Service Quality Management Setting in the Case of Black Lion Hospital by Damtew Tessema 2014

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Service Quality Management in the case of Black Lion Hospital

by Damtew Tessema 2014

INTRODUCTION

1.1 Background of the Study

For several decades “quality” and “quality management systems” have been leading philosophy

in the business world. According to Biolos (2002), numerous consultants have built their careers

around these topics, and quality issues in business have been responsible for the development of

new organizations and even industries. Now a day, many firms are adopting the quality

management system. According to Wolkins (1995) and NSWHEALTH (1998), the science of

quality management system is imperative to exercise in service institutions like hospital and

clinics. The system encompasses “continuous quality improvement, total quality management,

setting service standards, participative management and other related activities” (NSWHEALTH,

1998: 277). Therefore, the service centers like the health institutions, both the private and public

ones are in need for service quality management (SQM). According to the British Colombia

Institute of Technology (2001), health care quality management will prepare managers and

health care professionals to plan, develop and implement successful continuous quality

improvement/management programs in their organizations and health care regions.

With applying SQM principles, many service firms in both developed and developing worlds are

working to maximize their service quality to their customers. Similarly, such philosophy has

introduced into Ethiopian health service industries. One of the service organizations which have

been trying to provide quality services by exercising quality management systems is Black Lion

Hospital (BLH). “The hospital is one of the oldest and largest hospitals in the country’’ (Global

Health Reflections, 2011:2). In view to achieve the best result in its service BLH has its own

quality management setting. Moreover, according to BLH (2010), the focuses of the BLH are (1)

quality of clinical care provision (2) the provision of explicit accountability for the quality of

health care with a systemic orientation; (3) managing the quality of health services with applying

the Principles of Balance Score Card (BSC), striving to supply adequate health materials and

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work to promote the capacity of supportive stuffs members and the health science professionals.

Based on the above background, the study will examine the service quality management settings

and its problems in BLH with focusing on the post-2000 years. The components of health service

quality management and service quality management setting component, the stakeholders, the

change and continuity of practices and the entrenchment of BSC principles` in SQM practice of

BLH will be discussed. The variables of SQM and its conditions will be analyzed based on

respondents’ responses. Finally, the study will put findings, conclusion and recommendations.

1.2 Statement of the Problem

Black lion hospital is the country`s largest hospital that provides medical treatment services and

academic education (for both undergraduate and post-graduate students). Currently, it has short

comes to provide timely medical treatment to patients come from different corner of the country.

As stated above, the hospital is both education and treatment center, in which wide varieties of

activities are carried out. As an academic institution, according to (TAAAC, 2011), BLH is

Ababa University`s largest and oldest teaching hospital among all in Ethiopia providing teaching

for about 300 medical students and 350 residents every year. “It offers diagnosis and treatment

for approximately 370,000-400,000 patients per year” (Ibid: 1). For the sake of providing the

stated services, it has 800 beds, 130 specialists and 50 non-teaching doctors (ibid). However, the

professional manpower and the material resources are limited which would further constrain the

quality services. In regard to the materials, according to Broom (2011), materials that are basic in

the developed world like in America are not available. In this multi-service institution, there is

the dynamism of activities and managerial activities. The policy of the federal government like

the Growth and Transformation Plan, the introduction of Balance Score Card system and other

related newly adopted government programs exacerbates the dynamism of activities and service

quality management settings. The dynamism and program rearrangements are more rampant in

the post-2000. Further, it is no doubt in saying that, there are significant changes in the variables

of SQM. The changes are also visible within a year or less. This shows that continuous study and

assessment of the area is essential, although there are previous researches that conducted in 2012

and before. The previous researches related to this study are not enough to illustrate all the

impact of policy and program change on the SQM. The 2012/13 conditions of SQM in BLH is

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also the issue which has not yet studied. However, this does not mean that this study is limited to

the 2012/13 phenomenon.

Therefore, this research is aimed at filling these above stated research gaps. There is also a need

to conduct study on the change and continuity of SQM systems from the year 2000 to present. In

addition, the research has its own contribution to put directions in dealing with the prevailing

problems related to quality services.

1.3 Core Argument

The existence of an ever increasing number of patients enrolled to BLH is the reality any years.

The supply of materials that are essential to provide adequate and quality service is limited and

thus the supply and demand are not synchronized. The professional man power is also found to

be limited. Moreover, the dynamism and progress of demand for better service is a ubiquitous

phenomenon. Therefore, the actual service is less able to meet the demand for the service. Thus,

the core argument is concerned about that the service quality management setting of BLH lacks

adequacy to satisfy the health service requirements and demands of the customers.

1.4 Objective of the Study

The main purpose of the study is to examine the service quality management setting of Black

lion Hospital. Within this broad issue the adequacy and the challenges in SQM will be discussed.

This broad objective has also four specific objectives that the paper desired to address. These are:

• To know the service quality management system of BLH;

• To identify the changes and continuity in SQM system of the Hospital;

• To identify the stakeholders and components of service quality management and

• To articulate the challenges in providing quality service.

1.5 Research Questions

Due to the dynamism and changes in the condition of SQM system and service provision

activities of BLH, studying the setting of SQM from the year 2000 to present is imperative. For

this purpose, I have forwarded a general and, three specific questions. The general question is

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refers to that “what are that service quality management setting of BLH? In addition, the specific

questions of the study are stated as follow:

• What is the system of service quality management?

