CHAPTER – 1 INTRODUCTIONshodhganga.inflibnet.ac.in/bitstream/10603/8372/4/04_chapter 1.pdf · CHAPTER – 1 INTRODUCTION First chapter of the present study initiates with background

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CHAPTER – 1

INTRODUCTION

First chapter of the present study initiates with background of the select research

area. The discussion about need and scope of the study followed by literature review

conducted by various scholars and authors gives deeper insight of the research area. The

researcher also presents idea about how the research was conducted including objectives

of the present study, research approach, sample selection and data collection methods.

Disposition of the thesis is also presented at the end of the first chapter.

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1.1. INTRODUCTION

It is widely accepted by now that the contribution of service sector as against the

traditional manufacturing and agricultural sectors to aggregate output is significant across

the countries including our own. What is equally significant to note is that the quality of

the customer service rendered has not perhaps been a top priority with the Indian

manufacturing / service sector. Lack of customer / user friendliness and tardy response to

customer needs are common features in most of our utility services. Product quality and

customer service have perhaps taken a back seat in the mindset of personnel running the

organizations. As it is not enough, the customer is hit equally bad with high cost and

poor quality.

According to Global Competitiveness Report 2009 – 2010, India ranked 57 among 133

nations on the parameter “Degree of Customer Orientation”. On the parameter “Market

Size”, Domestic market Size index ranked 4th and Foreign market size index ranked 4th

among 133 nations. Switzerland tops the overall ranking and the United States falls one

place to second position and India ranked 49 among 133 nations in The Global

Competitiveness Report 2009-20101. Gone are the days where customers, being part of

the seller’s market, are prepared to take anything that is supplied. Because of the ever

increasing competition prevailing on the supply side consequent to economic

Liberalization, Privatization and Globalization (LPG) and increased internationalization,

the situation is changing fast on the demand side and customers these days have started to

assert themselves in asking for superior quality product / service at more affordable price

1 Klaus Schwab, Xavier Sala-i-Martin (2009), “The Global Competitive ness report 2009 – 2010”, WorldEconomic Forum – Geneva, Switzerland, pp. 13, 171.

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which is also the case with healthcare industry. The competition is intensifying in

Healthcare industry with the opening up of more and more hospitals.

Quality has thus gained a focal point in strategy crafting and implementation at the

organizational level. It has in fact become part of the vision and mission statement of

every economic organization in the society today. Quality2 is (1) Warranted for the

specific and general conditions (2) Cost efficient and (3) Payers expectations.

Quality refers to the closeness of an actual outcome to the outcome expected by the

observer, as defined or agreed to by that observed. Today, with the increased buyer

power in the market, customers have reached a stage where they start assuming that

quality of service is been given and looking for other attributes that make a big difference

among the offerings in the market place. Medical sector is being one of the important

service sectors in the economy is not an exception to this phenomenon.

Healthcare industry is one of the most challenging industries in India with projected

revenue of US$ 30 billion; it constitutes 5.2% of India’s GDP. The Indian health

industry has had a growth of over 12% p.a. in the past four years and is expected to grow

at 15% per annum to US$78.6, reaching 6.1% of GDP and employing 9 million people by

2012.3 The private sector plays a significant role by contributing 4.3% of GDP and 80%

share of healthcare provision. However, there is deficit with respect to access,

affordability, efficiency, quality and effectiveness, in spite of the high spending on

overall private and public health.

2 Padmaer Jadhav (2003), “Consumer Satisfaction & Perceived Quality of Healthcare Services in CorporateHospitals”, Osmaina University, Hyderabad, India, pp. 3 – 4.3 Federation of Indian Chamber of Commerce and Industry. India, http://www.ficci.com/.

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In order to be comparable with the healthcare parameters of other developing countries,

India’s healthcare sector faces many challenges. For example, to reach a ratio of two beds

per 1000 population by 2025, an additional 177 billion beds will be required which will

need a total investment of US$86 billion. There is an acute shortage of doctors, nurses,

technicians and healthcare administrators and an additional 0.7 million doctors are

needed to reach a doctor population ratio of 1:1000 by 20253.

The implementation of Service Quality in Healthcare sector improving its operational

efficiency resulting in efficient resource allocation, minimum wastage of the available

resource and significant improvement in the quality rendered, all leading to considerable

value addition to the end user of the hospital service i.e., the patient4. The hospital has a

primary obligation, a moral and legal responsibility to see that the quality care meets

acceptable standards and that the interests of the patients are well protected.

Service Quality looks critically at the services a hospital provides in relation to the

process it takes to create them, and the people who do the work to make certain that

output fully satisfies agreed patients requirements. The model claims that the patients

evaluate service quality experience as the outcome of the gap between expected and

perceived quality. The model emphasizes on the key requirements for a healthcare

provider delivering the expected service quality. Gauging service quality is a challenge

for healthcare marketers, SERVQUAL a comprehensive measurement scale/model is

empirically evaluated for its likely efficacy in a hospital service environment5.

4 Talluru Sreenivas, Ch. H.K.S Kumar (2006), “Service Sector in Indian Economy – Total QualityManagement In Hospitals”, Discovery Publishing House, New Delhi, India, 2006, pp. 237.5 Emin Babakus, W. Glynn Mangold (1992), Health Survey Research, Vol. 26(6): pp. 767-786.

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1.2. GROWTH OF HEALTHCARE INDUSTRY:

Health is one of the fundamental human right which has been accepted in the Indian

Constitution. Although Article 21 of the Constitution requires the State to ensure the

health and nutritional well being of all people6, the federal Government has a substantial

technical and financial role in the sector.

Hospitals are the backbone of the healthcare delivery system. Hospital care in India until

the early 1980s, were run by Government hospitals and those managed by charitable

associations. In the mid 80’s, the healthcare sector was recognized as an industry. In the

year 1991 Government of India initiated economic reforms. However post liberalization,

the sector attracted private capital and fresh investment that took place in setting-up

hospitals and smaller nursing homes. Large corporate groups and charitable

organizations brought private finance and these resources were invested in modern

equipments and technologies and in developing health infrastructure. This helped in

augmenting the availability of super-speciality services across the country. Corporate

groups such as Apollo Hospitals group, Care Health Foundation, Wockhardt group of

hospitals, Fortis Healthcare, Max India paved the way for corporate organization

structure for hospitals and have successfully developed a chain of multi-specialty private

hospitals. Private sector entry in India has opened many doors for medical and

paramedical manpower, medical equipment, information technology in health services,

BPO, telemedicine and medical and health tourism. There is an 20% increase over the

pervious year with an estimated 1,00,000 health tourists visiting India7.

6 Bhattachary. S (2005), Indian Journal of Medical Micro Biology, Vol. 23, No. 4, pp. 220-226.7 Federation of Indian Chamber of Commerce and Industry, India, 2008. http://www.ficci.com/health-more.htm

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Health sector which is estimated to be approximately Rs.80000/- crore is a massive sector

in India. The sector was uncared for and disjointed till recently. The new facilities

provided particularly in super speciality hospitals with the state-of-the-art equipment

should be able to provide not only quality services to the patients but also to meet the

expectations of all the stakeholders. Corporate sector has come up in many states of

India, who are adopting different business models like ‘hub and spoke model’ and

‘networking model’ to achieve their strategic objectives and goals. Regretfully, money is

generally at the top of the agenda. To meet the rising demands, India will need 80,000

beds every year for the next 5 years8.

Over the years the government has taken a number of policy steps to develop the hospital

sector in India. For example, the Union Budget of 2002–03 conferred infrastructure

status to the healthcare industry under Section 10(23 G) of the Income Tax Act. This

allowed the private hospitals to raise cheaper long-term capital. Similarly the Union

Budget of 2003–04 laid special emphasis on investment in private hospitals besides

giving the hospitals a true status of industry. Some of its specific policy changes were:

(a) benefit of Section 10(23 G) of IT Act extended to financial institutions providing

long-term capital to private hospitals with 100 beds or more, (b) rate of depreciation in

respect of life saving medical equipment increased from 25 per cent to 40 per cent9, (c)

reduction in basic customs and excise duties, (d) customs duty on specified life saving

equipment reduced from 25 per cent to 5 per cent, with exemption from additional duty

of customs. The Government also implemented a community based universal health

8 Wooster L (2007), “Is Healthcare ready for supply chain standards? Industry groups collaborate withNAHIT to identify protocols”, Material Manager Healthcare, Vol. 16(3): pp. 17-9.9 “Health for all: But man on the street has to wait”, The Financial Express, posted online Mar 16, 2003.

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insurance scheme covering hospitalization expenses. This was expected to provide

alternative source of financing and boost the hospital sector. All these initiatives were

expected to strengthen the hospital sector.

Govt. of India launched the National Rural Health Mission (NRHM) in 2005. Its

endeavor is to provide quality healthcare for all and increase the expenditure on

healthcare from 0.9% to 2-3% of GDP by 2012. The Union budget 2010–2011 has the

countervailing duty of 4% on all medical equipments, with full exemption from special

additional duty and Uniform/concessional basic duty of 5% for all medical appliances.

This budget focus is on rural healthcare, with the fund allocations rising to a whopping

Rs.22300 crore (Rs 223 billion/$4.82 billion) from Rs.19534 crore during the previous

fiscal year. This rise is keeping up the growing needs of the rising healthcare industry of

the country. Convergence of National Rural Employment Guarantee Act with wider

Health Insurance coverage for BPL families, through Rashtriya Swasthya Bima Yojana.

Commenting on the union budget 2010-2011 Rajen Padukone, CEO of Manipal Hospital,

says “Relaxation of FDI norms may see more international players coming into India in

the healthcare sector. Added to it, rationalization of duties on medical equipment can

make imports cheaper and can significantly lower healthcare costs in the country.10”

Andhra Pradesh state Government has enhanced its budget for qualitative health services

keeping its focus on rapid growth in health service delivery system. A budget provision

of Rs.925 crore has been made for Aarogyasri Health insurance scheme run by Govt of

10 http://www.rxpgnews.com/indianhealthcare/Biotech-industry-hails-tax-sops-in-budget_232404.shtml

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Andhra Pradesh for BPL families) and Rs.4295 crore allocated for Medical & Health

department for the year 2010-1111.

