advocates should also be considered.
What factors may influence satisfaction?

When including patient satisfaction mechanisms in health care systems, the options should take
account of the capacity of users to understand what is being asked of them and to communicate
their opinions and feelings effectively.
Important factors influencing patients/clients in this regard include literacy levels, intellectual and
physical/sensory disability levels and difficulties with language proficiency or ethnic and cultural
diversity. Social elements within our society must be considered as they can very often dictate
whether the consumer will provide feedback and express their satisfaction or otherwise, e.g.,
financial status, educational status, demographics (urban/rural), technology.
Previous measurements of patient satisfaction overwhelmingly show that the majority of
consumers, usually 80% or more, express overall satisfaction with their care, with few
respondents responding negatively to any given item. Satisfaction is, however, a relative measure
which research literature shows, may be influenced by many factors that should be considered.
Patient/client expectation
The meeting of patient/client expectations are assumed to play a role in the process by
which an outcome can be said to be satisfactory or unsatisfactory. Expectations are an
important influence on the patient/clients overall measurement of satisfaction with a
health care experience. Patient/client satisfaction is influenced by the degree to which care
fulfils expectation (Mahon, 1996). Some literature however suggests that a link between
satisfaction and fulfilment of patient/client expectations is not necessarily the case, since
it is possible that the patient/clients evaluation of a service may be largely independent of

actual care received (Williams, 1994).
Age
Older respondents generally record higher satisfaction (Pope and Mays, 1993; Williams and
Calnan, 1991; Owens and Batchelor, 1996) - possible explanations include lower
expectations of health care and reluctance to articulate their dissatisfaction.
Illness
While some studies have found that sicker patient/clients and those experiencing
psychological stress are less satisfied, with the possible exception of some chronically ill
groups, distinguishing between the experience of sickness or experience of health service
treatment or other factors as causes of dissatisfaction has proven difficult (Hall and
Milburn, 1998; Cleary et al, 1992).
Prior experience of satisfaction

Crow et al, (2003) in their review of literature identified that satisfaction was linked to
prior satisfaction with health care and granting patient/clients desires (e.g. for tests).
Patient/client professional relationship

There is consistent evidence across settings that the most important health service factor
affecting satisfaction is the patient/client-practitioner relationship, including information
and technical competence (Crow et al, 2003).
Choice of service provider

Choice of service provider is associated with higher satisfaction (Crow et al, 2003). Care
provided under fee-for-service arrangements generates greater satisfaction than that
delivered with prepaid schemes. Gate keeping organisations, where patient/clients have
little or no choice in their treatment or are assigned treatment, score relatively poorly on
satisfaction.
Gender, ethnicity, and socio-economic status

Evidence about the effects of gender, ethnicity, and socio-economic status is equivocal
due to the small amount of literature available on each (McGee, 1998; Crow et al, 2003)
Guide to Measuring Patient

Satisfaction
One of the critical success factors when measuring patient satisfaction is that the process is
planned effectively. It is important to identify clear objectives and link them with the
appropriate method of evaluation. Some areas for consideration are detailed below.
Planning an evaluation to measure patient

satisfaction
Those involved in planning an evaluation to measure patient satisfaction should consider a
number of key questions grouped as follows:
Questions to consider before identifying patients/clients who will be invited to participate
in the evaluation.
Questions to consider when you are ready to begin involving patients/clients.
Evaluation questions.
Why is satisfaction being measured?

What dimensions of quality / aspects of
satisfaction are to be measured?

What difference to patients/clients will this
measurement make?
What is the management commitment and
staff commitment to patient/client
participation? And what is the commitment
of the organisation to change?
Can we develop ways to ensure that
patients/clients who participate will be
listened to and their input valued?
What aspects of the organisations history
may impact on patient/client participation?
Define a clear purpose for seeking
patient/client views.
Clearly outline the dimensions of
satisfaction to be measured.
Identify the differences.
Clarify management commitment to
improve services based on information
Identify required resources and confirm
availability.
Confirm that results of feedback will result
in improvement.
Check has your organisation previously
consulted with patient/clients?
How were these results utilised?
1. Questions to consider before identifying patients/clients who will be invited to

participate in the survey
Questions to be asked Actions required
2. Questions to consider when you are ready to begin involving patients/clients

