Critically evaluate service quality as a determinant factor for patient satisfaction in gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala, India. BY ANEESH POOCHAPANDIYIL VELAYUDHAN PRASANNAN SUPERVISOR : MR. CILLIERS DIEDERICKS WALES ID : 1092227390326 KCB ID : 15040 Submitted in fulfilment of the requirements of the Taught Masters Dissertation to the University of Wales, for the degree of Masters in Business Administration (MBA). 1
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Critically evaluate service quality as a determinant factor
for patient satisfaction in gaining patient loyalty.
A case study of Travancore Medical College Hospital Kerala, India.
BY
ANEESH POOCHAPANDIYIL VELAYUDHAN PRASANNAN
SUPERVISOR : MR. CILLIERS DIEDERICKS
WALES ID : 1092227390326
KCB ID : 15040
Submitted in fulfilment of the requirements of the Taught Masters Dissertation to the
University of Wales, for the degree of Masters in Business Administration (MBA).
1
DECLARATION
This research work is purely the author’s own effort where the ideas of other
scholars and authors are referenced using the Harvard Referencing style. It has not
been previously accepted in substance in any degree and in not being concurrently
submitted in candidature in any degree
This dissertation is the result of my own investigation, except where otherwise
state, where correction services have been used, the extent and nature of the
correction is clearly marked in footnote(s). The ethical issues have been kept into
consideration during the preparation of this report and the responses of the
individuals to the research survey are kept confidential.
I hereby give consent for my work, if accepted to be available for
photocopying and for inter-library loan, and for the title and summary to be made
available to outside organizations.
Signed ……………………………………………………….. (Candidate)
Date: 14/02/2012
2
Table of contents Page No.
1. Introduction 1
1.1 Research background 2
1.2 Research Aim 4
1.3 Objectives 4
1.4 Rationale for choosing the research topic 5
1.5 Company profile 6
1.6 Conclusion 7
2. Literature review 7
2.1 Introduction 7
2.2 Aims and objectives 7
2.3 Literature Review 8
2.4 Service Quality Conceptualization 8
2.5 Dimensions of service quality 11
2.6 Measuring Service quality 12
2.6.1. Gap Model 13
2.6.2 SERVQUAL Model 15
2.6.2.1 Advantage of SERVQUAL Model 18
2.6.2.2 Criticism of SERVQUAL Model 18
2.6.3 SERVPERF Model 20
2.7 .Patient satisfaction 20
2.8. Patient satisfaction and its dimensions 23
2.9 .Theories of customer satisfaction 24
2.10. Measure of customer satisfaction 24
2.11. Patient Loyalty 25
2.12 Importance of custom loyalty 26
2.13 Measurement of patient loyalty 27
2.14 Service quality and customer satisfaction relationship. 29
2.15 Service quality and customer loyalty relationship 29
2.16 Customer satisfaction and customer loyalty relationship 29
2.18 Conclusion 30
3
3. Research Methodology
3.1 Introduction 31
3.2 Aims and objectives 31
3.3 Research Methodology 31
3.4 Research Design 32
3.4.1 Exploratory Research 33
3.4.2 Descriptive research 33
3.4.3 Explanatory research 33
3.4.4 Justification for research design 33
3.5 Research Philosophy 34
3.5.1 Epistemology 34
3.5.2 Positivism 34
3.5.3 Realism 34
3.5.4 Interpretivism 35
3.5.5 Ontology 35
3.5.5.1 Subjectivism 35
3.5.5.2 Objectivism 35
3.5.6 Axiology 35
3.5.7 Justification of research philosophy 36
3.6 Research approach 36
3.6.1 Justification of research approach 37
3.7 Research Strategy 38
3.7.1Quantitative data 38
3.7.2 Qualitative data 38
3.7.3 Justification of research strategy 38
3.8 Source of data 38
3.8.1 Primary data 39
3.8.2 Justification of primary data 40
3.8.3 Secondary data 40
3.8.4 Types of secondary data 41
3.8.5 Justification of secondary data 41
4
3.9 Sampling 42
3.9.1 Probability sampling or Representative sampling 42
3.9.2 Non Probability Sampling or judgemental sampling 42
3.9.3 Justification of sampling 42
3.10 Conclusion 42
4. Research findings and Analysis
4.1 Introduction 43
4.2 Aim and Objective 43
4.3 Analysis of primary data 44
4.4 Comparing primary data with secondary data 65
4.5 Conclusion 67
5. Conclusion and Recommendation
5.1 Introduction 69
5.2 Aim and Objective 69
5.2.1 Achievement of objective 1 69
5.2.2 Achievement of objective 2 70
5.2.3Achievement of objective 3 72
5.2.4 Achievement of objective 4 72
5.3Conclusion 73
5.4Research limitation 73
5.5Recommendations 74
5.5.1 Recommendation 1 74
5.5.2 Recommendation 2 77
5.5.3 Recommendation 3 80
5.5.4 Recommendation 4 82
5.5.5 Recommendation 5 82
5.5.6 Recommendation 6 84
5.5.7 Recommendation 7 84
5.5.8 Recommendation8 84
6. Reflective summary 85
5
7 Reference 86
8 .LIST OF FIGURES
1. Fig 2.1 Gap Model 14
2. Fig 2.2 Measurement of patient loyalty 27
3. Fig 2.3 Patient loyalty and service quality model 28
4. Fig 2.4 The relationship between service quality,
Customer satisfaction and customer loyalty. 30
5. Fig 3.1 Research onion 32
6. Fig 3.2 Source of Data 39
7.Fig 3.3 Primary data 40
8.Fig 3.4 Secondary data 41
9. List of Tables
1. Table 2.1 22 Items of SERVQUAL instruments 17
2. Table 2.2 Customer Benefits 26
3. Table 3.1 Types of Research Design 33
4. Table 3.2 Research Approach 37
5.Table 4.22 Patient satisfactory 65
6. Table 5.1 Gantt Chart of ERP 76
7. Table 5.2 Gantt Chart of recruitment of HR trainers 79
8. Table 5.3 Gantt chart of CCTV 81
9.Table 5.4 Gantt chart of purchase of medicines 83
9.List of Charts
1. Chart 4.1 Distribution of sample size according to age and sex 44
2. Chart 4.2 The reason for choosing hospital 45
3. Chart 4.3 The receptionist was friendly and courteous 46
4. Chart 4.4 The staff respects the patient with respect ,dignity and were
Courteous in the hospital 47
5. Chart 4.5 There is a lot of paper work for admission 48
6
6. Chart 4.6 The service cost for hospital is affordable. 49
7. Chart 4.7 All the staffs were in correct uniform 50
8. Chart 4.8 Hospital is visually attractive 51
9. Chart 4.9 Hospital is a convenient location 52
10 Chart 4.10 Hospital has good directional science 53
11. Chart 4.11 Hospital provides services at allocated time 54
12. Chart 4.12 Hospital department is working effectively 55
13 Chart 4.13 You felt ease during your appointment 56
14 Chart 4.14 Doctors listen carefully and adhered to your needs 57
15 Chart 4.15 Hospital addresses the patient complaint quickly 58
16 Chart 4.16 Do you think staff responded immediately 59
17 Chart 4.17 Hospital employee are sympathetic and re assuring 60