1.3. STATEMENT OF THE PROBLEM:

Hospitals play an integral part in healthcare system in India. They perform various

functions like In-patient, Out-patient services, Research and Development, Training etc.

Indian hospitals can be categorized into Public hospitals (Government), Private and not-

for-profit (Missionary/Trust owned) hospitals. The Public hospitals are run by the

Central and State Governments and Missionary hospitals by charitable trusts which

endows with free services or at subsidized rates to the needy12. Due to Liberalization,

Privatization and Globalization (LPG) there is a change in economical empowerment of

the middle class due to which there has been a boost in the number of corporate hospitals

and private hospitals that provide healthcare services in towns and cities.

Table 1.1Revenue expenditure on Health and Family welfare at Central level by Govt. of India and

Medical, Public health and Family welfare at State level by Govt. of Andhra PradeshYear wise

Health BudgetUnion Budget * State Budget **

2006-2007 Actual Rs. 10,567.85 crore Actual Rs. 1,853.93 crore2007-2008 Actual Rs. 13,951.00 crore Actual Rs. 2,439.06 crore2008-2009 Actual Rs. 16505.95 crore Actual Rs. 2,894.79 crore2009-2010 Actual Rs. 19,554.09 crore Actual Rs. 3,239.43 crore2010-2011 Revised Rs. 23,300.00 crore Revised Rs. 4,307.75 crore2011-2012 Budget Rs. 26,897.00 corre Budget Rs. 5,021.75 crore

* Revenue expenditure on Health and Family welfare13

**Revenue expenditure on Medical, Public health and Family welfare14

11 “Financing and planning”, Govt. of Andhra Pradesh, Budget 2010-2011,http://india.gov.in/allimpfrms/alldocs/13618.pdf12 Indian Law Offices, India, http://www.indialawoffices.com/pdf/healthcaresector.pdf13 Expenditure Budget 2011-2012, Pranab Mukherjee, Minister of Finance, Govt. of India, Presented inParliament, Total expenditure of Ministries/Departments, Statement 2, Vol. 1, Feb. 2011, pp. 6.http://indiabudget.nic.in/ub2011-12/eb/stat02.pdf14 Andhra Pradesh Budget in brief 2011-2012, Anam Ramanarayana Reddy, Minister of Finance, Govt. ofAndhra Pradesh, presented in Legislature, Vol. VI, Feb. 2011, pp. 32. http://budget.ap.gov.in/BIB.htm

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Huge investment is made and high awareness programmes have been launched by both

Central and State Governments on public healthcare to provide quality healthcare to all.

Also budgetary allocations have been made for hospital buildings, machinery,

equipments, drugs, and public awareness on health and diseases and on manpower to

acquire skilled employees in all medical and paramedical fields to provide quality

treatment to the patients by all means. Patients from BPL and lower income groups are

utilizing public healthcare services and other income groups availing treatment from

private hospitals.

The major concern for hospitals is patient satisfaction. Some of the problems of

Government hospitals include poor physical conditions, primitive health information

system and negligible formal quality control, absence of forward planning, grouping of

unrelated activities, faulty staffing procedures, ineffective leadership, lack of co-

ordination, unsatisfactory supply of drugs and medical supplies, absence of sound public

relations, among others. Some of the problems of Semi Government hospitals include

political interference, employee exodus, absence of transfers, corruption practices, and

irregular medical audit, among others. Self managed doctor hospitals are facing

problems relating to lack of continuing medical education, irrational drug use, sub-

standard medical care, lack of professional self regulations etc. The problems of

corporate hospitals are high treatment costs, unnecessary tests, non-utilization of services

of specialized people etc.

The present study is being carried out to assess Government, Private and Missionary

hospitals service quality and to analyze service gaps between perceptions and

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expectations of patients. If quality of services provided by healthcare sector is not up-to

expectations, the public will be at a very heavy loss in the form of ill health and low

working ability leading to low economic development. Many studies at macro level have

been conducted to measure quality of care in hospitals. Area specific and agency specific

studies are also necessary to have a clear picture about the quality maintenance of

healthcare services by hospitals. The present in-depth study will throw some light to the

administration of both Government, Private and Missionary hospitals on service quality

provided by them i.e., patient’s expectations and perceptions on healthcare services and

patients’ satisfaction levels to service quality with special reference to the Krishna

District, Andhra Pradesh.

1.4. SCOPE OF THE STUDY:

The medical profession has broadened its horizon globally and India is no exception.

Corporate hospitals are emerging as new breed in healthcare industry in India. These

hospitals are attracting a number of patients because of their super-specialties. There is

keen competition among these hospitals for market share. The emphasis is not only to

provide specialized services more efficiently and effectively, but also to maintain the

quality of overall services.

In view of changing needs of customers, changing world, changing life style and

technological innovations, the market has become customer service oriented. Therefore,

in service delivery and services management the service quality has become an essential

need in this competitive environment. As the physiological contentment of the people

got satisfied; there is a demand for more satisfaction. Human’s desire to live long has

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resulted in special healthcare services like health and fitness clubs, multi specialty

hospitals, nursing homes etc.

The patients evaluate service quality experience as the outcome of the gap between

expected and perceived quality. The SERVQUAL model measures Service Quality and

identifies potential gaps within the service organization that may lead to most serious

final gap named as Service gap i.e. the difference between what customers expected and

perceived against to what was delivered.

Many studies have been undertaken in this respect. But area and agency specific studies

are rare in number. Hence the present study i.e. “A study on Service Quality

measurement in Healthcare sector” is undertaken. The study is an attempt to diagnose

failure gaps in Service Quality. The present study analyses the gap between patients’

expectations and perceptions of the services offered and standards maintained by select

hospitals i.e., Government, Private and Missionary owned with the help of SERVQUAL

scale and suggest measures for better service quality offered by them.

1.5. REVIEW OF CURRENT LITERATURE:

Paper by Syed Muhammad Irfan et al. (2011)15 aimed to evaluate the service quality

delivered by the private hospitals in Pakistan which was literally based on patient

perception. A questionnaire was developed based on SERVQUAL model comprised of

22 variables representing five service quality dimensions; empathy, tangible, assurance,

timeliness and responsiveness. The target population of this study was the employees

15 Syed Muhammad Irfan, Aamir Ijaz, Saman Shahbaz (2001), “An assessment of Service Quality ofPrivate Hospitals in Pakistan: A patient perspective”, Indian Journal of Commerce & Management Studies,Vol–2, Issue -2.

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working at officer level in the service organizations and availing healthcare services

including consultation and in-patient from the best private hospitals in the city, Lahore of

Pakistan. A total 320 respondents considered for the study. The results of the study

indicate that service quality in private hospitals is meeting patients’ satisfactions i.e.

private hospitals are delivering better healthcare services. Results of the five factors

showed that the measurement model for service quality constructs had a good fit and the

model is valid and reliable.

Research was conducted by Laith Alrubaiee, Feras Alkaa’ida (2011)16 to study healthcare

quality of patient perception, satisfaction, and patient trust. It also aims to test the socio-

demographic variables in determining healthcare quality. SERVQUAL model was used

to measure and the results indicate its reliability. The study indicates that Socio-

demographic variables play a vital role in determining patient perception of healthcare

quality, satisfaction, and trust. On the other hand the study indicates better quality in

private hospitals compared to public hospitals.

Patient contentment is significant pointer of the quality of care and service in the

emergency department (ED). This study by Soleimanpour et al. (2011)17 was to evaluate

patient’s satisfaction with the Emergency Department (ED) of Imam Reza Hospital in

Tabriz, Iran. Patients were asked to complete the questionnaire prior to discharge. Five

hundred patients who attended ED were included in this study. The highest satisfaction

16 Laith Alrubaiee, Feras Alkaa’ida (2011), “The mediating effect of patient’s satisfactions of HealthcareQuality – Patient trust relationship”, International Journal of Marketing Studies, Vol.3, No.1.17 Hassan Soleimanpour, Changiz Gholipouri, Shaker Salarilak, payam Raoufi, Reza Gholi Vahidi,Amirhossein Jafari Rouhi, Rouzbeh Rajaei ghafouri, Maryam Soleimanpour (2011), “Emergencydepartment patients’ satisfaction survey in Immam Reza Hospital, Tabriz, Iran”, International Journal ofEmergency Medicine, Vol.4:2.

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rates were observed in the terms of physicians’ communication with patients (82.5%),

security guards’ courtesy (78.3%) and nurses’ communication with patients (78%). The

study findings indicated the need for evidence-based interventions in emergency care

services in areas such as medical care, nursing care, courtesy of staff, physical comfort,

and waiting time. The study suggested that efforts should focus on shortening waiting

intervals and improving patients’ perceptions about waiting in the ED, and also

improving the overall cleanliness of the emergency room.

The sample collected by Mohsin Muhammad Butt, Ernest Cyril de Run, (2010)18

consisted of 340 random participants over a period of 3 months to study private

healthcare quality applying SERVQUAL model. Here the data were analyzed to

establish the modified SERVQUAL scale's reliability, underlying dimensionality and

convergent, discriminate validity. A moderate negative quality gap for overall Malaysian

private healthcare service quality was indicated. It also indicated a moderate negative

quality gap on each service quality scale dimension. On the other hand developed a

modified SERVQUAL scale that yielded excellent results. The study's major

contribution is that it offered a way to assess private healthcare service quality. Secondly,

it successfully developed a scale that can be used to measure healthcare quality.