Do we know who our patients/clients are?
Do we know how patients/clients would like
to participate in our organisation?
What dimensions of quality / aspects of
satisfaction are to be measured?
Are there different levels that
patients/clients can participate within the
organisation?
What kinds of skills will be required by
patients/clients to do this work?
How will you support those patients/clients
who provide their time and expertise to your
organisation?
Identify all stakeholders whose views should
be sought.
Clarify the needs of the patient/client group.
Establish the optimum method for each
populations participation.
Develop appropriate strategies for
engagement.
Define the dimensions of quality / aspects of
satisfaction.
Recognise the value of the views of all health
service users.
Tailor participation strategies to individual
patient/client as well as groups (Eg. Personal
Outcome Measurement).
Identify skills requirement for participation.
Determine any training requirements.
Provide necessary training and support.
Reimburse patients/clients their out of
pocket expenses.
2. Evaluation questions
Ideally, evaluation questions should be asked along the way so that you are identifying and
addressing issues as you go.
What is the most appropriate method for
measuring the identified patient/clients
satisfaction?
Is the chosen method appropriate?
Are there any ethical issues to be considered?
Who should conduct the measurement?
How is the data to be analysed?
What report format should be used?
How will the report be disseminated and
published?
Identify the appropriate method of
measurement (see Methods of Measurement
Section overleaf).
Test with a pilot study.
Confirm if patients/clients have become
involved.
Evaluate what patients/clients say about their
experience of being involved.
Confirm how consent to participate will
obtained.
Clarify if proposal needs to be referred to
Ethics Committee.
Clarify Freedom of Information and Data
Protection requirements.
Confirm methodology and clarify if internal
or external independent measurement is
appropriate.
Identify the most reliable statistical methods.
Decide, given the evaluation method and the
attended audience, the appropriate format.
Agree methodology.
Attributes
A carefully planned small
group discussion, guided by a
skilled facilitator, designed to
obtain perceptions in a nonthreatening
environment.
Directed towards collecting
information on a specific
issue.
Can be used to provide
different insights into
problems and generate
potential solutions.
Skilled facilitator mandatory.
Strengths / Advantages
Provides an opportunity for
indepth exploration of
perceptions and opinions of a
selected number of
patients/clients.
Efficient collection of
qualitative information as it
usually involves 6-8
participants.
Provides detailed and
pertinent information.
Permits those not normally
attracted to participation to
express a view on issues of
special concern.
Assists with the interpretation
of quantitative results.
Weaknesses/Disadvantages
May not be representative.
Limited number of questions
can be asked in single session.
Can be time consuming.
Data is difficult to analyse in
a strict quantitative sense.
Quality of data is influenced
by skills of facilitator.
Facilitator can influence
results.
Language barriers.
Participants may be reserved
about expressing their views.
Measurement Tool: Focus Groups

Methods of Measurement
The following methods of measurement can be considered to evaluate patient satisfaction and an
appropriate model utilised.
Measurement Tool: Questionnaires

Attributes
A structured document, using
closed or open ended
questions, that can be selfadministered
or interviewer
administered.
Designed to elicit
patient/client feedback on
certain dimension of quality /
aspects of care.
Mode of collection
determined by resources,
length, sensitivity, complexity,
respondents, etc.
Suited to situations where
high response rate required.
Determination of appropriate
sample size is both a resource
and empirical issue.
Response scales play a key
function in the measurement
of patient/client satisfaction.
Strengths /Advantages
Agenda can be set by
organisation.
Allows for collation of both
qualitative and quantitative
data.
Relatively inexpensive.
Qualitative comments can be
included.
Agenda can be set by
organisation.
Questions must be carefully
designed so that they are
clear concise and relevant.
The choice of response
options can affect how
people think and respond to
questions.
Generally require software
support to record results.
Potential to excludes sections
of the population.
Measurement Tool: Postal Surveys - Questionnaires