18 Chart 4.18 Hospital doctor prescribes affordable medicine 61
19 Chart 4.19 Average waiting time in the hospital 62
20 Chart 4.20 Charges of TMC hospital is affordable 63
21 Chart 4.21 Recommending hospital to the friends and relatives 64
10. 1 Appendix 1 92
2. appendix 2
7
Chapter 1
Introduction
1 Introduction
All business organisations including health care organisation are interested in
achieving long term financial success (Al Hawary et al., 2011). Healthcare is one of
the most important elements of life and people always demand a better quality of
health to have a healthy life. This patient centric approach and consumer satisfaction
became the fundamental requirement for healthcare providers (Desai, 2011).In the
recent years the number of private and public hospitals had been increased
tremendously. In order to gain competitive advantages in the health care industry
and improve the operative efficiency the hospitals have adopted quality improvement
measures (Yasin et al., 2011) . Likewise Bullet (1996) had identified service quality
as a corporate market strategy and financial performance driver and had stated that
the hospitals can achieve competitive advantage and operational efficiency by
adopting service quality as a strategic tool. According to Shaktivel et.al (2005)
customer satisfaction is one of the critical factors that judges the service quality
delivered to the customers (Shaktivel et.al (2005); cited by Ooi et al., 2011).Impact of
patient satisfaction in choosing hospitals are important. Research had shown that
there are links between patient satisfaction and healthcare quality (Kessler & Mylod,
2011). Woodruff in 1997 had pointed out that service providers consider customer
loyalty as a competitive advantage. Many researches had proved that enhanced
customer loyalty increase profitability of the organisation (Woodruff (1997); cited by
Wang & Wu, 2012). On the other hand Strasser et.al in 1995 had stated that
negative word of mouth can cause hospitals a revenue loss of 6000$ to 400,000 $
(Naidu, 2009).With the increasing no of private and public hospitals the completion
to be the top health care provider is intense. The private hospitals compete with each
other to provide the best healthcare. According to Lim and Tag (2000) the public
awareness and rising literacy rate in the population made healthcare providers to
provide high quality treatment to the patient. Every patient have expectations what
their health care centre is going to provide them .Every healthcare centres should
8
give attention to reduce the gap between what patients actually expects and the
service that is actually delivered. (Lim and Tag (2000); cited by Suki et al., 2011). In
this research the author will be evaluating service quality as a determinant factor for
patient satisfaction in gaining patient loyalty.
First of all the author begins with the research background then the author had
discussed about research aims and objectives then the author had talked about
about the reason for choosing this research topic, the company’s background and
finally will conclude by summarizing the entire research research.
1.1 Research background
India has been witnessing increasing demand for quality healthcare after
globalization. Urbanization had improved quality of life which in turn had demanded
quality health care. Service quality has been chosen as an important element by
consumers for selecting hospitals (Dr.Vanniarajan & Arun, 2010).India has now
become a medical hub and the patients from the Western countries and other parts
of Asia and Africa use undergo treatment due to due to low cost and high quality
treatment. According to KGMP report of 2011 the healthcare industry in India will
grow from USD 79 Billion in 2012 to 280 Billion in 2020 (KMPG, 2012).Eventhoug
the health care spending in India is significantly low as compared to the developed
countries and other emerging countries. The average CAGR for the healthcare
industry in the next 10 years is 21%. . In India more than 50 percent of healthcare
expenditure comes from the individual against the state level government
contribution of less than 30 percent (Padma et al., 2010) .According to the WHO
health statistics 2010 private sector contributes approximately 75 % of the health
sector. The key factors for the growth of healthcare sector are Increase in
population, rising disposable income of the population, rising literacy rate,
demographic changes by 2026 there will be an increase in geriatric population from
current 96 million to 126 million which means that there will be an increased
dependence on hospitals, increase in lifestyle related diseases like cardiovascular
disease, diabetes. The health care industry in India is also facing many challenges
like lack of manpower and infrastructure. The healthcare infrastructure in India lags
behind the global average .India has only .6 doctors per 1000 population against the
global average of 1.3 it is evident from this finding that there is a gap of man power.
9
The no of bed available per the 1000 population is only 1.27 which is less than the
global average of 2.6%.However in the last decade there was an increase
participation of private sector in the healthcare industry. In the coming years the
healthcare sector will be facing stiff competition due to increased no of private
hospitals and because of the government policies allowing 100 % FDI in hospital
sector .In order to have a competitive advantage in this highly competitive
environment the hospitals should improve their quality standards in lieu with their
counterparts. Hospitals should implement healthcare accreditations like JCI (Padma
et al., 2010).
Despite of the growth of the healthcare industry the hospitals and other health
care organisations are struggling to deliver quality healthcare in this competitive
environment (Avgar et al., 2011).The service delivery system in the recent years
have been restructured and is now patient centric (Desai, 2011).Moreover the
studies done by Sahay (2008) shows that there is a need for improvement for
customer service (Padma et al., 2009). In recent years concern for service quality
had gained unprecedented levels. Service quality had now become an important
distinguishing factor between services to gain competitive advantage (Rashid &
Jusoff, 2009). According to Taner and Antony (2006) health care service has a
unique position among other service due to its very nature of highly involved risk.