The main motto of the study by Figen Yesilada, Ebru Direktor (2010)19 was towards

testing SERVQUAL instrument in the Northern Cyprus healthcare industry, so as to test

the service and quality provided in public and private hospitals. The study was

18 Mohsin Muhammad Butt, Ernest Cyril de Run (2010), "Private healthcare quality: applying aSERVQUAL model", International Journal of Health Care Quality Assurance, Vol. 23 Issue: 7, pp.658 –673.19 Figen Yesilada and Ebru Direktor (2010), “Health service quality: A comparison of public and privatehospitals”, African Journal of Business Management, Vol. 4(6), pp. 962-971.

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conducted in Northern Cyprus and collected data twice from the same sample of the

group who were of more than 18 years of age. And this was taken for a sample of 806

people. For this the factor analysis revealed three factor solution and did not support the

five factor model of SERVQUAL. The three factors were empathy, tangibles and

reliability-confidence. In all the mentioned three factors the private hospitals have lesser

gaps when compared with public hospitals.

The aim of the research by Ali Anbori et al. (2010)20 conducted at Sana'a the capital city

of the Republic of Yemen was to evaluate patients’ contentment and reliability to private

hospitals and to identify factors influencing patient truthfulness. It consists of 819

respondents who were admitted for at least 1 day in a private hospital. The scores were

evaluated on the modified SERVQUAL instrument based on six domains i.e. tangibility,

reliability, responsiveness, assurance, empathy, and cost that identify perception of

service quality. Loyalty was also part of this study and the respondents were asked

whether they would return to the same facility when they need future medical assistance.

No significant association was found between patient loyalty and, tangibility and

responsiveness score. The conclusion of the study was that enhancement is required to

achieve high-quality healthcare services in the private hospitals in Yemen and also an

increase in loyalty among patients.

20 Ali Anbori, Sirajoon Noor Ghani, Hematram Yadav, Aqil Mohammad Daher (2010), “Patientsatisfaction and loyalty to the private hospitals in Sana'a, Yemen”, International Journal for Quality inHealth care, Vol. 22, issue 4, pp. 310-315.

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A study was conducted at Sheri-Kashmir Institute of Medical Science, Tertiary hospital

for the out patients department by S.A. Deva et al. (2010)21. The study aimed at knowing

the satisfaction level of the patients and the treatment given by the doctors mainly at OPD

(Out. As almost 1500 patients use to come to the hospital per day, the study has taken

only 250 patients who were attending in a day. The result found that 20% were not

satisfied and are authentic in saying so as the doctor in OPD of SKIMS has to see at least

35-40 patients per hour whereas literature says a doctor should see 3-4 new, 6-8 old

patients per hour, on an average a doctor should see 9-12 patients per hour only. The

study found that the service time to patient is less compared to literature. The patient

service time may be maximize by developing new polices, procedures and OPD time

scheduling, new procedures of registration and to set up LAN (Local Area Network)

system.

The study by Minsoo Jung et al. (2009)22 was to evaluate the perception and the

satisfaction of outpatients those who made use of clinics and hospitals are structurally

connected with their readiness to approach the same institution in the future. 310

responses were collected via convenient sampling from 5 hospitals and 20 clinics located

in Seoul listed in the Korea National Hospital Directory 2005. Service quality was

utilized as the satisfaction measurement tool. The structural equation model showed that

the satisfaction of outpatients with the quality of medical services was influenced by a

few sub-dimensional satisfaction factors. Among these sub-dimensional satisfaction

21 S.A. Deva, M. Haamid, J.I. Naqishbandi, SM Kadri, S. Khalid, N. Thakur (2010), “Patient Satisfactionsurvey in Outpatient department of a tertiary care institute”, Journal of community Medicine, Vol. 6(1).22 Minsoo Jung, Keon-Hyung Leel, Mankyu Choi (2009), “Perceived service quality among outpatientsvisiting hospitals and clinics and their willingness to re-utilize the same medical institutions”, Journal ofpreventive medicine and public health, Vol. 42(3): pp. 151-159.

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factors, the satisfaction with medical staff and payment were determined to exert a

significant effect on overall satisfaction with the quality of medical services. The

structural relationship in which overall satisfaction perceived by patients significantly

influences their willingness to use the same institution in the future was also verified.

This groundwork evaluation paper by Coskun Bakar et al. (2008)23 tests the attitude of

the patients in service aspect by means of SERVQUAL. The University of Baskent made

survey towards the periodic patients’ satisfaction so as to know the weakness, strength,

problems and also issues with regard to the quality improvement. This particular study

was conducted for randomly selected patients in the year 2006 between the months of

January and February. The patients were of both in-patients and out-patients. The

reading says that the scores were higher than anticipated for a regular hospital but lower

than anticipated for a high quality hospital. Young and highly educated show high-

expected service when compared with uninsured patients who have fewer expectations.

The study conducted by Akter et al. (2008)24 to identify the service quality of the sub-

urban public hospital of Bangaladesh and to determine the service quality gap between

the expectation and perception based on a field survey. 110 interviews were planned

from uptown (sub-urban) Dhaka city (east, west, north, and south) alone. Evaluations

were obtained from patients on several dimensions of perceived service quality including

responsiveness, assurance, communication, discipline, and baksheesh. SERVQUAL Gap

analysis reveals that Mean perception score of responsiveness is higher than mean

23 Coskun Bakar, H. Seval Akgün, A.F. Al Assaf (2008), "The role of expectations in patients' hospitalassessments: A Turkish university hospital example" International Journal of Health Care QualityAssurance, Vol. 21, Issue:5, pp.503 – 516.24 Akter, Md Shahriar, Upal, Mohammad, Hani, Umme (2008), “Service Quality perception and satisfaction: Astudy over Sub-Urban public hospitals in Bangladesh”, Journal of Services Research, issue. Feb.

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expectation score of responsiveness in all dimensions. It was proposed that four more

incentives be considered to promote higher quality in hospitals in Bangladesh. These

include competitive, social, internal and regulatory incentives.

With lots of care, a cross sectional study was conducted by B.T. Shaikh et al. (2008)25 for

a year between 2004 and 2005 March at a secondary level hospital in Karachi of

Pakistan. For this, data was collected on a quarterly basis through SERVQUAL tool,

with interviews and it was taken on 1533 patients and found 34.4% of patients were

satisfied with the medical services offered by the secondary level hospitals. Apart from

this they also conducted workshops towards the quality improvement based on the results

of the four phases. This in turn within a year resulted in the improvement of patient’s

satisfaction level from 34.4% to 82.0 %( over a year).

The study by Khalid Farooq Danish et al. (2008)26 aims to know the degree of patients’

contentment with different aspects of care in Islamic International Medical College Trust

(IIMC-T) Railway Hospital, Rawalpindi. Patients were given a questionnaire form at the

time of discharge. Feedback concerning various aspects of services at the hospital and

suggestions for improvement of services was collected which formed the data.

Responses were ranked as excellent, good, and unsatisfactory. Out of 2,709 responses,

34% were excellent, 60% good, and 6% unsatisfactory. The best part of service was the

accessibility of doctors in wards (84% excellent and good) and worst part was cleanliness

25 B.T. Shaikh, N. Mobeen, S.I. Azam and F. Rabbani (2008), “Using SERVQUAL for assessing andimproving patient satisfaction at a rural health facility in Pakistan”, Eastern Mediterranean Health Journal,Vol. 14, No. 2, pp. 447-456.26 Khalid Farooq Danish, Umar Awwab Khan, Tahir Chaudhry, Muhammad Naseer (2008), “PatientSatisfaction: An Experience at IIMC-T Railway Hospital, Rawal”, The Journal of Pakistan MedicalAssociation, Rawalpindi-Islamabad, Vol. 33:pp. 245-248.

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of wards (12% unsatisfactory). The researcher concluded that IIMC-T Railway Hospital

was providing services to patients with a reasonable degree of patient satisfaction.

The objective of the study by Heather et al. (2008)27 was to develop and examine the

psychometric properties of a measure that would meet the need, the Patient Continuity of

Care Questionnaire (PCCQ). The PCCQ was administered after 4 weeks of discharge to

204 inpatients. The questionnaire was assessed by item and principal components

analysis. A principal components analysis resulted in six subscales including perceptions

of: (1) relationships with providers in hospital, (2) information transfer to patients, (3)

relationships with providers in community, (4) mgt. of written forms, (5) management of

follow-up and (6) management of communication among providers. The conclusions of

the study were the initial study supports the reliability and validity of the PCCQ for

measuring patient perceptions of factors central to continuity of care. The subscales may

be of value for identifying problems in continuity of care and for evaluating interventions

aimed at improving continuity of care for patients after hospital discharge.

Muller-Staub M et al. (2008)28 has conducted a comprehensive study examining

ambulatory patients' satisfaction with nursing care in a Swiss emergency department.

Patient contentment involves the following three dimensions: "interaction / interpersonal

dimension", "information/patient participation", and "nurses' knowledge". An explanatory

cross-sectional study scrutinized patient fulfillment towards nursing care by using well

27 Heather Hadjistavropoulos, Henry Biem, Donald Sharpe, Michelle Bourgault-Fagnou1 and JenniferJanzen (2008), “Patient perceptions of hospital discharge: reliability and validity of a Patient Continuity ofCare Questionnaire”, International Journal for Quality in Health care, Vol. 20, issue 5, pp. 314-323.28 Muller-Staub M, Meer R, Briner G, Probst MT, Needham I, “Measuring patient satisfaction in anemergency unit of a Swiss university hospital: concept clarification and results”, Pflege, 2008, 21(3):pp.172-9.

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thought out-patient contentment questionnaire. Sample selection was convenience and

114 patients have been well thought-out for the study. The psychometric characteristics

of the measurement instrument were also examined. No patient attained the utmost total

score and the mark values for "Interaction / interpersonal dimension", information/patient

participation, and "nurses' knowledge" was not attained. On the whole results were not

generally low, but reveal prospective for quality improvement.