Measurement Tool: Email/ Computerised Surveys
Measurement Tool: Key Informer Surveys
Attributes
As above but can be posted.
Questions must be carefully
designed so that they are
clear concise and relevant.
As above but administered
via the Worldwide Web.
Key Informers are described
as people who may be
assumed to have the
knowledge and ability to

report on social needs.
10-15 contacts are usually
considered an appropriate
sample.
Cost effective.
Specific segments can be
easily targeted.
Wider sample distribution
possible.
Encourages high response
rate.
Visuals may be used.
Little bias.
Patient/client anonymity.
Respondents given time to
complete.
Can use validated survey
instruments.
Qualitative comments can be
included.
Can be administered by
independent external
agencies.
Cost and time effective.
Visuals may be used.
Increased control to monitor
and ensure completed
questionnaires.
Ease of data collection.
Can be inexpensive and quick
to survey such people.
Difficulties associated with
procuring an accurate list of
client/patient details.
No opportunity for
explanation or follow up
questions.
Potential to excludes sections
of the population.
Provides limited
opportunities for large
numbers of community
members to participate in the
process.
Does not allow for the
exchange of ideas and
discussion.
Reliability dependent on
timing.
Potential for bias.
Low response rates yielding

higher satisfaction scores.
Access to computer may be
limited.
Does not allow for the
probing of data.
Key informers tend to
overstate a problem for their
interest group and to
underestimate the ability of
others to sort things out.
Measurement Tool: Personal Interviews

Measurement Tool: Telephone Interviews
Measurement Tool: Mystery Shopper
Measurement Tool: Consumer Panels
Attributes
Face to face detailed
discussion with people
selected on the basis of their
personal experiences.
Personal interviews may be
structured or unstructured.
Both methods require skilled
interviewers.
Not suited to surveying large
groups of people.
Requires careful selection.
Generally administered using
a structured questionnaire.
Requires trained surveyors.
The anonymous observation
of quality care.
Consultative process
structured and unstructured.
Ongoing relationship with
panel provides information
over time so covers changing
needs and circumstances.
Direct source of data.
Provides for a wide variety of
views and high levels of
flexibility.
Interactive, e.g. visual
questions can be used.
Allows interviewer the
opportunity to correct
misunderstandings.
Open ended questions may
facilitate acquisition of
quality data.
Direct source of data.
Interactive.
Generally less costly than
personal interviews.
Anonymous.
Snapshot view.
Provides valuable
commentary on services.
Combines research methods
with participatory approach.
Represents cross-section of
population.
Can tackle different issues
and track changes over time.
Allows continuing dialogue
with participants.
Provides research resource to
share between organisations.
Special needs can be
accommodated.
Time consuming for both
parties involved.
Skilled interviewer required.
Costly.
Scheduling may be difficult.
Interviewer bias can
influence results.
Must be conducted in a
conducive environment.
Time restraints on the part of
participants.
Low co-operation rates.
Interviewer bias can
influence results.
Excludes those without
telephones.
Bias may occur.
Limited focus.
Limited feedback by a single
reporter.
Setting up panels takes time.
Research skills needed. Poor
samples leads to unreliable
results.
Not suitable for consulting
with small numbers of people.
Does not involve people
active in decision making.
Objectivity can be lost if
panels get close to the
authority.
Measurement Tool: Workshops
Measurement Tool: Advisory Committees

Measurement Tool: Public Meeting/Forum
Attributes
Structured sessions aimed at
producing a plan or program
of recommendations.
Sub-groups of 8-15 people.
Provide ongoing advice on
community views or
specialist advice.
Up to 15 members.
Provides an opportunity for
community representatives
to become familiar with the
consultation/planning
process.
Serves secondary function of
bringing patients/clients
together to advise on policy
and inform them about
organisational policies.
Nominated by existing
groups and associations.
Facilitates the exchange of
views.
Provides existing groups with
a more informed and united
base from which to lobby
organisations and decision
makers.
System of interacting with
community groups.
Allows local experts or lay
specialists to contribute in
actual processes of planning.
A flexible technique which
can be used at all stages of
consultation.
Provides a forum for
receiving feedback.
Source of community
viewpoints.
Provides ongoing advice and
comment on developing
proposals or policies.
Allows members to identify
and seek measures to resolve
persisting local problems.
Assists in dealing with
multiple interest groups.
Allows people to respond to
the proposals or options
devised by experts.
Facilitates the exchange of
views.
Brings a wide range of
people together.
Can contribute to consensus
before actions taken.
May appear exclusive.
Advisory committees are not
elected, and therefore have
legitimacy problems claiming
to speak for others.
May be non-representative of
the community.
Meetings can be time
consuming and dominated
by members of unequal
status, knowledge and
expertise.
May have difficulty in
delivering the interest
groups or points of view they
are appointed to represent.
Ability of facilitator crucial to
success.
Glossy presentations can be
misled by an ill informed
audience.
Measurement Tool: Public Submissions

