Professional Documents
Culture Documents
A RESEARCH PROJECT
By
Karachi, Pakistan
May, 2017
SUPERVISOR
INTRODUCTION
The general procedure for a patient care can be seen in three steps i.e. waiting in OPD, during
consulting in doctor’s room and after taken service from the doctor. It is imperative for the
hospital to understand the whole processes included in the experience of the patient. The
experience of the patient includes various variables, for example, specialist's expertise, his
communication with the doctor, performance and behavior of the paramedical staff, different
medical services offered by the healthcare center, behavior of care staff, cleanliness and structure
of the hospital. Patient satisfaction and loyalty is an important performance measurement tool for
a private health care sector. There are various problems faced by the patients in outpatient
departments, like overcrowding, delay in consultations, lack of proper guidance that leads to
patient dissatisfaction. It is seen that like every other public healthcare sector, the patients have
received more attention and quality care; in private healthcare hospitals. The Hospitals effort to
maintain and establish relationship between patients and Hospital staff, has offered a great deal
the need to contend exclusively on cost premise and expanding new patient base by referrals.
This study will help the patients in enhancing and developing more comfortable and satisfied
association and loyal relationship with hospitals, and creating more trust and confidence towards
understand how to develop and nurture a long term patient- hospital relationships. The patients
develop loyalty towards hospitals based on their interpersonal experience with the doctors,
nurses and the quality of services offered by the hospital. Patients create their own judgment of
their experience about the management system of the hospitals they visit and thus it is important
to diagnose the most practical way of finding patient’s needs so that finding where care for
It is seen that, today, hospitals are facing tremendous pressure of competition and the attention
towards healthcare has continuously increased particularly wants and needs within the society
So, now-a-days hospitals are working hard to overcome this competition in a way to, expand
medical facility investment, high quality human resources, new system designs, and latest
Hospitals are facing competitive situations due to globalization and the open-door policy for the
health care market. The growth, new medical services and advance technological changes
towards health have continuously increased particular wants and needs of the general public.
Hence, private hospitals are working hard to increase their medical facility investment, good
quality human resources and provide quality services in order to develop competitive power.
To improve and provide quality healthcare services, Human Resource Management is being
Patient satisfaction is of prime importance when patients themselves make selection decisions.
Health care service dimensions and factors affecting patient satisfaction, researchers have
studied on various service quality areas in which patient satisfaction are considered the most
important tool for evaluating the quality aspects of hospitals such as latest equipment, physical
facilities, ease of supplementary services, nature and response of doctors and medical staff.
Today, hospitals are forced to deliver a good quality service to the patient and how it could be
best measured. A key factor in establishing and delivering quality medical services is the need
to understand the patient’s desire and requirements in order to provide quality services which
Out-patient department is located at the ground floor of the clinical division. It is a unit in which
walk-in patients are treated and provided medical services. Its primary objective is to provide
healthcare services at minimal cost. The outpatient services provide the main relationship
between the hospital and the public. Today, the outpatients are very important for every
The OPD department is the first impression of the hospital. The OPD is the entry point for
The health care sector in recent years has reshaped its medical service delivery system in order
to effectively satisfy the needs and desires of the patients. This patient-centered health care
service approach shifts the culture of the health care system from decisions of medical
The patient satisfaction is a fundamental requirement for health care providers. Satisfaction is
important when patients themselves make selection decisions. Impact on patient retention and
customer loyalty, patient satisfaction influences the rates of patient compliance with physician
advice. Researchers have defined various service quality dimensions, to understand various
Recent studies have shown that medical health service quality dimensions significantly
influence patient satisfaction. In order to provide health care resources effectively, health care
providers should identify patient’s priorities among service quality dimensions and to improve
The purpose of this study is to analyze very carefully the relationship between the qualities of
medical services, satisfaction level and re-visit intention of patients and to advise various
marketing solutions for private hospitals. This study will also help hospitals to offer patients the
best medical services and enhance their position in today’s very competitive environment.
Patient satisfaction and loyalty is an important performance measurement tool for a private
health care sector. This research study is based on the identification of various problems faced by
the patients in outpatient departments, like overcrowding, delay in consultations, lack of proper
guidance that leads to patient dissatisfaction. This research study will also justify the overall
experience for the patients facing in hospital like, doctor’s competence, his interaction with the
patients, behavior of the paramedical staff, various facilities offered by the hospital, behavior of
support staff and overall hygiene. This study will help the providers in developing stronger and
more loyal relationships with the patients. Researcher has identified several possible variables
that may result in patient’s satisfaction with the hospital’s services like tangibles, reliability,
The scope of this study would be developing stronger and more comfortable relationship with the
provider, patient’s loyalty towards hospital based on significant interpersonal experience they
have with the doctors and nurses and about the quality of services of the hospital.