The aim of Acharyulu et al. (2007)29 was to show that the usefulness of SERVQUAL for

measuring patients' perceptions of quality healthcare. The study has been conducted in

selected areas of Southern part of India, which include Bangalore, Chennai, and

Hyderabad. The study was further restricted to three corporate hospitals operated by

same management group one from each city having bed capacity of 350 plus. The name

of the study group was masked by researchers due to confidentiality. All important

demographic characteristics like age, education, income were taken into consideration.

The study concluded that the significant gaps and importance was associated to

reliability, responsiveness, and empathy implying that the health center is still only "cure

centre" and not “care centre”. It was suggested that Indian hospitals need to concentrate

on Reliability and Responsiveness and the remaining dimensions of service quality, and

allocate resources to provide better service to their patients.

29 Acharyulu, G.V.R.K., Rajashekhar, B, Journal of International Business and Economics, InternationalAcademy of Business and Economics, 2007, Vol. 7, issue 2.

20

According to Sirkku Rankinen (2007)30 the study aimed at the surgical patients'

acquaintance at admission with the knowledge they received during their hospital stay

and also discovering the association between demographic variables and patients'

knowledge expectations and knowledge received. The sample consisted of 362 surgical

patients and the study was conducted at a university hospital in Finland. The data were

collected in two questionnaires (patients’ perceptions and expectations) with forty item

instruments which were made as a distinction between various aspects like social, ethical,

experiential, financial etc. Ultimately the conclusion of the study was based on the need

for better patient learning while the surgical patients expect to receive more

understanding than they actually get on all proportions. The most difficult areas in the

learning of surgical patients are the pragmatic, moral, social and economic dimensions of

awareness. Of all, the younger, female less educated need more attention.

The study by Bayram Sahin et al. (2007)31 was aimed to identify factors affecting patient

satisfaction. The study was conducted at a training hospital in Turkey. The final sample

consisted of 302 inpatients. In this study, patient satisfaction was examined using a

survey questionnaire with 22 questions collected under five dimensions. Structural

Equation Model (SEM) was performed to determine the influence of patient

characteristics on patient satisfaction. The SEM analysis found that variables of

education and type of clinic (surgical v/s non-surgical) were significant on patient

satisfaction. Persons with a higher level of education were less satisfied when compared

30 Sirkku Rankinen, Sanna Salanterä, Katja Heikkinen, Kirsi Johansson, Anne Kaljonen, HeliVirtanen and Helena Leino-Kilpi (2007), “Expectations and received knowledge by surgical patients”,International Journal for Quality in Health Care, Vol. 19, issue 2, pp.113-119.

31 Bayram Sahin, Fatma Yilmaz, Keon – Hyung Lee (2007)“Factors Affecting In-patient Satisfaction:Structural Equation Modeling”, Journal of Medical Systems, Plenum Press New York, NY, USA, Vol.31,Issue 1, pp. 9 – 16.

21

to those with a lower level of education. Surgical patients are more satisfied with the

care they received when compared to non-surgical patients. The study concluded that

education level of patients and the type of clinics had a significant influence on patient

satisfaction. The analysis showed the questionnaire has an appropriate reliability and

validity.

The researcher Liz Gill, Lesley White (2006)32 evaluates studies of service quality in

healthcare, recognizing extra key domains. Total of 36 related studies of service quality

have been evaluated, only three have gone well beyond the SERVQUAL model and five

have deployed entirely diverse approaches. Based on considerations from the evaluated

studies a model is proposed to include those recognized key domains to measure service

quality of healthcare. In the public health sector the independent variables which are

suggested to determine service quality are Reliability, Responsiveness, Assurance, Joint

Decision Making, Caring, Risk, Continuity, Collaboration, Outcome, Empathy, and

Tangibles.

The aim of this article by Tolga Taner, Jiju Antony (2006)33 was to study the variation

in service quality between public and private hospitals in Turkey. SERVQUAL method

was used to study service quality offered by them. The sample consisted of a total of 200

patients. The outcome point to inpatients in the private hospitals was more contented

with service quality than those in the public hospitals. The outcome also proposes that

inpatients in the private hospitals were more contented with doctors, nurses and

32 Liz Gill, Lesley White (2006), “A proposed model for measuring service quality in the public healthcaresector”, The School of Advertising, Marketing and Public Relations-Queensland University of Technology,Brisbane, Australia, International conference, 4-6 Dec. 2006.33 Tolga Taner, Jiju Antony (2006), “Comparing public and private hospital care service quality in Turkey”,Leadership in Health Services, Vol. 19 Issue: 2, pp. 1 – 10.

22

supportive services than that of the public hospitals. In conclusion, the outcome shows

that contentment with doctors and reasonable costs is the major determinants of service

quality in the public hospitals. The research proves that SERVQUAL, as a standard

instrument for measuring functional service quality, is trustworthy and applicable in a

hospital environment.

The objectives of the research by Krishna Dipankar Rao (2006)34 were to develop a

dependable and applicable scale to measure in-patient and outpatient perceptions of

quality in India and to recognize aspects of perceived quality which have large effects

on patient contentment. The study has been conducted in primary health centers,

community health centers, district hospitals, and female district hospitals in the state of

Uttar Pradesh in North India. An assessment was conducted on health facilities and

patients at hospitals. A 16-item scale having good dependability and validity was

developed. Five dimensions of perceived quality were identified—medicine availability,

medical information, staff behaviour, doctor behaviour, and hospital infrastructure.

Multivariate regression analysis results indicate that for outpatients, doctor behaviour has

the largest effect on general patient contentment followed by medicine availability,

hospital infrastructure, staff behaviour, and medical information. For in-patients, staff

behaviour has the largest effect followed by doctor behaviour, medicine availability,

medical information, and hospital infrastructure. Perceived quality at public facilities is

only marginally favorable, leaving much scope for improvement. Better staff and

34 Krishna Dipankar Rao , David H. Peters and Karen Bandeen-Roche (2006), “Towards patient-centeredhealth services in India—a scale to measure patient perceptions of quality”, International Journal forQuality in Health care, Vol. 18, issue 6, pp. 414-21.

23

physician interpersonal skills, facility infrastructure, and accessibility of drugs have the

major effect in improving patient contentment at public health facilities.

The Egyptians hospitals service and its quality were tested by Mohamed M. Mostafa

(2005)35 through this paper. For this they considered both public and private hospitals.

SERVQUAL model was adopted for the study. A cross-sectional questionnaire survey

carried out in 2005 took a random sample of 332 patients from 12 hospitals of Egypt was

chosen. Factor analysis revealed three factor solutions and did not support the five factor

model of SERVQUAL. The three factors were empathy, tangibles and reliability-

confidence. In all the mentioned three factors the private hospitals have lesser gaps when

compared with public hospitals. Patients may have a multifaceted set of significant

viewpoint that cannot be confined in the opinion poll.

According to Gonzalez-Valentín et al. (2005)36 the quality of hospital service is seen

clearly through the Patient satisfaction. Hence an assessment was conducted at the

regional university hospital in southern Spain and resolute the applicable socio-

demographic and attendance distinctiveness. For this the tests were conducted using

SERVQUAL with a cross-sectional questionnaire survey. Reliability and validity of the

SERVQUAL instrument was established. The only communication measured was gender

and education level. Scrutiny of covariance demonstrated for lower patients satisfaction

were female gender, higher educational level, and lesser overall satisfaction with the

hospital.

35 Mohamed M. Mostafa (2005), "An empirical study of patients' expectations and satisfactions in Egyptianhospitals", International Journal of Health Care Quality Assurance, Vol. 18 Issue: 7, pp. 516 – 532.36 Gonzalez-Valetin, Araceli, Padin-Lopez, Susana, De Ramon-Garrido, Enrique (2005), “PatientSatisfaction with Nursing care in a Regional University Hospital in Southern Spain”, Journal of NursingCare Quality, Vol.20, Issue 1, pp. 63-72.

24

The aim of the study conducted by Al-Mailam, Faten Fahad (2005)37 was to establish the

extent of patient contentment with care provided in a 110-bed private hospital in Kuwait.

Random sample of 420 in-patients was collected to establish the degree of their

contentment with the overall care offered at the hospital. The patient contentment with

the quality of care provided at the hospital was found to be quite high (Excellent, 74.7%;

Very good, 23.7%). Individually, nursing care received the maximum patient satisfaction

ratings (Excellent, 91.9%; Very good, 3.9%). The researcher concluded that the overall

patient contentment is connected with quality nursing care, which in turn depends on the

quality of leadership practiced at the institution. Transformational leadership behaviour

promotes nurse satisfaction, which adds to their work efficiency and inspires them to

provide quality patient care.

The research study by Wisniewski et al. (2005)38, aims to apply the SERVQUAL

measurement instrument in a Scottish colposcopy clinic. Patient outlook of service were

acquired on first attendance at the clinic. Patient opinion of service was acquired at the

end of treatment. Though patient contentment on the whole with the service offered was

by and large high, the instrument offered proof of where precise service enhancements

were considered necessary. The largest service quality gap was for the trustworthiness of

service. Research concluded that the SERVQUAL instrument has a useful investigative

role in measuring and supervising service quality in nursing, facilitating nursing staff to

recognize where upgrading was needed from the patients’ point of view.

37 Al-Mailam, Faten Fahad (2005), “The effect of Nursing care on overall patient satisfaction and itspredictive value on return-to-provider behavior: A survey study”, Quality Management in Health Care,Vol.14, Issue 2, pp. 116-120.38 Wisniewski, Mik; Wisniewski, Hazel (2005), “Measuring service quality in a hospital colposcopyclinic”, International Journal of Health Care Quality Assurance, Emerald Group Publishing Ltd.,Vol.18, No.3, pp.217-228(12).