Measurement Tool: Complaints
Measurement Tool: Incidents and Near Misses
Attributes
Oral or written submissions
designed to keep interested
groups informed about the
current state of policy
development.
Generally attract organised
groups or individuals with a
well defined position.
Written submissions allows
for considered, thoughtful
and detailed points of view,
but it restricts those voices
heard in the debate.
Any expression of
dissatisfaction which needs a
response.
Complaint mechanisms can
range from internal
procedures to more formal
structures such as boards of

review and appeal, and the
Office of the Ombudsman.
INCIDENT: Any occurrence,
which is not consistent with
the professional standards of
patient care or the guidelines
of the healthcare organisation.
NEAR MISS: An occurrence
which, but for luck or skilful
management, would in all
probability become an
incident.
Demonstrates commitment
to open planning.
Designed to keep interests
informed.
Seeking written submissions
is a cost effective form of
consultation.
Written submissions will
become part of the public
domain, the most tangible
evidence of a consultation
process.
Views drawn from submissions
may be included in any final
report, along with tabulation of
arguments for and against
particular aspects of the overall
policy proposal.
Early warning system.
Valid means of patient/client
feedback.
Timelines often provides
opportunity to respond in
real time.
Identifies some problems.
Timely.
Pre-determined processing.
Submissions tend to favour
the articulate, and those with
sufficient resources to
prepare detailed analysis and
documentation.
Those opposed to a proposal
are most likely to invest the
time and effort required to
prepare a submission.
Patients/clients fear making a
complaint may lead to
victimisation.
Fail to identify sensitive
problems.
Can be perceived as a
punitive measure.
Conclusion
Evaluation of patient satisfaction should form part of continuous improvement. Patient
satisfaction, as a method of evaluating health services is essential. Whilst satisfaction with
delivered services is important, focusing on it alone fails to address customer needs.
Understanding the difference between customer needs and customer satisfaction is crucial to the
organisations success in quality management.
There are a number of suggested models to assist the integration of patient/client
satisfaction. Examples include the quality improvement cycle (FIG. 1); it lays out a road map for
continuous improvement. The EFQM model (FIG. 2&3) identifies the leadership commitment
necessary to facilitate system wide quality improvement
Fig 1
Where are we now?

Assess present status /
conditions
Did we make it?
Monitor
Go there
Action Plan
Where do we want to go?
Vision / Goals
Patient/client participation is a legitimate method of
evaluating health services.
Quality
Improvement
Cycle
How will we get there?
Methodology / Strategy
Fig 2.
Adapted from the European Foundation Quality Management
Model (EFQM)
LEADERSHIP
Chief executive
responsibility
Designated senior
managers
Leadership development
programmes
Values & principles
Director leads (e.g. quality,
clinical audit, risk
management, complaints)
Corporate ownership
PEOPLE
Management supervision
Teamwork
Workplace planning
Time to plan
Communication
Lifelong learning
Staff appraisal
PROCESSES
Training needs analysis
Client/patient audit
Record keeping & storage
Risk management
Complaints management
actions
Critical incident reporting
& actions
Pathways of care
Performance management
Self-assessment reporting
& action
Standards & frameworks
Process mapping &
improvement
Organisational
development
Focus groups
Consumer panels
PDP & lifelong learning
POLICY & STRATEGY
National Strategies
HIQA
Patients Charter standards
Policies/protocols
PARTNERSHIPS &
RESOURCES
HSNPF
ISQSH
Information systems
Library
Research
National Standards
Patient facilities
Voluntary groups
CUSTOMER RESULTS
Patients/clients quality
measurement
Comment boxes
Lessons learned from
complaints & critical
incidents
Audit involving patients
User/carer involvement
feedback
PEOPLE RESULTS
Staff satisfaction survey
Recruitment and
retention
Access to managerial &
clinical supervision
Celebration of
achievement
SOCIETY RESULTS
Public confidence in
health service
Public access to health
related information
Positive publicity
Public health
National standards
implemented
HIQA
National patient/client
survey
Lack of successful
litigation
Patients Charter
monitoring
External medical audit &
results
Ombudsman Reports
implemented
Information
Commissioner
Comptroller and Auditor
General.
KEY PERFORMANCE RESULTS
resultsenablers
Fig 3.
EFQM Model
Leadership
People
Policy &
Strategy
Partnerships
& Resources
People
Results
Customer
Results
Society
Results
Processes
Key
Performance
Results
ENABLERS RESULTS
INNOVATION & LEARNING
Appendix One
Recommendations
The recommendations detailed below have been presented to health board Chief Executive
Officers:
Customer feedback should be recognised as a legitimate method of evaluating health
services.
Healthcare service providers must continually capture, measure and evaluate patient
satisfaction through a range of agreed mechanisms.
The results of these evaluations should be analysed and inform the service planning
process.
Organisations should integrate the learning opportunities from customer feedback into
their quality improvement plans.
National Performance Indicator/s should be developed that measure compliance with
Action 48 (Health Strategy, Quality and Fairness).
Patient centred models of care should be integral to the core education curricula of health
professionals.
In recognition of the cultural diversity of Irish society and the emerging change in
attitudes to service provision in the different care groups, feedback from patient
satisfaction surveys should be disseminated widely and through all available means
possible.
A Patient Satisfaction Toolkit should be developed to ensure that best practice information
in relation to all facets of patient satisfaction (instruments, models, guidelines, feedback) is
centrally collated and widely available.
Bibliography
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implementation in health care. Philadelphia: WB Saunders Co.
4. Cleary, P.D., Edgeman-Levitan, S., and McMullen, W., 1992. The relationship between reported
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Factors influencingCustomer