Patients in OPD, emergency, diagnostics and pharmacies. Patients whose age ranges are from
18-50 years old. Patients, who are willing to give consent. Patients, who are able to listen/read
and understand local language. Patients who visit the hospital as outpatient in the hospital.
Patients who have psychological illness, inpatients, gyne and ops, patients whose age ranges are
less than 18 or greater than 50 years. Patients, who are not willing to give consent.
H01 The hospital facility has significant influence upon patient satisfaction.
H02 Behavioral and personal attention of doctors and paramedical staff has a significant
H03 Patient satisfaction has a significant influence on re-visit intention for medical services.
H04 Patient satisfaction has a significant influence for referring hospital to other patients.
Service Process
Customers of service organization obtain benefits and satisfactions from the services themselves
Empowerment
A management practice of sharing information, rewards, and power with employees so that they
can take initiative and make decisions to solve problems and improve service and performance.
CHAPTER 2
Literature Review
2.1 Introduction
A review of the literature reveals many studies that have shown a significant relationship
between patient satisfactions and impact of hospital services on outpatient departments and also
between service quality perceptions and satisfaction. Researchers have identified several possible
variables that may result in patient’s satisfaction with the doctor’s services. Fred David, Garner
C.Alkin (2006) felt that these variables have included perceived doctor’s competence, care and
concern towards patients, cost of treatment and communication between doctor and patient.
In their study Gilmore Audrey, Goodman Bill Reidstead man (2006) state that patients and
consumers perception of quality service in health care is not accurate because of the inability of
patients to analyze and judge the technical competence of medical practitioners with accuracy. It
is further observed that our medical courses focus on imparting technical knowledge to the
students and hence doctors do not receive any soft skill training which will enable them to get
Further it is seen that Boonshoof and Gray (2004) have conducted the studies on the
relationships between service quality, customer satisfaction and buying intentions in the private
hospital industry. Their study attempted to assess what dimensions of both customer satisfaction
and service quality drive „Overall Satisfaction and Loyalty‟ in the South African private hospital
industry. The results revealed that the service quality dimensions, empathy of nursing staff and
The results also revealed that the customer satisfaction dimensions are: satisfaction with food,
satisfaction with the nursing staff and satisfaction with the tariff. All effect positively on both
loyalty and satisfaction. The survey and study conducted, aimed to investigate the relationship
between outpatient satisfaction and service quality dimensions where patients have substantial
freedom in choosing their medical service providers. Results show that the pattern of
relationships between service quality and patient satisfaction was similar across the gender, age
and service type subgroups; it was an exploratory study on service quality. Themes showing
patient satisfaction with healthcare delivery in India were conducted by Sachin Kamble (2007)
who has stated that very little emphasis was given by patients on service quality dimensions. The
A detailed study was done by Hardeep Chahal (2004) of Ahmedabad Civil Hospital, which
showed that the more satisfied the patients are with the quality of interactions with staff, more
likely they will opt for treatments for similar and different medical problems and would
recommend the hospital to their friends and relatives. Patients basically from pediatric, obstetrics
and gynecology had been selected for the study. Results stated that it is necessary to capture
information on patient‟s needs, expectations and perceptions. Main concerns of patients relate to
being treated with dignity and respect, given clear information and psychological support. Older
patients tended to be more satisfied with medical care services than their younger counterparts.
Further it is seen that the role of government in assuring that our nation’s healthcare system
provides optimal services for its population has been emphasized upon in the World Health
Report, (2000). The meaning of quality on healthcare system has been interpreted differently by
different researchers.
The choice of hospital depends on numerous factors. There is need to understand the service
context and the nature of service offering. Lovelock and Wright, (1999) have given an insight
into the classification process of service which affects the nature of operation chosen.