This makes measuring service quality and patient satisfaction in healthcare setting
more important and more complex (Taner & Antony, 2006; cited by Rashid & Jusoff,
2009)
According to Kotler in 1998 customer loyalty is an indispensable tool for profit and
non profit organisation to sustain competitive advantage and to enhance business or
service measures (Chahal, 2008). The research done by many researchers like
Berry et .al (1989) had emphasised the fact that “good service quality leads to the
retention of customers and attraction of new ones, reduced cost ,enhanced
corporate image, positive word of recommendation increases profitability of an
organisation”. Service quality has become an important element in selecting
hospitals by people (Berry et .al (1989) ;Reichheld and Sasser (1990);Rust and
Zahorik (1993) ;Cronin et.al (2000);Kang and James (2004) ;Yoon and Suh
(2004); cited by Dr.Vanniarajan & Arun, 2010).According to Analeeb (1998) was in
the point of view that hospitals who don’t give importance to customer satisfaction
10
may be inviting extinction. Service quality are of great importance for the service
marketers because they are under the direct control of the service providers and its
consequence may improve service satisfaction and it will influence the buyers
behavioural intention which will lead to use the service again .This will ultimately lead
to customer loyalty (Padma et al., 2010).By doing this research the author can find
the gaps in the service provided by the hospital and can recommend the hospital to
reduce the gap between the customers expectation and the actual service delivered
so that they can increase patient satisfaction and gain patient loyalty .
1.2 Research Aim
Critically evaluate service quality as a determinant factor for patient satisfaction in
gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,
India.
1.3 Objectives
1. To review literature on service quality, patient satisfaction and patient loyalty.
2. To investigate the current service quality measures adopted by Travancore
Medical College Hospital
3. To evaluate the service quality offered by Travancore Medical College
Hospital and its effect on patient satisfaction in gaining patient loyalty.
4. To recommend Travancore Medical College Hospital to improve the service
quality so that they can increase patient satisfaction and gain patient loyalty.
1.4 Rationale for choosing the research topic
Service quality is an important determinant to appraise the triumph of any entity as
success in meeting the client’s expectation is the definitive objective of business.
Customer contentment has been considered as significant success factor in today’s
spirited business milieu, as they facilitate in retaining customers and maintaining
market share. It is also not different in case of hospital. It is one of the imperative
benchmark used to measure the patient satisfaction in gaining fidelity towards the
hospital. Because the totality of services rendered by the hospital to its patients is
the input en route for the patients and the contentment derived is the output.
11
Escalating customer satisfaction is vital for customer allegiance. Service providers
should always manage to improve customer satisfaction it is one of the factor by
which the patient measures the quality of the medical services offered. Hence an
attempt has been done to articulate to evaluate service quality as a determinant
factor for patient satisfaction in gaining patient loyalty, for which a case study was
done in Travancore Medical College Hospital, one of the leading private sector
hospitals in Kerala, India.
1.5 Company Profile
Travancore Medical College Hospital Kerala, India. The TMCH consists of 800
bedded multi speciality hospital with state of the art facilities. It is a unit of Quilon
medical trust started with the view to promote medical education and health care to
the minorities of the society with the motto “service with love”. The hospital has a
highly qualified doctor, dedicated nursing staff and a technically sound paramedical
staff. The hospital has unique facilities like 15 bedded medical ICU unit, 15 bedded
emergency ICU unit, 6 bedded neuro ICU unit. There are about 10 operation
theatres in the hospital along with other laboratory units such as biochemistry It is
one of the premier medical facility for trauma, emergency, critical care and
ambulatory care. TMCH is one of the reputed medical emergency care centres in the
south Kerala region, and receives most complicated referral cases from many other
hospitals. The administration and medical team are highly qualified based on
education training. The hospital is equipped with the most advanced high technology
instruments to provide the best treatment available. The hospital has a dedicated
highly experienced nursing staff to avoid mal practice. They have a medical college
and a nursing college attached to the hospital .TMCH is the leading medical
education provider in Kerala. They admit nearly 100 students each year. The
hospitals have the best infrastructure available and the best available medical
teachers in India. The hospital has 22 department with the most experienced and
eminent doctor of Kerala. As a part of the social commitment the hospital was
providing free treatment for the patients hospitalised in the ward. The hospital also
has satellite centres in the interior parts of the kerala where there are no hospitals
and the patients around that place fully depend on these hospitals. As a part of the
professional development in career the hospital proves continuing medical education
12
programmes on regular basis so that all the doctors in the hospital can participate
and be updated (Travancore medical college, 2012).
1.6 Conclusion
The author had divided the dissertation into 5 chapters. In Chapter 1 the author
gives a brief overview of the entire research which includes the research aim and
objective a brief back ground of the health care industry and the hospital selected .
In Chapter 2 the author critically reviews all available literature which are in the forms
of journals, books, website and newspaper which forms the secondary data. In
Chapter 3 the author forms a framework for the primary analysis .The author then
discuss about the various methods adopted in research which include research
strategy, research approach, research philosophy, sample size and the sampling
method used. In Chapter 4 The author will be analysing the primary data,
questionnaire that were distributed to the patients of the TMC hospital and then the
author will be comparing the findings with the secondary research. In Chapter 5 the
author draws a conclusion from the primary and secondary research and the author
put forwards some suggestions that can improve the service quality standards of
TMCH to improve patient satisfaction so gain patient loyalty.
13
Chapter 2
Literature Review
2 .1 Introduction
In the present chapter author reviews the literature related to Service Quality,
Patient satisfaction and Patient loyalty get a deep insight and understanding of these
topics and to form the basis of future primary research .All the data’s that we collect
both the primary and the secondary should be compared so that the researcher can
draw conclusions from it and suggest recommendation for improving the present
situation. The author can suggest good recommendation’s only if the author has
done a strong secondary research. So the author had made use of all the available
data to frame a strong foundation for the research.
First of all the author begins the chapter by restating the aim’s and objective
and then begins reviewing the literature by discussing about the conceptualization of
service quality then about the dimensions of service quality. The author had also
discussed the different models of service quality used to measure them.
The author then had focused on patient satisfaction its dimensions and theories.
The discussion then moves on to patient loyalty, importance of patient loyalty and
measurement of patient loyalty. Finally the chapter had concluded by discussing the
relationship between service quality and customer loyalty, relationship between
customer loyalty and customer satisfaction and the relationship between customer
satisfaction and customer loyalty.
2.2 Aim and objective
Critically evaluate service quality as a determinant factor for patient satisfaction in
gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,
India.