A Introduction about Pakistan Healthcare Services:

these expenditures among the people of different areas of thecountry.

Malnutrition is big problem in Pakistan. Human Conditions Report

climate must also encourage information sharingand support safety

the U.S. Healthcare System By Sameer Kumar1, Neha S. Ghildayal2 and

income) characteristics. The questionnairebased on Ware et al. (1978)

3. Theoretical Frame Work:

ultimately responsiblefor hospital policy and decisions that affect the

Availability of Medicines and other support staff:

government is the Moderating variable thus a hypothesis can be

industry needs a Which Hospital

Do Pakistan health care industry needs a research?

Ho: Its Tested that Research on Healthcare industry is Needed

H1: Large number of people trend to go to Private hospitals rather then

Will Discounts influence customer satisfaction?

H4: Discounts offered in medicines trend towards customer satisfaction

Will Caring staff

Will Quality control safety influence

What is your Income level?

Less then 10,000

30,000 and above

Will Quality control influence customer satisfaction?

Nither agree nor Disagree

H1: Quality control is one of the tested variable of customer satisfaction.

Will patient safety influence customer satisfaction?

Nither agree nor disagree

H2: Patient safety is a tested independent variable to wards customer satisfaction.

Nither agree nor disagree

Will Medicines &suport stuff customer satisfaction?

Nether agree nor disagree

How much Doctor's Fee you can afford?

What is your Income level? *

What is your Income level? *

How much Doctor's Fee you

What is your Income level? * Which Hospital you Preffer? Crosstabulation

Less then 10,000

30,000 and above

Crosstabs : Income level Vs Hospital preffred:

30,000 and above

Crosstabs : Income level VsQuality Control:

In this cross tabs majority of people agreed that quality control is a

30,000 and above

Crosstabs : Income level Vspatient Satisfaction:

In this cross tabsmajority of people agreed Patient safety is the key

Crosstabs : Income level VsMedical & other support stuff:

In this cross tabs majority of people agreed Medical & other

Crosstabs : Income level VsCaring stuff:

In this cross tabs majority of people disagreed Caring staffis the

Will Discounts influence customer satisfaction? * Which Hospital you

Crosstabs : Income level VsCaring stuff:

In this cross tabs majority of people agreed Discountsis the key

Crosstabs : DiscountsVsQuality control:

In this crosstabs majority of people agreed Quality controlis the key

In this cross tabs majority of people disagreed caring staffis the

Crosstabs : DiscountsVsmedicines & other support stuff:

In this cross tabs majority of people agreed Medicines and other

Crosstabs : Doctors FeeVsPrivate of Govt hospital:

Crosstabs : Doctors FeeVsQuality control:

Crosstabs : Doctors FeeVsQuality control:

Crosstabs : Doctors FeeVspatient Safety:

Crosstabs : Doctors FeeVscaring Staff:

Crosstabs : Doctors FeeVsMedicines & Other Suport Stuff:

1. Health care service quality perception in Japan by Miss amiraeleuchepkoubaa Vol. 24