The required elements are:
evaluating the quality of the patient satisfaction (care) in the outpatient department. In a study
conducted at Mageburg, Germany only 3.6% of patients were dissatisfied. Thorne L, Ellamushi
(2002) at the Neuro-surgical care department of National Hospital, London, observed that most
organizational behavior and the retention of a qualified and committed nurse work force might
be a promising area to improve hospital care safety and quality, both nationally and
Observed by Yesudian (1994), Bhat (1996) and Kutty (2000) tells us that outpatient care has
been dominated by the private sector for decades and Uplekar, Rangan (1993) and Kamat (2001)
feel that poor quality and lack of public health care are observed and noted, particularly in the
treatment of tuberculosis and malaria. However, despite numerous studies on healthcare systems
in India, direct systematic comparisons of the nature of clinical care offered by public and private
sector practitioners are lacking. Such evidence is badly needed to inform policies that seek and
Carlucci D. (2013), Arab M. (2014) and Kleefstra S. (2010) observed that patient satisfaction is
one of the most important and widely used indicators in measuring health care quality and
outcomes. According to Carlucci D. (2013), there has been a growing interest in assessing
It is observed that the value in Hospitals is complicated because, first of all the high level of
information asymmetry between patient and the Hospital means that the patient must have trust
in the Hospital to ensure its efficacy, tarrifs and product design are well matched to his or her
requirements. Taner & Antony (2006) are of the opinion that a patient must have a lot of trust in
the health provider, which implies the patient must be highly involved in the delivery process,
despite less expertise. Due to the lopsided information received by Hospitals, the health care
administrator determines the services that will suit the patient’s requirements.
Hogg, Laing, & Newholm (2004) are of the view that there is high patient involvement. Taner &
Antony (2006) felt that there is usually a very high quantam of risk associated with the very
A study conducted by Ekrem & Fazil (2007) suggests that for Hospitals it has become extremely
important to analyse and take strategic steps as a result of tremendous competition and medical
reforms in technology. If we have more Private Hospitals then the authorities need to develop
new methods to maintain their existing patients and increase the new patient numbers. Duncan &
Breslin (2009) are of the view that Hospitals have difficulties creating meaningful value through
innovation because of poor Health care financing and lack of vertical and horizontal integration
and the slow change of basic research into practical health outcomes for the patients.
Duncan & Breslin, (2009) further stated that Hospitals that can overcome all these difficulties
stand a better chance to survive competition by offering high-value care. Hospitals need to study
and understand why patients purchase such professional services as this may be the key to a
through value-enhancement strategies Richardson & Gurtner (1999), Beresford & Branfield
(2006), Nordgren (2009), propose that marketing managers today are committed to develop plans
Today many professional firms fail to do so and thus offer inferior value to customers. Ekrem &
Fazil, (2007) are also of the view that Hospital management authorities aiming at incorporating
quality, customer satisfaction and loyalty have evolved, as seen by their attempts to make
patients influence customer perceived value, by getting patients involved in value creation.
However Laing & Hogg (2002), Ham & Alberti (2002) state that in spite of all these changes in
the healthcare industry and a shift towards a more patient-centred enviornment patients still tend
Laing & Hogg, (2002) are of the view that the patients are usually passive because of the belief
that the doctor knows best, which granted power primarily to doctors who became dominant in
their approach, while the patient deferred to the doctors opinion and obeyed instructions that the
doctor knew best for patient’s health. Alternatively, patients themselves may not be willing to
express their expectations and behaviour with respect to health care. The environment according
to Beresford & Branfield, (2006) and Lo (2006), in Hospitals may be changing from a traditional
Robinson (2001) are of the opinion that the decline of restrictive forms of managed care and
rapid increases in the availability of health care information via the Internet may produce a
situation in which consumer - provided information is more highly valued by recipients during
their information searches and selection. Word of mouth communications or referrals have
significant importance for the health care system, both traditionally as a means to cut through
information asymmetry and more recently as a tool for health care providers to gain
The provider’s intention to offer positive word of mouth communications correlates positively
with customer perceptions of value and quality; this was stated by Derbaix & Vanhamme (2003)
2.2 History
customer’s perspective in the service industry. Parasuraman et al., (1988) has initiated a lot of
discussions and debates on medical services quality from the perspective of patients. He
performance by users and of expectations based upon the five dimensions of service quality i.e.
Later on these researchers classified the factors of medical services quality into: (i) services that
satisfy needs without any defects, (ii) the ease and convenience of services and the operation
process, and (iii) service provision which satisfies a patient’s expectations and also felt that a
very wide approach is required that is necessary in order to measure the service quality in
Hospitals.
There is another study where Babakus and Mangold (1992) measured expectation level and
responsiveness, assurance and empathy. When it came to research on the quality of patient-
focused Hospital medical services, Choi (1999) focused on outpatients in large-sized hospitals in
Korea and classified medical services quality into (i) treatment, (ii) care (iii) promptness and
convenience of medical procedure. Further, Kim et al. (2003) emphasized on quality of services
for dental outpatients in hospitals and clinics and laid emphasis on four dimensions of medical
services quality i.e. the convenience of doing the procedure, the latest technology available, the
courtesy of the personnel communicating, tangibility and visibility of the care in the department.
A detailed survey was conducted by Lee (2005) to test outpatients in dental clinics which were
available in the greater Daegu area of Korea and he differentiated medical services quality into:
(i) treatment, (ii) professionalism, (iii) courtesy, (iv) convenience, and (v) comfortableness.