1. To review literature on service quality, patient satisfaction and patient loyalty.
14
2. To investigate the current service quality measures adopted by Travancore
Medical College Hospital
3. To evaluate the service quality offered by Travancore Medical College
Hospital and its effect on patient satisfaction in gaining patient loyalty.
4. To recommend Travancore Medical College Hospital to improve the service
quality so that they can increase patient satisfaction and gain patient loyalty
2.3 Literature Review
In the last few decades the hospitals are thriving to provide the highest possible
service quality to its patients at a lowest possible cost. Morris and Bell (1995) had
stated that the issue of defining, measuring and monitoring the quality of healthcare
had been addressed from ancient times (Morris and Bell,1995; cited by Sivakumar &
Srinivasan, 2010).According to Youseff et.al (1996) all hospitals in healthcare sector
provides same type of service but different quality of service (Youseff et.al, 1996
cited by; Suki et al., 2011). According to Berry et al (1988) with the constant increase
in customer and increasing competition service quality is the key factor that major
service companies have (Berry et.al, 1988 ; cited by Sainy, 2010).It is easy to see
that with the rising income of people and literacy rate of people they demand high
quality healthcare.. In a patients view point service quality is ultimately how they
judge the service they had encountered in the hospital which includes the interaction
with the doctors , nurses the staffs of the hospital outcome of the service. There fore
service quality of hospitals can be the key deciding factor for the selection of
hospitals
2.4 Service Quality Conceptualization
First of all there are different concepts for service quality to begin with initially
Takeuchi and Quelch (1983) had assessed the service quality of healthcare by six
dimensions namely reliability, service quality, prestige, durability, punctuality and
ease of use (Takeuchi and Quelch, 1983; cited by Dr.Vanniarajan & Arun, 2010),
Gravin (1984) had established 5 categories or approaches to the concept of quality
namely transcendent based on degree of excellence, product based which involves
measurable characteristics of products, User based which involves meeting the
needs of the user, manufacturing based on the conformance with design or
15
specification and finally value based which involves how much of something is
related to price (Gravin ,1984; cited byAl Hawary et al., 2011).
Similarly Gonroos (1984) had stated “that the perceived service quality is an
evaluation process where the customer compares his expectation with the service
that he had received ’’. He had proposed that there are two types of service quality
the functional ‘’service quality’’ and ‘’technical service quality’’. The functional service
quality is that the manner in which serve quality is delivered and technical service
quality is what actually the customer received from the service ( Gonroos 1984;cited
by Alrubaiee & Feras, 2011). Later in 1990 Gonoroos had added image of service
providers as a third dimension which acted as a filter in consumers perception of
quality (Padma et al., 2009).However Lehitmere and Jukka (1985) had presented a
holistic view to measure, monitor and operational customer perception of service
quality in health care organisation (Lehitmere and Jukka,1985; cited by
Dr.Vanniarajan & Arun, 2010).
Bopp (1986) had developed a “medical service quality active satisfaction model”.
The mode evaluates the service quality in consumption stage of patients purchase
cycle”. The finding of the study revealed that the factors that that played a role in
patient evaluation include expressive caring, expressive professionalism and
expressive competence of the service interaction. The study results emphasised that
staff’s with expressive caring, professionalism and physicians expressive caring has
a significant effect on patient satisfaction. (Bopp, 1986; cited by Sivakumar &
Srinivasan, 2010)
According to Parasuraman (1988) “service quality is defined as a global
judgement or attitude, relating to overall superiority of the service’’ (Parasuraman
1988; cited by Blery et al., 2011).John (1987) had developed an instrument to
measure the construct the “perceived service quality”. The findings of the study were
encouraging for other researchers by revealing that the measure of perceived
service quality is a multi dimensional construct containing variables namely
From the Table 4.20 (appendix1) and Chart.19 it is clear that the opinion of patients
regarding fee charged by the hospital towards various services rendered when
compared to other private hospitals shows unique opinion among the patients.
From the Table 4.20 (appendix1), it can also be seen that the chi-square value
(12.63) shows that there is significant association in the distribution of sample for the
opinion of patients regarding fee charged by the hospital towards various services
rendered when compared to other private hospitals and gender wise group of
patients in the hospital. It means that the difference in the opinion regarding fee
72
charged by the hospital towards various services rendered when compared to other
private hospitals and gender wise group of patients in the hospital significant and
associated to each other. This shows that fee charged by the hospital towards
various services rendered when compared to other private hospitals is almost
similar, and there is no difference in the charges favourable to patients
Will you recommend this hospital to relatives and friends?
From the Table 4.22 (appendix), chart 4.21 it can also be seen that the chi-
square value (4.47) shows that there is no significant association in the distribution of
sample for the opinion about recommending this hospital to relatives and friends and
gender wise group of patients in the hospital. It means that the difference in the
opinion about recommending this hospital to relatives and friends and gender wise
group of patients is not significant and not associated. This shows that patients are
unique in supporting the fact that they will not recommend this hospital to their
friends and relative for treatments.
Chart 4.21 Will you recommend this hospital to relatives and friends
73
Strongly agree Agree No opinion Disagree Strongly Disagree0
5
10
15
20
25
30
21.05 20.39
23.68
17.76 17.115.82
20.86
17.98
20.83
24.46
Males Females
Author (2012)
Patient satisfaction factors
Table 4.22 Patient satisfaction factor
1 Affordable charges for services rendered 3 62 Lower Service cost 2 83 Sense of wellbeing you felt in the hospital 4 34 Prompt services( no waiting time) 9 25 Services provided as expected 5 76 Location easily accessible 1 107 Efficiency of admitting procedure 7 58 Friendly and courteous staff/doctors 10 99 Healthy, neat and clean environment 8 4
10 Prompt diagnosis of diseases 6 1
Author(2012)
From the Table 4.22 it is clear that the ranks assigned by the male and
female respondents were separated and analysed. It is clear that “Location easily
accessible” is the first rank assigned by male respondents; where as female
respondents are giving preference for prompt diagnosis of diseases at right time.
The second rank is for Lower Service cost opined by male respondents, where as it
is the prompt services by the hospital as opined by the female respondents. It is
74
also note that male respondents gave third rank to Affordable charges for services
rendered and that of female it is sense of wellbeing felt in the hospital.
Based on the findings “Rho test” was done. The value obtained is -0.07. This
shows that there is low negative relationship among the ranks assigned by the male
and female regarding various factors relating to satisfaction towards the hospital
which shows that there is independent opinion regarding gender wise respondents of
the hospital.