25

This article by Sivabrovornvatana N et al. (2005)39 intends to investigate the connection

stuck between technology and quality management for improving Thai hospital service

quality. Based on the interviews carried out with respondents in Thai hospitals, the first

group consisted of professionals as internal customers in direct contact with external

customers, while the second group consisted of external customers of the same hospitals.

The findings propose that hospitals can build up a suitable method, which can improve in

service quality as perceived by patients and professionals. They can also make enhanced

quality choices based on planned measurement and knowledge. The study recommends

that managers relate this knowledge for triumphant accomplishment of actions related to

service quality in their organizations.

The aim of the study by Nerea Gonzalez (2005)40 was to develop a psychometrically

sound, hospital patient contentment questionnaire. Random samples of 650 patients had

been considered for the study and study was conducted at Basque Health Service, Spain.

The results of factor analysis showed six dimensions i.e. information, nursing care,

comfort, cleanliness, visiting and privacy that generally had good internal consistency.

No socio-demographic differences were found between respondents and non-

respondents. Comfort was the dimension with the lowest level of patient contentment,

whereas privacy was the most agreeable. The results obtained from the development and

validation of the questionnaire provided proof of its psychometric properties, though it

would be useful to carry out further analyses to assess time-based properties of

39 Sivabrovornvatana N, Siengthai S, Krairit D, Paul H (2005), “Technology usage, quality managementsystem, and service quality in Thailand”, International journal of healthcare quality assuranceincorporating Leadership in health services, 18(6-7): pp. 413-23.40 Nerea Gonzalez, Jose M. Quintana, Amaia Bilbao, Antonio Escobar, Felipe Aizpuru, AndrewThompson, Cristobal Esteban, Jose Antonio San Sebastián and Emilio de la Sierra (2005), “Developmentand validation of an in-patient satisfaction questionnaire”, International Journal for Quality in Health care,Vol. 17, issue 6, pp. 465-72.

26

dependability. The in-patient contentment questionnaire could become a useful

instrument in quality care assessment.

According to J. Veillard, F et al. (2005)41 for the quality upgrading in hospitals the World

Health Organization (WHO) has launched in the year 2003, a flexible and complete tool

which intended at sustaining hospitals in evaluating their performance, questioning their

own consequences, and converting them into procedures for upgrading, by

giving hospitals with tools for routine assessment and by enabling collegial support and

networking among participating hospitals. In turn this has also developed from four

workshops by meeting specialists, a wide review of the literature on hospital performance

projects, more than 100 performance pointers were inspected and a review were

conceded out over twenty European countries. Thus, it resulted in various concepts and

implementation of various tailor made strategies of the performance assessment

framework for hospitals (PATH framework). PATH is at present being steer

executed in eight countries and evaluates the viability and expediency of the approach

used to assess and refine for additional development.

The objective of this study by Bekele Chaka (2005)42 was to assess quality of nursing

care as indicated by patients’ satisfaction. A Cross-Sectional Survey was conducted at

Public Hospitals in Addis Ababa, namely Tikur Anbessa, Saint Paul and Zewditu

Memorial Hospitals from July, 2004 to April, 2005. A total of 631 adult patients were

considered for this study. Participants who were females, age group 41 – 50 years of old,

41 J. Veillard, F. Champagne, N. Klazinga, V. Kazandjian, O. A. Arah and A.-L. Guisset (2005), “Aperformance assessment framework for hospitals: the WHO regional office for Europe PATH project”,International Journal for Quality in Health Care, Vol. 17, issue 6, pp.487 – 96.42 Bekele Chaka (2005), “Adult Patient Satisfaction with Nursing Care”, Addis Ababa University, Schoolof graduate studies, Ethiopia.

27

having low income, less educated, patients who were admitted in third classes, and have

no history of previous admission were more satisfied. The over all rating of satisfaction

was 67%. The top aspects that patients scored highest for their satisfaction with nursing

care were the amount of freedom given, nurses capability in their work, and nurses

treatment of patients as an individual. The aspects with which patients were least

satisfied were the amount and type of information they received regarding their condition

and treatment and also the amount nurses knew about patients’ care. The need of

improving interpersonal relationship of nurses with patients was recommended.

The aims of the study by Kjell I. Pettersen (2004)43 were to describe the development of

the Patient Experiences Questionnaire (PEQ) and to assess dependability and soundness

of constructed summed rating scales. Postal based survey has been conducted in 14

hospitals in Norway. Patients of 16 years and above discharged from medical and

surgical departments received a questionnaire 6 weeks after discharge. Questionnaires

were sent to 36845 patients and 19578 patients (53%) were further analyzed. The

researcher constructed 10 summed rating scales based on factor analysis and theoretical

considerations: Information on future complaints, Nursing services, Communication,

Information examinations, Contact with next-of-kin, Doctor services, Hospital and

equipment, Information medication, Organization and General satisfaction. The research

concluded that The PEQ is a self-report instrument covering the most important subjects

of interest to hospital patients. Results are presented as 10 scales with good validity and

reliability.

43 Kjell I. Pettersen, Marijke Veenstra, Bjørn Guldvog and Arne Kolstad (2004), “The Patient ExperiencesQuestionnaire: development, validity and reliability”, International Journal for Quality in Health Care,Vol. 16, issue 6, pp. 453-63.

28

This research by Kui-Son Choi et al. (2004)44 proposes an integrative model of healthcare

consumer satisfaction based on established relationships among service quality, value,

patient satisfaction and behavioural intention, and tests it in the framework of South

Korean healthcare market. Results based on the data collected from 537 South Korean

healthcare consumers corroborated the causal sequence among these constructs suggested

by the multi attribute attitude model framework, i.e. cognition (service quality and

value)→affect (satisfaction)→conation (behavioural intention). Between the two

cognitive constructs, service quality emerged as a more important determinant of patient

satisfaction than value. Results also showed that both service quality and value have a

significant direct impact on behavioural intention while value assessment was influenced

by perceived service quality.

The Pain Treatment Satisfaction Scale (PTSS) was to assess patient satisfaction for those

receiving treatment for either acute or chronic pain. The initial questionnaire of the study

by Evans C. et al. (2004)45 included a comprehensive literature review and interviews

with patients, physicians and nurses in the United States, Italy and France. After initial

items were created, psychometric validation was performed on the participating patients.

Analyses on this survey included principal components factor analysis tests of reliability,

clinical validity, and confounding. All dimensions except medical care discriminated

well according to pain severity. The PTSS survey has been proven a valid and

comprehensive instrument to assess and evaluate satisfaction with treatment of pain

44 Kui-Son Choi, Woo-Hyun Cho, Sunhee Lee, Hanjoon Lee and Chankon Kim (2004), “The relationshipsamong quality, value, satisfaction and behavioral intention in health care provider choice: A South Koreanstudy”, Journal of Business Research, Vol. 57, Issue 8, pp. 913-21.45 Evans C., Trudeau E., Mertzanis P., Marquis P., Peña B., Wong J., Mayne T (2004), “Development andValidation of the Pain Treatment Satisfaction Scale (PTSS): Patient Satisfaction Questionnaire for Use inPatients with Chronic or Acute Pain”, Pain, Vol. 112, Issue 3, pp 254-66.

29

based on independent modules that have demonstrated satisfactory psychometric

performance.

Another study made by Unni Krogstad et al. (2004)46 aimed at investigating the doctors

and nurses insight of inter-professional teamwork and their contentment in hospitals. It

could also differ in manifestation of cultural diversity from the quality improvement point

of view. Even for this they conducted a cross cultural data and collected from a sample

of 15 at Norwegian in 1998 with five hundred and fifty one doctors and two thousand

fifty nurses at different wards. The overall response rate was 65%. The study discloses

that doctors were considerably more often than nurses contented with the inter-

professional co-operation of the two groups. Well it was based on various work

situations for doctor and nurses. Ultimately the study concluded that inter-professional

co-operation was different for doctors and nurse, for which the Hospital management

ought to bring about an understanding of cultural diversity towards quality improvement.

The paper by M. Sadiq Sohail, (2003)47 examines and measures the quality of services

provided by private hospitals in Malaysia. A modified version of SERVQUAL was

adapted to measure service quality for the study. Survey questionnaire was mailed to a

sample of a thousand people drawn from patients who had been discharged from five

private hospitals across Malaysia. A total of 186 responses were obtained in which 150

were usable, representing a response rate of 15%. Results based on testing the mean

differences between expectations and perceptions indicate that patients’ perceived value

of the services exceed expectations for all the variables measured, indicate that

46 Unni Krogstad, Dag Hofoss and Per Hjortdahl (2004), “Doctor and nurse perception of inter-professionalco-operation in hospitals”, International Journal for Quality in Health Care, Vol. 16, issue 6, pp. 491-97.47 M. Sadiq Sohail (2003), "Service quality in hospitals: more favourable than you might think", ManagingService Quality, MCB UP Ltd, Vol. 13 Issue: 3, pp.197 – 206.

30

Malaysians perceive the quality of service positively. However, the present findings

must be treated with caution because private hospitals have been mushrooming to cater

for the growing affluent population. Health and medical service expectations are likely to

change with time.

According to another study by A. A. J. Hendriks (2002)48 the Satisfaction with Hospital

Care Questionnaire (SHCQ) reliably establishes for calculating the patient contentment

and assessment of quality care at hospital. The study was conducted at Amsterdam, at an

Academic Medical Center. There they applied SHCQ and used it for two measurement

purposes. One of them is used for measuring patient satisfaction and the other one is

used by establishing hospital care quality. The study involved 275 Patients and 83 staff

members with four hospital wards. All this took 57-item SHCQ tackling thirteen features

of care. Ultimately this research concluded that the SHCQ reliably establishes both

patient satisfaction and in general quality of hospital care. However, results should

be understood more carefully as in most of the cases the patients usually cannot give the

difference in quality of care.