Hence, factors involving medical services quality in Hospitals vary considerably depending upon
the various kinds i.e. (dentist department versus general department) and the types i.e. (inpatient
Irfan et al (2012) found that public hospitals are not making any visible efforts to meet patient’s
needs and wants. The studied service quality construct does not have a significant impact on
Zarei et al. (2012) studied service quality in the private hospitals of Iran from the patients’
perspective. Results indicated that tangible has the highest expectations and perceptions and the
management. Study found that the service quality level of the hospital implementing lean is
moderate. In addition, the largest positive gap between patients’ perception and expectation is in
Yousapronpaiboon & Johnson (2013) studied Out-patient service quality perceptions in private
Thai hospitals, results found that assurance was the dimension most strongly associated with
Essiam (2013) examined the quality dimensions and patient satisfaction in a public university
hospital in Ghana. Findings revealed gaps across all the SERVQUAL dimensions with
reliability.
Mosadeghrad (2014) conducted an exploratory in-depth individual and focus group interviews
with 222 healthcare stakeholders including healthcare providers, managers, policy-makers, and
payers to identify factors affecting the quality of healthcare services provided in Iranian
healthcare organizations. Results found that personal factors related to the provider and patient,
factors pertaining to the health care organization, health care system and broader environment
Belaid et al (2015) studied the impact of health service quality and its impact on patient’s
satisfaction, case in a public hospital in Bechar. Results indicated that there was a relationship
between overall service quality and patients' satisfaction with the services of specific hospital.
Özlü and Uzun ( 2015) found that there were differences in patient satisfaction with nursing care
the hospital in which the patients stay and previous hospital experience.
Shan (2016) found that lack of trust was behind patient dissatisfaction with hospital inpatient
Devi and Muthuswamy (2016) investigated service quality perception in multispecialty hospitals
in India. Result indicated that tangibility, reliability and responsiveness were the three most
Zamil et al ((2012) investigated the impact of health service quality on patients’ satisfaction over
private and public hospitals in Jordan. The result indicated that there was an impact of health
service quality on patient's satisfaction. Responsiveness dimension has the lowest mean out of
In the healthcare sector the front-line staff increasingly perceives themselves as an enterprising
self. Meeting the expectations of the frontline staff can lead to a more effective patient care.
According to Boaden et al. (2008), "Professional ideology enables performance that might
otherwise not be achieved". Individual performance was concerned with how an individual does
It was noticed that organizational performance was perceived as being assessed using 'targets'
that were seen by some to be in conflict with patient care. Many individuals being unable to
describe a link between their own individual performance and that of the organization. The new
service management school of thought as per Korczynski (2002) celebrates a set of new HRM
practices, underpinned by the concept of the satisfaction mirror between customers and front-line
workers. The production line approach to services leads to failure because its narrow, low-skilled
jobs and emphasis on the use of technology leads to workers either having a poor service attitude
workforce or human resources. HRM is responsible for adding new employee, new doctor, new
nurse, search particular employee detail from the hospital database. Effective HRM enables
employees to contribute effectively and productively to the overall company direction and the
In a study of six organizations, Hyde et al. (2009), found frequency distribution of employee‟s
expectations to be 22 percent for infrastructure, 45 percent for HR practices and 33 percent for
help and support. Expectations were remarkably consistent across organizations and job roles.
McKee, Eerlie & Hyde (2008) are of the opinion that many expectations concern HR practices
and other aspects of HRM so HR function has an important role to play in developing,
It is a known fact that the primary front-line staff (customer-facing employees) in the healthcare
industry is doctors and nurses. According to Korczynski (2002) the doctors have a more
impersonal relationship with the patients while the nurses provide tender loving care. The
interaction of the doctors is limited to the diagnosis and discussions related to the treatment and
during the treatment. However, the nurses interact with patients throughout their stay as in-
patients. They pay regular visits to the patient and help them with their needs.
Korczynski (2002) states that this form of authority is in line with bureaucratic authority and is
termed as 'medical rational authority'. 'Patient advocacy', where nurses act as the voice for the
often voiceless patients is a concept exclusive to the healthcare organizations and something that
contradicts the concept of medical rational authority. In the current scenario of healthcare sector,
especially for the profit-maximizing hospitals, another distinct challenge to medical rational
Although the direct assessment of work practices and performance in healthcare trails similar
inquiries in other industries, researchers have examined the relationship between a variety of
work arrangements and patient care indicators. For example, researchers have studied the
relationship between human resource management (HRM) practices, teamwork and relational
coordination, and quality of patient care. Gittell et al. (2010), West et al. (2006), Preuss (2003),
Borrill et al. (2000) and Aiken et al. (1994) all provided one of the first comprehensive analyses
of the link between work practices and healthcare related performance outcomes.