4.4 Comparing Primary research with Secondary research
In the second chapter the author had explained the relationship between Service
quality, patient satisfaction and patient loyalty with the help secondary data like
journals and books. So the final findings from the primary data should be compared
with the secondary data to give the final conclusion to the research.
In the chapter 2 (2.3) the author had discussed price of a service is one of the key
factor which acts as a service winner for an organisation which is coherent with the
findings of table 4. This shows that the main reason for the selection of the hospital
is the cost. In the chapter 2 (2.1) the author had discussed the interaction quality of
the staff of an organisation evaluates the service quality of the hospital .The findings
of the chapter 4 supports the fact that the receptionist are very cordial to the patient.
The patients usually have the first interaction with the receptionist they are the face
of the organisation. In the chapter 2 (2.4) the author had discussed that location of
the hospital is an important dimensions of service quality and it is proved by the
findings of chapter 4 that patient considers it as an important factor.
In the chapter 2 (2.4) the author had discussed that the patient measures
the service quality of the hospital on the interaction quality i.e. It refers to the
interaction they encounter with the different staff of the hospital even though they
had warm welcome from the receptionist the interactions with the other staff was
disappointing. The finding of this chapter points out that the patient were not
satisfied in the way they were treated by the staff, they were in the that the staff were
not in proper uniform and the staff had a swift response when asked for help and
they were feeling uneasiness during their appointment.
75
In chapter 2 (2.3 and 2.5.2) the author had discussed time as a dimension
of service quality and had stated that waiting time is an important customer care
quality factor that is critical for health care facility. The patient considers the time
spent for the service as a factor which measures the service quality of the
hospital .The findings of this chapter shows that the patient has disappointed with the
paper work in the hospital and it has caused an increased waiting time in all the
departments of the hospital.
In the chapter 2 (2.4) the author had discussed patients evaluation of tangible
assets of the organisation which includes the physical facility and staff. It is evident
from the finding of this chapter that the patients are not satisfied with the visual
appearance of the hospital and the directional’s signs of the hospital.
In the chapter 2(2.7) the author had discussed that patient satisfaction is an
antecedent of service quality and patient satisfaction enhanced by the interaction of
patients and doctor but the findings of this study points out that patients are not
satisfied with the attitude of the doctors not listening to them and prescribing
expensive medicines.
In the chapter 2 (2.13) the author had discussed about that the strongest
measure of customer loyalty is referring the service providers to others is the
strongest form of patient loyalty. But the findings of the research done on TMCH
shows that they will not be recommend the hospital to their friends and hospital.
Based on the findings “Rho test” was done. The value obtained is -0.07. This
shows that there is low negative relationship among the ranks assigned by the male
and female regarding various factors relating to satisfaction towards the hospital
which shows that there is independent opinion regarding gender wise respondents of
the hospital
4.5 Conclusion
The analysis of the findings shows that there is an independent association among
the distribution of sample age and sex group of patients and the hospital they
76
belong. It means that the difference in the distribution of sample age and sex from
the hospital is not significant and not associated to each other
The analysis of primary data and comparing it with secondary data aided the author
to achieve the research objective. The conclusions the author made from the
research is as follows. Even though the management of hospital had managed to
reduce the gap between the patient expectation and the actual service delivered in
some areas. There are certain gaps in the service which the management of the
TMCH hospital must give attention in order to improve patient satisfaction to gain
patient loyalty.
The findings of this chapter support the fact that the receptionists are very cordial to
the patient. The patients usually have the first interaction with the receptionist they
are the face of the organisation which is coherent with the secondary data.
The finding of this study shows that the main reason for the selection of the hospital
is the cost which is coherent with the secondary data
The findings of the study shows that location of the hospital which is an important
dimensions of service quality is the factor for the selection of the hospital which is
coherent with the secondary data
The finding of this study shows that even though they had warm welcome from the
receptionist the interactions with the other staff was disappointing. The finding of this
chapter points out that the patient were not satisfied in the way they were treated by
the staff, they were in the opinion that the staff were not in proper uniform and the
staff had a swift response when asked for help and they were feeling uneasiness
during their appointment. The patients measures the service quality on interaction
quality the management of the hospital should attention to reduce this service gap .
The patient considers the time spent for the service as a factor which measures the
service quality of the hospital .The findings of this chapter shows that the patient
were disappointed with the paper work in the hospital and it has caused an
increased waiting time in all the departments of the hospital. The management of the
hospital should pay attention to reduce the this gap in the service,
77
The patient satisfaction is an antecedent of service quality and patient satisfaction is
enhanced by the interaction of patients and doctor but the findings of this study
points out that patients are not satisfied with the attitude of the doctors not listening
to them and prescribing expensive medicines. The management should pay
attention to this service gap.
The patient evaluates the tangible assets of the organisation which includes the
physical facility and staff. It is evident from the finding of this chapter that the patients
are not satisfied with the visual appearance of the hospital and the directional’s signs
of the hospital. The management of the hospital should reduce this service gap,
The strongest measure of customer loyalty is referring the service providers to others
is the strongest form of patient loyalty. But the findings of the research done on
TMCH shows that they will not be recommend the hospital to their friends and
hospital
78
Chapter 5
Conclusion and Recommendation
5.1 Introduction
In this chapter the author had presented a general conclusion for the entire research
and had put forward recommendation to improve the service quality of TMCH so that
they can increase patient satisfaction and gain patient loyalty.
The Author begins the chapter by restating the aims and objectives of the research
which is followed by the discussion how objectives were achieved. The author then
5.2 Aim and objective
Critically evaluate service quality as a determinant factor for patient satisfaction in
gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,
India.
1. To review literature on service quality, patient satisfaction and patient loyalty.
2. To investigate the current service quality measures adopted by Travancore
Medical College Hospital
3. To evaluate the service quality offered by Travancore Medical College
Hospital and its effect on patient satisfaction in gaining patient loyalty.