This article by Uzun O (2001)49 reports the outcome of a survey on patient contentment

with nursing care, from a university hospital in Turkey. In this study, SERVQUAL scale

was used for determining patient satisfaction with nursing care by interview to 422 adults

discharged from the same hospital. Socio-demographic characteristics of the patients

(age, gender, education level) with regard to patient contentment were determined.

48 A. A. J. Hendriks, F. J. Oort, M. R. Vrielink and E. M. A. Smets (2002), “Reliability and validity of theSatisfaction with Hospital Care Questionnaire”, International Journal for Quality in Health Care, Vol. 14,Issue 6, pp. 471-82.49 Uzun O (2001), “Patient satisfaction with nursing care at a university hospital in Turkey”, Journal ofnursing care quality, Vol. 6(1): pp. 24-33.

31

Significant differences were found between the socio-demographic characteristics and

weighted scores for dimensions of SERVQUAL (p < 0.5). As per the results, the service

quality gap scores for five dimensions were negative to meet expectations. The negative

scores for tangibles, reliability, responsiveness, assurance, and empathy indicate these

areas need improvement. In this hospital, outcome of this study support necessitate for

nurses to plan strategies to improve patient satisfaction with nursing care as they are valid

indicators of quality nursing care.

The article by Tengilimoglu D et al. (2001)50 speaks out the results of a patient

contentment survey directed for 420 adults discharge from a chief public hospital in

Turkey. A system was considered alike to those available in the US and was applied

during an exit interview. The analysis is concluded in three different areas: openness and

accessibility of services, supposed quality of patient care and organizational and

administrative issues. Ultimately, the individuals were content with direct patient care,

though in it was different in some areas. Above all, many reported unhappiness with

managerial and directorial maintenance. The researcher also recommends that hospitals

in Turkey become accustomed to regular policies similar to those in the US for

accomplishing these types of assessments.

Patient contentment survey was conducted by Prasanta Mahapatra et al. (2001)51 in 25

District or Area Hospitals managed by the Andhra Pradesh Vaidya Vidhana Parishad

50 Tengilimoglu D, Kisa A, Dziegielewski SF (2001), “Measurement of patient satisfaction in a publichospital in Ankara”, Health services management research: an official journal of the Association ofUniversity programs in Health Administration, Vol. 14(1): pp. 27-35.

51 Prasanta Mahapatra, Srilatha. S, Sridhar.P (2001), “A Patient Satisfaction Survey in Public Hospitals”,Journal of the Academy of Hospital Administration, Vol. 13, No. 2.

32

(APVVP). Patients’ feedbacks were collected using a modified version of the Patient

Satisfaction Questionnaire-III originally developed by Ware and others (Hays, Davies

and Ware; 1987) from patients and from patient attendants if patients were not in a

position to answer. The study period was May 1999 to July 1999. In total 1179 persons

were interviewed, including 237 attendants, considered 40-50 patients per hospital. On

the whole, the level of patient satisfaction in APVVP was about 65%. The main reason

for displeasure was corruption which was rampant. Other significant areas of hospital

services contributing to patient displeasure were basic utilities like water, fans, lights,

etc., poor maintenance of toilets, lack of cleanliness, and poor interpersonal relationship.

1.6. RESEARCH METHODOLOGY:

OBJECTIVES OF THE STUDY:The following are the specific objectives for the study:

1. To study Need and Scope of Service Quality in Healthcare sector.

2. To depict Healthcare systems and Infrastructure in India.

3. To present the Role of Government in Healthcare management.

4. To measure Service Quality in Healthcare sector.

5. To analyze Service Quality in Hospitals.

6. To suggest appropriate measures to Hospitals.

33

RESEARCH DESIGN:

There are many definitions of research design, but no one definition imparts the full

range of important aspects. Several examples from leading authors can be citied:

The research design constitutes the blueprint for the collection, measurement, and

analysis of data. It aids the scientist in the allocation of limited resources by posing

crucial choices: Is the blueprint to include experiments, interviews, observation, analysis

of records, simulation, or some combination of these? Are the methods of data collection

and the research situation to be highly structured? Is an intensive study of a small sample

more effective than a less intensive study of large sample? Should the analysis be

primarily quantitative or qualitative?52

Research design is the plan and structure of investigation so conceived as to obtain

answers to research questions. The plan is the overall scheme or program of the research.

It includes an outline of what the investigator will do from writing hypotheses and their

operational implications to the final analysis of data. A structure is the framework,

organization, or configuration of the relations among variables of a study. A research

design expresses both the structure of the research problem and the plan of investigation

used to obtain empirical evidence on relations of the problem53.

These definitions differ in detail, but together they give the essentials of research design

as follows.

The design is an activity and time-based plan.

52 Bernard S. Phillips (1971), “Social Research Strategy and Tactics”, 2nd ed., pp.93.53 Pred N. Kerlinger (1986), “Foundations of Behavioral Research”, New York: Holt, Rinehart & Winston,3rd edition, pp. 279.

34

The design is always based on the research question.

The design guides the selection of sources and types of information.

The design is a framework for specifying the relationships among the study’s

variables.

The design outlines procedures for every research activity.

Thus, the research design provides answers for questions such as these: What techniques

will be used to gather data? What kind of sampling will be used? How will time and cost

constraints be dealt with?. Research Design applied in this study is the Exploratory

Study.

EXPLORATORY STUDY:

The exploratory research study is mainly helpful when researchers lack a clear idea of the

troubles they would encounter during the course of the study. Through this type of study

they build up concepts more clearly, set up priorities, develop operational definitions, and

improve the final research design. Exploration possibly will save time, energy, and

money.

Exploration serves other purposes as well. The area of investigation may be so new or so

vague that a researcher needs to do an exploration to find out something about the

dilemma faced by the manager. Important variables may not be known or thoroughly

defined. Hypotheses for the research may be needed. Also, the researcher may explore

to make sure that it is practical to do a formal study in the area. An exploration to

discover, if industry executives would divulge adequate information about their decision-

making on this topic, was essential for the study’s success.

35

The present Exploratory study entitled “A study on Service Quality measurement in

Healthcare sector” is to assess the need of service quality in healthcare industry and to

measure quality of service rendered in select hospitals all with a view to suggest

measures to change as patient centered hospitals.

POPULATION FOR THE STUDY:

Indian healthcare delivery system has variety when it comes to its institutions and

ownership patterns. Tertiary care is dominated by private and/or public-private

partnerships, while secondary healthcare is an asymmetrical mix of private, public, and

missionary. List of hospitals in Krishna District having head quarters at Machilipatnam

which serves as population for the study.

Table 1.2Population for the study.

Sl.No. Type Total No.1. Government owned hospitals having bed strength of 500 and

above- NTR Health University General Hospital, Vijayawada- Dr. Gururaj Government Homoeopathi College &

Hospital, GudivadaNori Ramamohana Sastri Ayurvedic College &Hospital, Vijayawada

3

2. Hospitals being privately owned having bed strength of 500and above

- Pinnamaneni Siddhartha Medical College & Hospital,Chinaoutapalli

1

3. Government owned hospitals having bed strength of 100 andabove

- Government District Hospital located atMachilipatnam with 350 beds

- Employee State Insurance Scheme Regional Hospitalwith bed strength of 185 located at Vijayawada

- Railway Hospital with bed strength of 200 located atVijayawada

3

4. Hospitals being privately owned having bed strength of 100and above

- Dr. Ramesh Cardiac & Multispeciality Hospital,Vijayawada

- Pinnamaneni Care Hospital, Vijayawada- Andhra Hospital, Vijayawada

9

36

- Charethasri Hospital, Vijayawada- Help Hospital, Vijayawada- Vijetha Hospital Vijayawada- Usha Cardiac & Multispeciality Hospital, Vijayawada- Global Hospital, Vijayawada- Nagarjuna Hospital, Vijayawada

5. Hospitals being owned by Trust, having bed strength of 100and above

- St. Anns’ Hospitals, Vijayawada

1

6. Government owned Area Hospitals (AH) having bed strengthof 50 to 100.

- Area Hospital, Gudivada- Area Hospital, Nuzvid

2

7. Privately owned hospitals having bed strength of 50 to 100.- Family Hospital, Vijayawada- Trust Hospital, Vijayawada- Vijrala Siva Kumar Hospital, Vijayaada- Poorna Heart Institute, Vijayawada- Heart Care Centre, Vijayawada- Praveen Cardiac Centre, Vijayawada- Prasanth Hospital, Vijayawada- M.J. Naidu Hospital, Vijayawada- Suraksha Neuro Centre, Vijayawada- VINS, Vijayawada- Citi Cancer Hospital, Vijayawada- Sri Devi Eye Hospital, Vijayawada- VIMHANS Hospital (Psychiatric Hospital), Vijayawada- Arun Kidney Centre, Vijayawada- Sitha Nursing Home, Hanuman Junction- Karuna Nursing Home, Gudivada- Sacred Heart Hospital, Gudivada- Annapurna Hospital, Gudivada- Brundavana Nursing Home, Machilipatnam- Vaishnavi Nursing Home, Machilipatnam- Rajeevi Nursing Home, Machilipatnam- Balaji Nursing Home, Machilipatnam- Gowthami Srinivasa Hospital, Machilipatnam

23

8. Trust owned hospitals having bed strength of 50 to 100.- St. Anns’ Hospital, Nunna- Gifford Memorial Hospital, Nuzvid

2

9. Government owned Community Health Centres (C.H.C)having bed strength of 30 to 50.

- Nandigama- Avanigadda- Mylavaram- Tiruvur

9

37

- Vuyyur- Jaggaiahpeta- Kaikaluru- Gannavaram- Rajeev Nagar, Vijayawada

10. Privately owned Hospitals / Nursing Homes having bedstrength of 30 to 50.

- Safe Hospital, Vijayawada- Latha Super Speciality Hospital, Vijayawada- Sri Rama Nursing Home, Jaggaiahpet- Padmavathi Nursing Home, Gudivada- Venkateswara Nursing Home – Machilipatnam- Venkateswara Mother & Child Nursing Home,