According to Ash and Seago (2004) the effects of workplace practices on organizational
outcomes in healthcare is also available from studies of the relationship between unionization
and organizational performance. Taken together, this evidence suggests that other work-related
systems and practices that promote communication and collaboration, such as Patient centered
care, are likely to increase the quality of patient care as well. A number of areas remain relatively
under explored in this growing body of literature. First, much of the research on work practices
in healthcare has focused on those that provide employees with a greater level of input and
coordination.
Gittell et al. (2008) surveyed that patient centered care, provides a unique opportunity to examine
a workplace innovation that is intended to affect both patients and the workforce that cares for
them i.e. for a similar analysis regarding the effects of relational coordination on employee and
patient outcomes. Gittell et al. (2010) felt that studies regarding work organization in the
healthcare setting have tended to focus either on innovations regarding the delivery of care, such
as patient rounding and clinical pathways, or on work practice innovation, such as the use of
High involvement work practices (HIWP) and other HRM practices. There is apparently little
research that examines the complementarities between how patients are cared for and how
2.3.3 The Effects of Patient-Centered Care on Quality of Care and Patient Satisfaction
Robinson et al. (2008), Wolf et al. (2008) and Daviset al. (2005) stated that the Patient centered
care (PCC) approach to the over arching goal of the Patient centered care (PCC) model is to
provide care that is most conducive to patients preferences, needs and desires. The Patient
centered care (PCC) approach to healthcare departs from the physician or institution centered
model, which places almost all the power and authority regarding patient care in the hands of the
treating professionals, primarily the physicians and the organizations in which treatment is
provided.
Wolf et al (2008), Lemieux Charles and McGuire (2006) observed that the primary mechanism
used to deliver patient-centered care is the organization of work around inter disciplinary teams.
The Institute of Medicine claims that this newer model of patient care necessitates a particular
work design aimed at increasing coordination and opportunities for patient and staff input, and
this was even stated by Corrigan et al. (2001). In fact, this dimension of Patient centered care
resembles other well established work arrangements that have received significant attention in
the literature.
Researchers found that the focus on quality through specific “production” processes, staff
similar to the innovations currently pervading healthcare. Unlike the HIWP model however,
Patient centered care entails the facilitation of input and participation from both frontline staff
and the patients for whom they care. According to Audet et al. (2006), Bergeson and Dean
(2006), Davis et al. (2004) and Fiach et al. (2004) the existing Patient centered care literature has
identified five dimensions of the delivery care model i.e. (1) access to care (2) patient
engagement in care or patient preferences (3) patient education or information systems (4)
coordination of care across hospital staff and (5) patient emotional support.
Charmel and Frampton (2008) and Wolf et al. (2008) feel that despite the increased use of
patient centered care-based methods for delivering care, empirical research has not kept pace
with them, and the evidence regarding their effectiveness is limited. What evidence there is
supports a positive relationship between the adoption of Patient centered care and improved
Hospitals have always been a place of care that provides the population with complete
healthcare, both curative and preventive. In the hospitals, quality of care is measured with two
metrics: patient outcomes and patient satisfaction. Satisfaction is a person’s feelings of pleasure
outcome) in relation to his or her expectations. (Kotler, 2000). Patient satisfaction is defined as
the appraisal, by an individual, of the extent to which the care provided has met that individual’s
expectations and preferences (Brennan 1995). It is the degree to which the individual regards the
healthcare service, product or the manner in which it is delivered by the provider as useful,
effective, or beneficial (Online Medical Dictionary, 2012). Patient satisfaction mostly appears to
represent attitudes towards care or aspects of care (Jenkinson et al.. 2002).It is referred to patient
satisfaction as patients’ emotions, feelings and their perception of delivered healthcare services
(Mohan & Saikumar, 2011). The concept of patient satisfaction is multidimensional, and reflects
patient perceptions and expectations compared to the actual care they receive (Edlund MJ,et al,
2003) . Speight (2005) saw that the implicit in patient satisfaction definitions is the assumption
that the patient attaches values to specific attributes of the treatment or service, and that these are
unique to each individual’s experience. It is found that patient satisfaction increases patient
retention, willingness to recommend, improve the rate of patient compliance with physician
advice and requests. It improves trust, loyalty and decreases the number of lawsuits. Service
quality is often regarded as the antecedent of patient satisfaction Irfan (2012), Speight (2005),
Zarei et al. (2012), Shan et al. (2016). For these reasons patient satisfaction survey is an effective
tool that provides information and insight on patients’ views of the services they receive. For the
purpose of this research overall patient satisfaction was defined as “the extent to which
outpatient is content with the healthcare services which they received from al-Bashir Hospital”.