4. To recommend Travancore Medical College Hospital to improve the service
quality so that they can increase patient satisfaction and gain patient loyalty
5.2.1 Achievement of objective 1.
The author had critically reviewed the literature available on service quality, patient
satisfaction and patient loyalty. In the beginning of the chapter 2 the author had first
discussed about the service quality then moved on to the how to measure service
quality. Then discussed about different models of service quality. Then the author
had talked about patient satisfaction ,patient satisfaction and its dimensions, theories
of customer satisfaction and measuring customer satisfaction. Then the author had
79
discussed about patient loyalty then its importance and measurement of patient
loyalty. Then the author had discussed about service quality and its relationship
between customer satisfaction, then about service quality and its relationship
between customer loyalty, and finally the relation between customer satisfaction and
customer loyalty.
5.2.2 Achievement of objective 2
The author had coined the objective of analysing the current service quality
measures adopted by TMCH was made to find the present service quality standards
offered by the hospital. Without knowing the present status the author cannot put
forward recommendation for the improvement of the organisation. For understanding
the service quality of the TMCH parameters of the service quality were considered
like cost, interaction quality of the staff, responsiveness of staff, the infrastructure,
the atmospherics of the hospital, patient satisfaction.
The analysis of the findings shows that there is an independent association among
the distribution of sample age and sex group of patients and the hospital they
belong. It means that the difference in the distribution of sample age and sex from
the hospital is not significant and not associated to each other.
After the analysis of the primary data and by comparing it with secondary data
helped the author to achieve the second objective by having the data of current
service quality mesaures .Even though the management of hospital had managed to
reduce the gap between the patient expectation and the actual service delivered in
some areas. There are certain gaps in the service which the management of the
TMCH hospital must give attention in order to improve patient satisfaction to gain
patient loyalty.
The findings of this chapter support the fact that the receptionists are very cordial to
the patient. The patients usually have the first interaction with the receptionist they
are the face of the organisation which is coherent with the secondary data.
The finding of this study shows that the main reason for the selection of the hospital
is the cost which is coherent with the secondary data
80
The findings of the study shows that location of the hospital which is an important
dimensions of service quality is the factor for the selection of the hospital which is
coherent with the secondary data
The finding of this study shows that even though they had warm welcome from the
receptionist the interactions with the other staff was disappointing. The finding of this
chapter points out that the patient were not satisfied in the way they were treated by
the staff, they were in the opinion that the staff were not in proper uniform and the
staff had a swift response when asked for help and they were feeling uneasiness
during their appointment. The patients measures the service quality on interaction
quality the management of the hospital should attention to reduce this service gap by
giving more customer relation training.
The patient considers the time spent for the service as a factor which measures the
service quality of the hospital .The findings of this chapter shows that the patient
were disappointed with the paper work in the hospital and it has caused an
increased waiting time in all the departments of the hospital. The management of the
hospital should pay attention to reduce the this gap by investing in the IT
infrastructure of the hospital.
The patient satisfaction is an antecedent of service quality and patient satisfaction is
enhanced by the interaction of patients and doctor but the findings of this study
points out that patients are not satisfied with the attitude of the doctors not listening
to them and prescribing expensive medicines. The management should pay
attention to this service gap and enhance patient centred consultation.
The patient evaluates the tangible assets of the organisation which includes the
physical facility and staff. It is evident from the finding of this chapter that the patients
are not satisfied with the visual appearance of the hospital and the directional’s signs
of the hospital. The management of the hospital should reduce this service gap by
investing in the interior of the reception in the first phase and alteron continuing after
evaluation.
81
5.2.3 Achievement of objective 3
Even though the management of hospital had managed to reduce the
gap between the patient expectation and the actual service delivered in some areas.
There are certain gaps in other areas service where the management of the TMCH
hospital must give attention in order to improve patient satisfaction to gain patient
loyalty.
From the findings it is clear that “Location easily accessible” is the first rank
assigned by male respondents, where as female respondents are giving preference
for prompt diagnosis of diseases at right time. The second rank is for Lower Service
cost opined by male respondents, where as it is the prompt services by the hospital
as opined by the female respondents. It is also note that male respondents gave
third rank to Affordable charges for services rendered and that of female it is sense
of wellbeing felt in the hospital. “Rho test” value obtained is -0.07 and there is low
negative relationship among the ranks assigned by the male and female which
shows that there is independent opinion regarding gender wise respondents of the
hospital.
However the strongest measure of customer loyalty, referring the service
providers to others is the strongest form of patient loyalty. But the findings of the
research done on TMCH shows that they are unique in the opinion that will not be
recommend the hospital to their friends and hospital. This pinpoints a fact that there
is a serious lapse of customer quality measures adopted by TMCH and the
management of TMCH should immediately take steps to reduce the gaps in the
service. As Analeeb (1998) had said that hospitals that fail to understand the
importance of customer satisfaction are inviting a possible extinction.
(Analeeb ,1998; cited by Padma et al., 2010)
5.2.4 Achievement of objective 4
Steps to take to improve the service quality measures of TMCH have been
discussed by the author under the topic ‘Recommendation’ later in this chapter there
achieving the fourth objective.
82
5.3 Conclusion
In the conclusion part the author will be summarizing from Chapter 1 to Chapter 4.
The author begins the chapter 1 by giving a brief overview of the entire
research .Then the author starts the second chapter by restating the aims and
objectives of the research then the author had talked about the service quality, the
dimensions of service quality, measuring of service quality, the gap model of service
quality the SERVQUAL model and the author had criticised SERVQUAL model.
Then author had discussed about the patient satisfaction, then its dimension and
theories and how to measure it. Later the author had discussed about the Patient
loyalty, how to measure the service quality, and discussion had further moved on to
service quality its relationship between customer satisfaction and patient loyalty and
customer satisfaction and patient loyalty.
The author had started the chapter 3 by restating the aims and objectives discusses
about the primary research of the research method. The author had adopted
explanatory research as research design. The research approach was deductive
approach and positivism as research philosophy. Books journals and the hospital
website will be used for secondary research and primary data will be collected by
distributing questionnaires to 500 patients. Simple random sampling of Probability
sampling will be uses as sampling technique.
In the chapter 4 the author had started by stating the aims and objectives .It is the
most important part as it deals with the analysis of primary data and later own the
author had done a discussion by comparing the primary data with the secondary.
5.4 Research limitations
Time was the main constrain for my research. The author could have done a better
analysis by using of SPSS.