Machilipatnam- Vishnu Children Hospital, Machilipatnam- Madhu Hospital, Machilipatnam- Patmavathi Nursing Home, Chalapalli- Noori Mothers & Child Hospital, Vijayawada- Harini Gastro and Liver centre, Vijayawada

11

11. Trust owned hospitals having bed strength of 30 to 50.- St. Anns’ Hospital, Avanigadda

1

12. Government owned Primary Health Centres (P.H.C) 8213. Government owned Family planning, Mobile medical units &

other clinics7

14. Government owned Ayurvedic Dispensaries 4715. Government owned Homoeopathi Dispensaries 1216. Government owned Unani Dispensaries 417. Government owned general and maternity hospital hospitals

bed strength below 309

18. Privately owned Hospitals / Nursing Homes with bed strengthbelow 30

DNF

19. Employee State Insurance Scheme Dispensaries- Bapulapadu- Kondapalli- Milk Project - Vijayawada- Nakkalaroad – Vijayawada- Gunadala – Vijayawada- Ganguru- Machilipatnam- Auto Nagar – Vijayawada

8

20. Ex-service men Contributory Health Scheme (E.C.H.S)Dispensary located at Viajaywada.

1

21. S.C Railways Hospital located at Rayanapadu with 25 Beds. 122. Road Transportation Corporation (RTC) Dispensaries

- Vidyadharapuram- Bus stand – Vijayawada

3

38

- Machilipatnam.23. Postal & Telegraphs (P&T) Dispensaries 124. Total number of doctors registered under “The Association of

Homeopathi Doctors”, Krishna District141Doctors

25. Total number of doctors registered under “National MedicalAssocian”, Krishna District

318Doctors

26. There is no registered body available for Unani Medicine inKrishna District

There isnoregisteredassociation

SAMPLING:

Sampling is the most vital part of statistical practice. The selection of individual’s

observations intended to yield some knowledge about a population of concern, chiefly for

the purpose of statistical inference. The prime initiative of sampling is that by selecting

some of the elements in a population, one may draw conclusions about the whole

population. Population factor is the subject on which the measurement is being taken and

it form the unit of study. There are three main advantages of sampling54: (1) The cost is

lower, (2) Data collection is faster, and (3) It is possible to ensure homogeneity and to

improve the precision and quality of the data because the data set is smaller.

Sampling techniques are many. The researcher should select the suitable technique

depending on the requirement of the project, its objectives, and based on availability of

funds. Choosing a probability sampling technique despite of all due care, the actual

sample achieved will not match perfectly the sample that is originally drawn because

patients may leave the hospital when we are in the field of study, if we consider patients

appointments, some times patients may or may not come on that day, though they are

available in the hospital some patients may be reluctant/refuse, not in a position to

54 Ader, H. J., Mellenbergh, G. J., & Hand, D. J. (2008), “Advising on research methods: A consultant'scompanion”, Huizen, The Netherlands: Johannes van Kessel Publishing.

39

participate and some hospitals especially in government hospitals not follow appointment

system. If we want to conduct research on already treated patients the full details of the

patients would not be available in some hospitals both in government and private and it is

associated with high cost and time consuming. Often probability sampling is not feasible

because the population may not be available. Then, too, frequent breakdowns in the

application of probability sampling discount its technical advantages. Thus, the ideal

probability sampling may be only partially achieved because of the human element.

Because of the reasons noted above, probability sampling procedures are not applicable /

suitable for the current study. The alternate sampling procedures are non-probability

sampling. Often non-probability sample is used to test ideas or even to gain ideas about a

subject of interest. Carefully controlled non-probability sampling often seems to give

acceptable results. Non-probability sampling procedures satisfactorily meet the sampling

objectives of the present study.

While considering the population for sampling for the present study P.H.Cs and rural

hospitals have been omitted as per the quality standards laid by National Accreditation

Board for Hospitals and Healthcare providers (NABH)55. Government and Private

owned Dispensaries / clinics i.e. Allopathi, Ayurveda, Homeopathi, and Unani medicines

providing primary healthcare to the public and have no bed strength which come under

the above category have been omitted. Quality standards are applicable for Secondary

and Tertiary Healthcare. In Government sector secondary healthcare is meant for more

complex problems. This care includes basically healing services and is provided by the

55 “National Accreditation Board for Hospitals and Healthcare Providers, A guide book to NABHstandards on Hospital Accreditation”, New Delhi, First Edition, August 2006, pp. 2.

40

Community Health Centers (CHC) and Area Hospitals having bed strength ranging from

30 and above based on population. This serves as the first referral level in the healthcare

system. Hence, below 30 bedded hospitals both in private and government sectors are

omitted from the study. Out of the remaining hospitals 10 % of the overall population or

a minimum of 1 Hospital from each category (i.e. Government owned, Private owned and

Trust owned) has been considered as sample.

A sample of 12 hospitals purposively has been chosen for the present study from the

population listed above. St. Anns’ Hospital, Vijayawada – have bed strength 100 &

above and St. Anns’ Hospital, Avanigadda – have bed strength 30 to 50 have not

permitted to carryout survey of patients towards service quality offered by them. Thus,

the sample size of select hospitals was arrived at 10 hospitals. On an average 2040

patients per day are availing out-patient services from select sample hospitals, in which

10% of the out-patients have been considered as sample for the present study. But the

average number of in-patients who are hospitalizing in select sample hospitals are 395

per day is nearly 1/5 of the out-patients of select hospitals per day. To have meaningful

sample 50% in-patient from the select hospitals have been considered for the present

study.

20 Out-patients and 20 In-patients (for In-patients, at least for one day hospitalization

required for inclusion in the survey) in total 40 from each hospital have been selected.

Thus, the total sample size was arrived at 400. Among the sample respondents out-

patients and in-patients have purposively been chosen. Thus, the sample becomes

purposive sampling.

41

Table 1.3Sample for the study

Sl.No. Type Total No.1. Government owned hospital having bed strength 500 and above

– NTR Health University General Hospital, Vijayawada1

2. Privately owned hospitals having bed strength 500 and above– Pinnamaneni Siddhartha Medical College Hospital,

Chinaoutapalli.

1

3. Government owned hospitals having bed strength 100 and above- Government District Hospital, Machilipatnam.

1

4. Privately owned hospitals having bed strength 100 and above- Dr. Ramesh Cardiac and Multispeciality Hospital,

Vijayawada

1

5. Government owned Hospitals having bed strength 50 to 100- Area Hospital, Nuzvid

1

6 & 7. Privately owned hospitals having bed strength 50 to 100- Prasanth Hospital, Vijayawada- M.J. Naidu Hospital, Vijayawada

2

8. Trust owned hospitals having bed strength 50 to 100- Gifford Memorial Hospital, Nuzvid

1

9. Government owned hospitals having bed strength 30 to 50- Community Health Centre (C.H.C), Jaggaiahpeta

1

10. Privately owned hospitals having bed strength 30 to 50- Latha Super Speciality Hospital, Vijayawada

1

PERIOD OF THE STUDY:

The period of study for the Primary data collection is 2008 – 2010. However, for the

secondary data, the immediate past 10 years are considered.

COLLECTION OF DATA:

There are two approaches to collect information about a situation, person, problem or

phenomenon. Sometimes information required is already available and need only be

extracted. However, there are times when the information must be collected. Based

upon these broad approaches to information gathering data is categorized as:

1. Primary Data.

2. Secondary Data.

42

Primary data is collected through observation, interviews and/or questionnaires.

According to Creswell (2003)56 data collection procedure in qualitative research involves

four basic types i.e. observations, interviews, documents and audiovisual materials.

According to Saunders et. al., (2003)57 interview can be conducted based on structured

interview, semi-structured interview and unstructured interview. Secondary data is

collected from secondary sources such as Govvernment publications, personal records,

census, news papers, magazines and journals.

In the present study in-depth face-to-face interviews were used as primary data collection

method. Primary Data was collected from 400 respondents covering 10 select hospitals

of Krishna District, Andhra Pradesh by administering Service Quality Measurement by

SERVQUAL questionnaire. Before administering the questionnaire, pilot study was

conducted with a sample of 20 respondents (Out-patients and In-patients each from 10

respondents). Testing was carried out for the reliability of the questionnaire, for its

consistency to ensure that the respondents interpret the questions the same way as

intended. The tested respondents however raised their concerns about the significant

length of the questionnaire and the ability of an average customer to understand the

process. Based from these 20 responses and the suggestions and directions given by the

experts given below, the main questionnaire was redesigned and administered.

56 Creswell, J.W. (2003), “Research Design: Qualitative, Quantitative and Mixed methods approach”, 2nd

Edition, Sage publication, Inc.57 Saunders, M., Lewis, P., Thronhill, A. (2000), “Research methods for business students”, 2nd Edition,UK, Financial Times, Prentice Hall.

43

Combining the expectation and perception items of SERVQUAL, results in a 44-item

survey instrument. Carman (1990)58, Gronroos (1993)59, Lewis (1993)60, Bouman and

Van der Wiele (1992)61, Babakus and Boller(1992)62, Babakus et al. (1993)63 argue that

SERVQUAL instrument 44 items are highly repetitive and unnecessarily increase the

questionnaire’s length. Experts including Zeithaml herself (Boulding et al., 1993)64

further argue that the expectations section of the instrument is of no real value and that

the perceptions (actual performance) section should be utilized alone to assess service

quality65.