A number of studies report that Patient’s satisfaction is influenced by a number of factors and
according to Peprah (2014), the following factors play a critical role in the satisfaction of
patients; the attitudes of nurses toward patients, the capacity to deliver prompt service without
wasting time, ability to disseminate information to patients and the availability of up-to-date
equipment. Others include the hospital’s ability to render 24 hour service, the patience of the
doctor to clearly explain what was wrong with patients before giving treatment, providing
patients with detail information about their medication, and attractiveness and cleanliness of the
hospital.
A review of the literature reveals numerous studies that have reported a positive relationship
between satisfactions and measures of purchase intentions and between service quality
perceptions and satisfaction. Researchers have identified several possible variables that may
result in patient's satisfaction with physician's services. These variables have generally included
perceived physician's competence, care and concern towards patients, cost of treatment and
Bonshoff and Gray have conducted the studies on the relationships between service quality,
customer satisfaction and buying intentions in the private hospital industry. The studies
conducted aim to investigate the structural relationship between out patient satisfaction and
service quality dimensions where patients have substantial freedom in choosing their medical
service providers and to further study the causal relationship between service quality and
satisfaction.
An Exploratory Study on Service Quality Themes determining patient satisfaction with Health
Care delivery in India was conducted by Sachin Kamble who has stated that very little emphasis
was given by patients on service quality dimensions. Aim of the research was to acquire an
service quality as seen by the patient is equally important to nursing because it is a concept
integral to the provision of a better and more focused service for patients. Results stated that it is
necessary to capture information on patient's needs, expectations and perceptions. Main concerns
of patients relate to being treated with dignity and respect, given clear information and
psychological support. Older patients tended to be more satisfied with medical care services than
their younger counter parts. Results also revealed no consistent satisfaction pattern between male
The quality of services plays a primary role in achieving patient satisfaction (Margaritis E,
mortality.
However, in recent decades, the patients’ perception of their care has also been taken into
consideration (Shirley ED, 2013). Thus, the patients’ perception of the service quality
contributes critically to achieving satisfaction (Choi KS, 2004). In some studies, the positive
assessment of service quality is considered as satisfaction, and these terms are used
interchangeably; however, patient satisfaction is only one of several measures of care quality.
According to Carlucci D (2013) and Jen W (2011), quality judgments are fairly specific, whereas
satisfaction judgments are more general. Patient satisfaction is a positive or negative attitude
reflecting the patient’s feelings in relation to the received services. To obtain satisfaction, the
patient must experience a service; in contrast, the perceived quality of services is not necessarily
the result of experiencing those services (De Man S, 2002). The quality of services is associated
with cognitive judgments, whereas patient satisfaction is associated with affective judgments
(Choi KS, 2004 and Lai WT, 2011). The distinction between service quality as a cognitive
which the quality of services is a predictor of patient satisfaction (Choi KS, 2004). Several
studies have been done on the relationship between service quality and customer satisfaction.
Not surprisingly, the results show that the quality of services leads to higher satisfaction (Lai
Lovelock, Writz, and Chatterjee (2006) observed that a natural tendency in such situations is for
patients to use process factors and tangible cues as proxies to evaluate quality. In the competitive
service industries, if core service outcome is the same, the customer may evaluate the service
performance in terms of process quality. In the health care settings, the medical treatment and
medical outcome may be the same but the process quality framework may vary between the
hospitals. Researchers have tried to integrate the effects of clinical quality and process quality on
customer satisfaction and behavioral intentions. The majority of the patients with no or less
medical knowledge may not evaluate the clinical quality but may evaluate the process quality.
There is limited empirical research which has investigated the relationship between process
quality, patient satisfaction and behavioral intentions in the health care sector. However, certain
sub dimensions of process quality have been tested in different service industries. According to
Marley, Collier, and Goldstein, process quality is a result of the service (non-technical) delivery
process engaged in during and outside of the medical procedure. Process quality includes making
the patient’s experience in the hospital proceed efficiently and effectively. Examples of process
quality include the level of personalization and patient service provider interaction, delivery of
medication and food to the patient, the efficiency of admission and checkout, and the timeliness
Kotler, Bowen, and Makens (2004) surveyed and found that the fundamental aim of today‟s total
Carrillat, Jaramillo, and Mulki (2009) in their survey noticed that studies demonstrate that
service quality has both a direct and indirect effect on attitudinal loyalty and purchase intentions.