83
5.5 Recommendation
5.5.1 Recommendation 1
Implementation of Enterprise Resource Planning (ERP)
The findings of table highlight that there is predicament in the admission procedure
in the hospital due to bungling paper work at the time of admission. The author
feels that Implementation of ERPin the hospital will improve the overall efficiency of
the hospital. ERP helps in streamlining and integrating the day to day activity of the
hospital and information flow in the hospital to synergize the resources like the
Staffs, the equipment, operational activities, administration, discipline and the cash
flow. By the implementation of EPR, it is possible to integrate information system of
the hospital covering all departments of the hospital.
By the execution ofERP, it is possible to trim down the admission process,
the billing procedure of both inpatient and outpatient, retrieving old patient file quickly
by entering the registration no. with the help of Electronic medical record, the
receptionist can dispatch the patient file directly to the doctor’s computer.ERP can
connect to the Radiology department and pathological labs. If the doctor needs a
further examination, he/she can send the report directly to the laboratory or the
radiology department and the doctor can access the results as soon as it enters in
the respective departments. It will help in tumbling the waiting time of the results.
The patient will also have a print out of prescription or the discharge summary.
Introduction of all these procedures will standardize the procedures of the hospital
and improve the hospital brand image. With the help of this system the receptionist
or the front desk staff can give flexible appointment to the patients of the visiting
doctors. In his way it is possible to reduce the waiting time significantly and will ease
the pressure on doctors and staff.
With the help ERP it is possible to improve inventory stock
management of the pharmacy more easily and thereby it helps the management in
reducing operational cost.
84
In order to implement, a detailed project report on the HIS must be submitted to the
top management of the company. After the approval of the management,
advertisement for bid for ERP should be given on news paper and the company site.
From the bidders we should choose the most credible bidder with good track records
of implementing healthcare ERP. The training for the ERP can be finished in 10-15
days . The ERP can be implemented in 5 weeks time and it is shown in Table 5.1.In
this hospital we can opt for a phased approach so that it will not disturb the normal
business of the hospital. Implementation of ERP in the hospital is a costly procedure
and the project should be implemented with the given time. Many hospitals had
acknowledged that after the implementation of ERP there was a increase in
operation efficiency.
Table 5.1: Gantt chart for implementation of Enterprise resource planning
85
Work
Time Frame
Wee
k 1
Wee
k 2
Wee
k 3
Wee
k 4
Wee
k 5
Wee
k 6
Wee
k 7
Wee
k 8
Wee
k 9
Approval from
the officials
Bidding
Procedure
Selection of
Bidder
Awarding
Contract
Implementatio
n
Training
86
5.5.2 Recommendation 2
Recruitment of HR trainers for motivating the doctors and the staffs of the hospital to
implement a patient cantered approach
It is evident that the present approach adopted by the hospital is directive approach
in which the doctor and the management have an upper hand over the patients. The
hospital should change its approach to patient centred approach.
The healthcare managers and executives must ensure that there should be a
proper system in hospital for regular collection and reporting of patient care. The
manager should ensure that while executing health service action plan the
organisation should consider the quality improvement feed backs of the patients
experience in the hospital along with the clinical and operational data. The managers
should adopt evidence based patient centred care by recording and publishing
changes in the patient outcome in regular intervals. l. The managers should develop
and implement policies and procedure to involve patient families and care in service
level quality improvement and patient safety initiatives and healthcare design can be
improved. The managers should implement customised training strategies to build
capacity for all staff to support patient centred approach. The top management
should also focus on working environment, work culture and satisfaction of staff as
they play a vital role for improving patient centred care. Monitoring of the work
environment can be done at regular intervals through survey of workforce, reviewing
the recruitment policies of the staff and monitoring the retention rates of the staff.
The managers can integrate the care experience of patients they had in the hospital
in tune with staff performance appraisal and will foster patient culture. There are
different methods to promote patient cultured approach.
By implementing patient centred consultation the interaction time between the
doctors and patients are increased and this will lead to patient satisfaction which in
turn will lead to patient loyalty
The hospital should change the tradition way of delivering health care. New
methods should be adopted by the management which includes more interaction
with the patients and employees. The managers should foster a culture to go around
each department and have a chat with the employees so that they will have first an
87
experience about what happening around each unit. Also the managers should have
chat with the patients who are using the service of the hospital. The direct interaction
will help the organisation to reduce the service gaps. The managers should also
invite employees to have a chair side chat so that they can have an in depth
knowledge of what is happening in each unit. The managent should develop a
patient centred advisory council in which the staffs and clinicians of the hospital are
includes all these fosters patient centred culture in the hospital.
In patient centred approach the importance should be also give to the staff and
clinicians of the hospital as they are the care givers and any factors that affect them
will also affect the end users. So the hospital should motivate the employees by
implementing employee of the month programme, public acknowledgement of staff
member in the news letter which is published by the hospital for their impact on
patient experience. The more informal approach includes thanking the staff during
routine manager staff rounding. The staff satisfaction can be monitored by close
monitoring of the managers of the employees and addressing their issues with the
work place. An open door policy should be adopted by the management to address
the problems. They can be also monitored by surveys as we have mentioned earlier.
Value training is another factor that helps in achieving patient centred approach is
employee’s behaviour. Only when the employee’s personal value stimulates, the
core value of the organisation the cultural transformation takes place..
We should implement these training programmes in a phased manner in each
department within 7 weeks so that there will be smooth transition from the existing
directive work culture to the patient centred work culture. We can implement all these
strategies by recruiting an induction team of experienced HR trainers in the human
resource department. new trainers will be enough for the existing team. The salary
for the HR trainer will be around 240,000 Rs to 300,000 Rs per annum. The first
evaluation of the training can be done after 2 weeks of implementation department
wise
The return of the investment can be seen in within 6 months and the progress
can be evaluated by the feedback of patient experience in the hospital
88
Table 5.2: Gantt chart for Recruitment of HR Trainers
Work Wee
k 1
Wee
k 2
Wee
k 3
Wee
k 4
Wee
k 5
Wee
k 6
Wee
k 7
Approval
Advertisement
Interview
Recruitment
Framing of
policies
Implementatio
n
Department
wise training
Evaluation
5.5.3 Recommendation 3
89
Implementation of surveillance camera to close monitors the overall functions of the
hospital.
As it is evident from the findings that the patients are not satisfied with
the support staff. It shows that there is a lapse of close monitoring of staff by the
management. Since it is large hospital with 800 beds employing more and more mid
level manager will be a financial burden for the hospital. The available option will be
implementation of CCTv camera in and around the hospital and appoint an CCtv
operator. In a long run it will be feasible than appointing more people.