Creative suggestions have been made for maintaining the expectations component and at

the same time reducing the questionnaire’s length by 22 questions. Three approaches

have been suggested: 1. on a single scale, ask respondents where they would rate a high-

quality company and then where they would rate the firm under investigation; 2. utilize

the scale’s midpoint as the expected level of service from a high-quality company, and

then rate the specific firm in relation to the midpoint above expectation or below; and 3.

utilize the end point (e.g., 7 on a 7-point scale) as the expected level of a high-quality

58 Carman. J.M. (1990), “Consumer perceptions of service quality: an assessment of the SERVQUALdimensions”, Journal of Retailing, Vol. 66 No. 1, pp. 33-5.59 Gronroos, C. (1993), “Toward a third phase in service quality research: challenges and future directions”,in Swartz, T.A., Bowen, D.E. and Brown, S.W. (Eds), Advances in Services Marketing and Management,Vol. 2, JAI Press, Greenwich, CT, pp. 49-64.60 Lewls, B.R. (1993), “Service quality measurement”, Marketing Intelligence and Planning, Vol. 11, No.4, pp. 4-12.61 Bouman, M. and Van der Wiele . T. (1992), “Measuring service quality in the care service industrybuilding and testing an instrument”, International Journal of Service Industry Management, Vol.3, No.4,pp. 4.-16.62 Babakus, E. and Boller, G.W. (1992), “An empirical assessment of the SERVQUAL scale”, Journal ofBusiness Research, Vol. 24, pp. 253-68.63 Babakus, E., Pedrick, D.L. and Inhofe. M. (1993), “Empirical examination of a direct measure ofperceived service quality using SERVQUAL items”, unpublished manuscript, Memphis State Univ., T.N.64 Boulding. W., Kalra. A., Staelin, R. and Zeithaml. V.A. (1993), “A dynamic process model of servicequality: from expectations to hebavioral intentions”, Journal of Marketing Research, Vol. 30, 99. 7-27.65 A. Parasuraman, Valerie A. Zeithaml, and Leonard L. Berry (1994), “Reassessment of Expectations as aComparison Standard in Measuring Service Quality: Implications for Future Research”, Journal ofMarketing, pp. 111-124.

44

company, and rate the specific company relative to the high quality company on the same

scale. All three approaches provide alternatives for assessing customer perceptions and

expectations while reducing the questionnaire’s length66.

Babakus and Boller (1992)67 employing a single seven-point scale to collect gap data

recommended earlier by Carman (1990), the scale ranges from 7= “greatly exceeds my

expectations” to 1= “greatly falls short of my expectations”.

In view of responses form the pilot study and considering experts directions given above

2nd approach has been considered for the present study. The questionnaire contained the

modified SERVQUAL scale, with 22 statements relating to patients’ perceptions and

expectations on the quality of the services that offered.

Before starting the interview, the participants were informed about the purpose of the

study and how the interview would be conducted.

Secondary data for the study was collected from the select hospitals by interacting with

the officials to get the internal information regarding quality systems and procedures

related to service quality to delight patients. The data was also collected from various

66 Douglas Hoffman K., John E.G. Bateson (2008), “Marketing of Services”, South-Western CengageLearning, pp. 173-174.67 Babakus, E. and Boller, G.W. (1992), “An Empirical Assessment of the SERVQUAL scale”, Journal ofBusiness Research, Vol. 24(3), 253-268.

45

journals, reports, text books, standing orders, Acts, government offices (DMHO office)

and the internet.

DATA ANALYSIS:

After collecting all the data, the process of analysis begins. To summarize and rearrange

the data several interrelated procedures are performed during the data analysis stage

(Zikmund 2000)68.

The data collected from the respondents relating to quality, as well as other variables are

studied independently and compared across the hospitals studied based on bed strength,

to find the patterns based on commonality and difference. An attempt has been made to

find out the factors by stage wise, which influence the patient satisfaction in terms of

quality.

Data Analysis has been done using SERVQUAL scale proposed by Parasuraman, Berry

et al. 198869 and statistical tools using SPSS 14, Chi-square, and Analysis of Variance.

SERVQUAL: SERVQUAL is method for gauging service quality. SERVQUAL is

defined by the gap between customers’ expectation and perceptions. SERVQUAL splits

service quality into five basic dimensions; i.e. Reliability, Assurance, Tangibles,

Empathy and Responsiveness, often referred to as RATER. The formula for Service

quality = Perception – Expectation.

68 Zikmund, W.G. (2000), “Business research methods”, 6th edition, Harcourt Inc. 6277, Sea Harbor Drive,Olando, FL 32887-6777.69 A. Parasuraman, Valarie. Zeithaml, and Leonard Berry (1988), “SERVQUAL: A Multiple Item Scale forMeasuring Consumer Perceptions of Service Quality”, Journal of Retailing, Vol. 64: 12-40.

46

The adequacy of the SERVQUAL scale for assessing patients' perceptions of service

quality in the hospital environment was examined in accordance with the

recommendations provided in the recent measurement literature (e.g., Anderson and

Gerbing 198870; Bagozzi 198171; Bagozzi and Yi 198872; Churchill 197973). Therefore,

the analyses conducted related to the scale's reliability; underlying dimensionality; and

convergent, and discriminate validity. Reliability assessments were based on the internal

consistency of the items representing the same dimension of service quality as well as the

overall scale.

Chi-square (X2): X2 is a statistical test commonly used to compare observed data with

data we would expect to obtain according to specific hypotheses. That is, chi-square is

the sum of the squared differences between observed (O) and the expected (E) data,

divided by the expected data in all possible categories i.e. X2 = (O – E)2 / E.

ANOVA: Stands for Analysis-of-Variance, Statistical technique for determining

the degree of difference or similarity between two or more groups of data. It is based on

the comparison of the average value of a common component.

70 Anderson, J. C., and D. W. Gerbing (1988), “Structural Equation Modeling in Practice: A Review andRecommended Two-Step Approach”, Psychological Bulletin, Vol. 103, no. 3: 411-23.71 Bagozzi, R. P. (1981), “Evaluating Structura Equation Models with Unobservable Variables andMeasurement Error: A Comment”, Journal of Marketing Research, Vol. 18: 375-81.72 Bagozzi, R. P., and Y. Yi (1988), “On the Evaluation of Structural Equation Models”, Journal of theAcademy of Marketing Science, Vol. 16, no. 1: 74 – 94.73 Churchill, G. A., Jr. (1979), “A Paradigm for Developing Better Measures of Marketing Constructs”,Journal of Marketing Research, Vol. 16: 64 – 73.

47

HYPOTHESES:

The following hypotheses have been formulated and tested for the present study.

1. H0. Overall mean perception score is lower than overall mean expectation score of

Government Hospitals.

2. H0. Overall mean perception score is higher than overall mean expectation score of

Private Hospitals.

3. H0. Over all mean Perception score is lower than overall mean expectation score of

Missionary Hospitals.

The above hypotheses will be tested to conclude on service quality offered by select hospitals

of Government, Private and Missionary owned hospitals based on SERVQUAL scale

dimensions i.e. tangibles, reliability, responsiveness, assurance and empathy.

1.7. LIMITATIONS OF THE STUDY:

Start from the research design stage to final survey of this present study lot of efforts and

attempts have been taken to minimize the limitations. However,

1. Primary Health Centers (P.H.C) and rural hospitals have not been considered in

the study as per the Quality standards prescribed by National Accreditation Board

for Hospitals and Healthcare Providers (N.A.B.H)74.

2. Allopathi, Ayurveda, Homeopathi, Unani Dispensaries / clinics / hospitals

providing primary health having bedded strength below 30 have also been not

considered for the study as quality standards are not applicable to them.

3. The period of the study is also restricted to two years i.e. 2008 – 2010.

74 “National Accreditation Board for Hospitals and Healthcare Providers, A guide book to NABHstandards on Hospital Accreditation”, 1st Edition, Aug, 2006, pp.2.

48

4. St. Anns’ Hospital, Vijayawada – have bed strength 100 & above and St. Anns’

Hospital, Avanigadda – have bed strength 30 to 50 have not permitted to carryout

survey of patients, hence omitted for present study.

5. Missionary Hospitals named St. Anns’ Hospital, Vijayawada & St. Anns’

Hospita, Avanigadda have not been permitted to carry-out present study. Hence,

the results of missionary hospital limited to Gifford Memorial Hospital.

6. The size of the sample selected for the study constitutes only a small segment of

the population. Hence, the findings may have the limitations pertaining to the

size of sample.

7. As the study is conducted in the Krishna District of Andhra Pradesh, hence the

study may have the limitation of generalizing the findings of entire industry of

Andhra Pradesh state.

8. Despite all the care taken, the authenticity and accuracy of data depends upon the

reliability of the information provided by the respondents. Therefore, this

limitation bound to be present in the study.

1.8. PLAN OF THE STUDY:

Chapter One introduces the background to the research, Growth of Healthcare Industry,

need and scope for the study, review of literature, objectives of the study, research

methodology, how the sample was selected and supported, theoretical underpinnings of it

and the ethical considerations taken into account during the entire process and statistical

tools used and limitations of the study.

49

Chapter Two gives information related to Healthcare systems and Infrastructure in India

i.e., concept of health, health and development changes in India, Healthcare systems and

infrastructure in India, Rural Healthcare Systems in India - the structure and current

scenario and Rural Health infrastructure – a statistical overview.

Chapter Three presents the role of Government in healthcare management – World and

Indian scenarios, Public Health system in India, National Rural Health Mission, Role of

Insurance in Healthcare management and 108 & 104 unique healthcare services.

Chapter Four reviews definition of service and service quality, need of service quality,

dimensions of quality and service quality, failure gaps in service quality, importance of

service quality, measuring service quality by SERVQUAL model, limitations of

SERVQUAL model, standardizing healthcare quality through hospital accreditations –

World and Indian scenarios.

Chapter Five deals with the data analysis and findings by using SERVQUAL scale,

statistical tests and graphs applied to the data through in-depth interviews that have been

collected from the patients. Further, analyzed results were tested with formulated

hypotheses to conclude on service quality offered by the select hospitals.

Chapter Six offers findings that emerged from the entire study and necessary

suggestions for Service Quality improvement in hospitals and conclusion followed by

opportunities for further research.