The empathy of nursing staff and their assurance as per Boshoff and Gray (2004) enhance the
loyalty of patients in the case of private hospitals. Patients are more likely to return to a hospital
if they perceive the fees that they are charged as fair, reasonable and good value for the money
paid. The research findings based on developed countries may or may not be applicable to
Improving the quality of medical care services has become a primary concern for patients, and,
in order to provide better service to patients, service quality has become increasingly important
for hospitals in respect of satisfying and retaining patients (Alhashem et al., 2011; Arasli et al.,
2008). Patients who value the relationships are more likely to stay loyal to their hospital (Kessler
According to Carlucci D. (2013), Arab M. (2014), Sherly ED (2010) and Gasquet I (2004)
satisfaction is important from several aspects for healthcare organizations. Satisfied patients are
more likely to comply with treatment regimens, maintain a continuing relationship with a
physician, and thus enjoy better treatment. Therefore, through the continuity of care and
adherence, patient satisfaction has the potential to improve health care outcomes (Sherly ED,
2010).
It is seen that the business value of IT literature is replete with exam plus describing relationships
between IT and various types of value and suggestions as to what to control, how to measure,
and when to measure. What seems apparent from this stream of research is that “context”
matters. It is observed that researchers do not often delve into key contextual questions such as
“Why does a hospital adopt information technology?” Is it out of competitive necessity, or the
belief that there is value associated with the use of IT? Or is it simply the government
requirement that makes it necessary to adopt it? These and other explanations have been used to
explain why firms, in general adopt IT, but as it are noted earlier; the intent of the adopter or
context under which the IT was adopted determines what “success” really is.
Schantin (2004) states that a business process is a sequence of steps which transform inputs into
outputs. It is customer focused, i.e. is activated by market and external or internal customer
needs, value adding, i.e. creates value which is appreciated by the customer, and has a process
owner who has the end-to-end responsibility for the whole process. Furthermore it has access to
all necessary resources and information. As per Reijers (2006) process orientation means
focusing on business processes ranging from customer to customer instead of placing emphasis
on functional structures. Davenport (1993) too feels that process orientation does not only work
for process industry, but can be applied to service industries as well. There is empirical proof that
hospitals with a high degree of process orientation are moderately but significantly more
Management approach according to Gulledge & Sommer (2002) has gained much advertence in
industrial engineering and management literature, but less in public sector management
literature. Smith & Fingar (2003) too found that Business process management does not only
incorporate the discovery, design, deployment and execution of business processes, but also
By focusing measurement on processes rather than functions, Hammer (2007) concluded that
alignment and common focus across separate organizational units can be achieved.
Implementing measures and taking corrective actions are operating precepts of process
management. With the help of measurement, a process can be controlled. Process control is an
It is noticed that patient’s perception about health care systems seems to have been largely
ignored by healthcare managers in developing countries. Patient satisfaction depends upon many
factors such as: quality of clinical services provided, availability of medicine, attitude, behavior
of doctors and staff, cost of services, hospital infrastructure, physical comfort, emotional support
and respect for patient preferences. Mismatch between patient expectation and the service
according to World Health Organization, Report (2000), gives them a voice which can make
private and public health services more responsive to people’s needs and expectations.
There are very few studies in India that measure patient satisfaction with the services provided
understanding of user’s needs and their perception of the services received. Patients attending
each hospital are responsible for spreading the good image of the hospital and hence the
satisfaction of the patients attending the hospitals is equally important for the hospital
management. Surveys of (OPD) outpatient’s services have elicited problems like overcrowding,
delay in consultation, proper behavior of staff, logistic arrangements, support services, nursing
care, doctor’s consultation, etc. If there are delays in consultation it has to be explored to elicit
the lacunae.
There is tremendous scope to improve the OPD services of a public or private hospital. More
than a decade ago, two landmark reports: The World Health Organization’s- The World Health
Report (2005) and the Institute of Medicine’s crossing the Quality Chasm (2001) called for the
realignment of incentives to balance the competing goals of cost containment and quality
improvement. Both reports concluded that responsiveness to citizen’s expectations was a valued
Efforts to measure patient satisfaction have thus increased and in some countries, incentives have
been adopted to increase patient satisfaction and care. Till today few studies in the developing
settings were conducted to understand the types of relationships that exist between patient-
loyalty and service quality. The hardworking competitive scenario and mushrooming growth of
service organization have invigorated the need to look beyond customer satisfaction towards
Thus, it is important to determine the exact way of tracking patient perception over the time as
well as diagnosing where healthcare services need to be improved. Hence, the researcher sees a
definite gap, i.e. a need for a comparative study of patient satisfaction in private and public
hospitals so as to get an insight as to why a patient uses the same hospital for same treatment,
same hospital for other ailments and why he refers the same hospital to other patients.