First of all a project report should be submitted to the top officials
then we should seek their approval and then it should be send to the finance
department of the hospital for approval. After that a tender for the implementation of
tender should be published in a leading news paper. As soon as the bidding
procedure is completed the tender should be awarded to a company which has good
track record and credible. The CCTv can be implemented in 2 weeks Soon after the
implementation of the CCTv The HR department have to recruit the CCTv operator.
The average salary for a CCTv operator in India will be nearly 70,000 per year. The
return of investment can be appreciated earlier as it is more cost effective than
implementing more staffs for closes monitoring of staffs. The evaluation of the CCTv
implementation can be done on the 9th week.
90
Table 5.3: Implementation of CCTV
Work
Time Frame
Wee
k 1
Wee
k 2
Wee
k 3
Wee
k 4
Wee
k 5
Wee
k 6
Wee
k 7
Wee
k 8
Wee
k 9
Approval
Bidding
procedure
Selection of
bidder
Awarding
contract
Implementatio
n of CCTv
Recruitment
of CCTv
operator
Training
Evaluation of
progress
5.5.4 Recommendation 4
91
It is evident from the findings that the patients are not satisfied with the
atmospherics of the hospital and the uniform of the staff as they were not in proper
uniform. The management should invest in the interior of the waiting area and
reception. They should provide a television and magazines to the waiting area, so
that it can make feel of comfort to the patients. The management should also invest
in buying hospital furniture’s like chairs and tables in the reception. The management
should implement a dress code for each section of staff. All the front desk staff
should be given same uniform likewise administrative department should have a
different uniform each section of the department should be given different uniform.
There should be a uniformity in uniform in each department The management should
provide identity card to all the staff. The management should emphasise that they
should greet the patients with a smile.
It can be implemented within a time frame of 3 months. we
can give a advertisement in the leading newspaper inviting bids for hospital
furniture ,dress for staff and identity card. From the potential bidders we can choose
credible bidder with good track record. By opting this method the hospital can save
lot of money.
5.5.5 Recommendation 5
It is evident from the finding that the medicines prescribed by the doctors are not
affordable for the patients. The first step in this regard is to ask the doctors to
prescribe generic medicines .But it is the sole decision of doctor to choose which
company’s medicine. Steps may also taken to negotiate directly with company of
reputed in nature to supply bulk quantity at reduced/concessional price, so that the
benefit received can further extend to the patients.
After getting the list of stock needed for the pharmacy an advertisement can be
placed in the local newspaper so that the potential bidders can bid for the contract of
the medicines. After the contract process we can purchase the medicine from the
bidders who have a good track record. Before placing the order for the medicines a
meeting with the clinical staff to ensure the quality of the medicine that we will be
92
purchasing. The entire process can be done within 9 weeks, Table 5.4. Evaluation of
the progress of the sales of medicines can be done after 4 weeks
Table 5.4 Gantt chart for the purchase of medicines at competitive price
Work
Time Frame
Wee
k 1
Wee
k 2
Wee
k 3
Wee
k 4
Wee
k 5
Wee
k 6
Wee
k 7
Wee
k 8
Wee
k 9
Approval
Bidding
procedure
Discussion
with
doctors
Selection of
bidder
Awarding
contract
Arrival of
stock
Available in
pharmacy
Evaluation
of progress
93
5.5.6 Recommendation 6
The TMC hospital should start their own health care insurance programmes by
having tie up with leading insurance agents. This will prove a competitive advantage
for the hospital as the hospital can provide cashless treatment for the patients who
come there for service. By having this insurance system the patients will come again
and again to avail treatment and this will ultimately lead to patient loyalty. There is
an increased penetration of health care insurance sector. Indian govt is also taking
steps to cover the poor people under insurance schemes.
5.5.7 Recommendation 7
The TMC hospital should implement a quality cell in the hospital where all the issues
of the quality will be dealt with. Since there are service gaps in the hospital a
dedicated wing quality assessors should be recruited. The Hr department of the
hospital should place an advertisement on newspaper and all other medium. An
interview date should be placed in the advertisement .Soon after the interview
eligible experienced guys should be recruited. Soon after their placement they
should implement new policies to improve the quality of the hospital. Performance
appraisal of the newly recruited should be conducted on a regular internal.
5.5.8 Recommendation 8
TMC hospital should work toward the implementation accreditation of JCI (Joint
Commission International) in the hospital which will help in maintaining the service
quality standards of the hospital as they often conduct standard checks. By having
JCI standards it opens a new horizon of business. The hospital can attract more and
more foreign patients. As the hospital is located in one of the famous tourism
destination .The hospital can attract more foreign patient and this will enhance the
profitability of the hospital. By having the accreditation it will improve the brand
image of the hospital.
94
Chapter 6
95
Reflective summary
In this chapter the author will discuss his experience throughout this course and
completing this dissertation. They have also developed skill after completing MBA
and my dissertation within the time frame was one of the greatest challenge the
author have faced in his life. By completing this dissertation the author have also
developed some skill which will be useful for future the author learned how to work
under pressure and meet deadlines. The multicultural experience that the author had
in UK will also help him to shape his career.
96
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Website
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Q30 Will you recommend this hospital to relatives and friends?
Table 4.22 :- Will you recommend this hospital to relatives and friends?
Status
Male Female Total
No % No % No %
Strongly Agree 32 21.05 22 15.82 54 18.55
Agree 31 20.39 29 20.86 60 20.61
Neutral 36 23.68 25 17.98 61 20.92
Disagree 27 17.76 29 20.83 56 19.24
Strongly Disagree 26 17.10 34 24.46 60 20.16
Total 152 100 139 100 291 100
c2test 4.47
Table value for df 4 at 0.05 level 9.49
Source :Author( 2012)
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Appendix 2
Questionnaires for the patients
I Aneesh .Prasannan is doing a survey questionnaire and collecting the data from the most valuable patients of the TMC hospital. Your opinion is very critical in my dissertation research. My analysis and recommendations are based on the response you give to the questioner. All the information submitted by you will be utilized for the academic purpose. Thanks for your co-operation.
Title: Critically evaluate service quality as a determinant factor for patient satisfaction in gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala, India.
For the following question please tick one of the following.
1. About you
Male Female
2. Age group
Under 18 19-34 35-5 55-74 75 and above 3. Are you employed?