To be the leaders in today’s challenging scenario of cut throat competition among hospitals, all
private and public hospitals need to take a fresh competitive look at their objectives and
patient relationships have found to be part of reputed hospitals like Apollo and Fortis, more
the western countries as well. There are no studies available that analyze the Impact of
Healthcare services on outpatient satisfaction in Public and Private Hospitals; hence the need to
health care industry has caught the providers’ attention in the present competitive conditions
(Laohasirichaikul, Chaipoopirutana, & Combs, 2010). For the hospitals, satisfied patients are
important because the patients’ greater satisfaction with the care would entail the patients’ more
adherence of the doctor’s orders, more loyalty, positive word of mouth by the patient, reducing
the number of the patient’s complaints, higher profitability, higher rates of the patient return and
more patient referrals (Choi, Cho, S. Lee, H. Lee, & Kim, 2004; Dawn & Lee, 2004; Wu, 2011).
For these reasons, the patient’s satisfaction evaluation has become a part of the strategic process
of health care organizations. Measuring the patient satisfaction and recognition of its effective
factors is important to the health care managers due to the impacts they make on the health and
financial results of the health care organizations (Raposo, Alves, & Duarte, 2009).
Customer satisfaction is a general attitude that is formed based on the customer experience after
reaction in relation with the difference between what the customer expects and what he/she
receives (Lai & Chen, 2011; Liu, Guo, & Lee, 2011). If the received services by the patient be
weak and inconsistent with his/her expectations, he will then be dissatisfied. However if the
received services conform to or beyond the patient’s expectations, this will result in his/her
satisfaction (Laohasirichaikul et al., 2010). In other words, satisfaction reflects the degree to
which a customer believes the usage of a service has caused positive feelings in him (Cronin,
The interest in health care service quality is increasing. With increasing pressure to measure
quality, patient based assessments of medical care are becoming increasingly important. Patients
offer a unique perspective for evaluating the nontechnical aspects of medical care. In literature,
there are various definitions of healthcare service quality. The Institute of Medicine defines
healthcare quality as "the degree to which healthcare services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current professional
healthcare quality is “the application of medical science and technology in a manner that
maximizes its benefit to health without correspondingly increasing the risk”. Ovretveit &
Twonsend (1992) looked to healthcare service quality care as “the provision of care that exceeds
patient expectations and achieves the highest possible clinical outcomes with the resources
available”.
providing efficacious, effective and efficient healthcare services according to the latest clinical
guidelines and standards, which meet the patient’s needs and satisfies providers”. For the
purpose of this research healthcare service quality is defined as “healthcare services provided in
Murshid hospital whose characteristics and features meet or exceed patient’s needs and
expectations”.
The patient’s perception of the service quality plays an important role in achieving customer
satisfaction and the causal relationship between the service quality and satisfaction has been an
important topic of discussion in many relevant studies (Choi et al., 2004; Karatepe, 2011).
Zeithaml, Berry and Parasuraman (1996) in their study of service quality consequences have
pointed out that customer perception of the service quality is the most important predictor of the
customer satisfaction. In practice, satisfaction and quality are often used interchangeably, but the
consensus of researchers is that these are two distinct constructs, although highly correlated with
each other (Padma et al., 2010). The quality judgments are relatively specific, while the
satisfaction judgments are mainly general (Jen, Tu, & Lu, 2011). To achieve satisfaction, the
patient should experience a service while the perceived service quality is not necessarily the
result of an experience of a particular service (De Man, Gemmel, Vlerick, Van Rijk, & Dierckx,
2002). Also the quality of services is related to the cognitive judgments, while the customers’
satisfaction relates to the affective judgments (Choi et al., 2004; Lai & Chen, 2011). The
differentiation between the service quality as a cognitive construct and the customers’
satisfaction as an affective construct suggests a causal relationship in which the service quality is
a predictor for the patient satisfaction (Choi et al., 2004). H. Lee, Y. Lee and Yoo (2000)
conclude that the customers are (dis) satisfied only when they have perceived and experienced
the services; this shows that the service quality evaluation has priority over the customers’
satisfaction. Therefore the service quality is often seen as the customers’ satisfaction antecedent
(Dabholkar, Shepherd, & Thorpe, 2000; Lei & Jolibert, 2012; Amin, Yahya,
Ismayatim, Nasharuddin, & Kassim, 2013) and the notion that the service quality has a direct
effect on satisfaction, has been widely accepted (Cronin & Taylor, 1992; C. M. Chen, S. H.