• What are the changes and continuity in SQM and related issues?

• Who are stakeholders and components of service quality management of BLH?

• How and why the inability to provide adequate services BLH?

1.6. Significance of the Study

This research would help to identify the post-2000 service quality management setting and

practice of BLH. More specifically, the study enables to know the change and continuity of the

practice of service quality management. It enables to identify the areas of services in need for

improvement. It helps to assess the customers’ feelings and service delivery satisfaction as well

as the challenges to the service quality. The research enables the reader to know the components

of service quality management setting of the state hospital.

1.7. Methodology

Both quantitative and qualitative study design will be applied for the investigation because that

the data are the mix of descriptive type (qualitative literatures) and numerical (quantitative) one.

In order to achieve the objective of the study, I used purposive sampling (deliberate selection of

few service providing Medical Doctors and experts who are in the quality management position)

for interview because I believe that the targeted individuals have knowledge about the area of the

study. For the questionnaire, to get informants from the customers of the hospital, sampling is

used. Accidental sampling (sometimes known as grab, convenience or opportunity sampling) and

is used to access 78 and 62 emergency and outpatients clients respectively. Accidental sampling

is a type of no probability sampling which involves the sample being drawn from that part of the

population which is close to hand. In the three building there are 800-850 beds and single

respondents are selected from each floors the inpatient take bed. The nurse and doctors who

assigned to care the patients are also given response to the questionnaires.

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Both the primary and secondary sources will be applied to same purpose. As primary source,

interview has conducted with 3 persons who are two Medical Doctors are attended in BLH for

both their undergraduate and specialization and one Managing Director (1) in Black Lion

Hospital). Furthermore, 70 questionnaires are distributed for customers, medical employees and

administrative officers. As a secondary source of data, magazines books and government

documents will be reviewed.

1.7. Scope of the Study

The study covers the issue of Service Quality Management Setting in black Lion Hospital with

focusing to the post-2000 period. Here, the major focus of the research is the assessment of

Service Quality Management Setting in the case of Black Lion Hospital to examine the

challenges for the adequacy of services.

1.8. Limitation of the Study

The long time pending and the bureaucracy to get the officers for interview are considered as the

top of the limitation. The cancelation of appointment time by the officials is the constraints to

access the targeted key informants. The other problems are the difficulty to organize and collect

the diversified literatures related to the issue. Moreover, it is true to say that the time shortage to

conducting the research is a limitation in the study.

1.9. Organization of the Study

The research has organized into four chapters. The first chapter contains the introductory part. It

includes the background: statements of the problem, the core argument, objectives, research

questions, significance, methodology, and limitation, scope and organization of the study.

Second, the literature review embraces the definition and conceptualization of service quality

management, components of health service quality management and service quality management

setting component in BLH. In this part, different publications will be reviewed. The third chapter

describes the stakeholders in and practices of quality management in BLH. This section has also

contains the issue including, the stakeholders before and after 2000; the change and continuity of

practices and the entrenchment of Balance score card (BSC) in QM practice. In the fourth

chapter, all the data will be presented and analyzed. The general characteristics of the

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respondents and the variables of health service quality management will be discussed and

articulated. The findings and conclusion are the last part of the study

CHAPTER TWO

LITERATURE REVIEW

In this part, the concept of service and quality, Service Quality Management (SQM), the

components of health service quality management are discussed. For this discussion different

publications have reviewed.

2. 1. Concept of Service, Quality and Service Quality Management

Before the assessment of service quality management saying something about quality and service

is important because that it is not possible to understand service quality management without

having knowledge about the terms (service and quality).

2.1.1. Quality

According to the American Society for Quality (2004), “quality” can be defined in the following

three ways: First, based on customer’s perceptions of a product/service’s design and how well

the design matches the original specifications. Second, the ability of a product/service to satisfy

stated or implied needs; third, the achieved result by conforming to established requirements

within an organization (Ibid). The satisfaction of customers/ clients and extent to meet the

established high standards of services can be the yardstick point to talk about quality. There are

several elements to a quality system, and each organization is going to have a unique system

because that the quality variables may differ from organization to organization. Furthermore, the

most important elements of a quality system include participative management, quality system

design, customers, purchasing, education and training, statistics, auditing, and technology

(www.bussinessballs.com/dtrireresuorces).

According to American Society (2004), health service has six dimensions of quality on which the

framework is based are; safety, effectiveness, appropriateness of care, consumer participation in

health care, access to services and efficiency of the health care (health services must ensure that

resources are utilized to achieve value for money).

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2.1.2. Service

Service is refers to “any activity or benefit that one party can offers to another that is intangible

and does not result in the transfer of ownership of any physical object” (Dictionary of

Business,1996:454). According to Crowther, Kavanagh and Ashby (2006), service is a business

performs work or supplies goods for customers, but does not make goods. Services can be

delivered by any organizations that are government of non-governmental and private one.

Indivisibility, customer participation, intangibility and simultaneity (consumption and supply

occur at one time) are the manifestation of service. Thus, quality service implies that the service

which meets customer demand and pre-established standard. In regard to the concept of

healthcare/ health service quality, “the most durable and widely cited definition of healthcare

quality was formulated by the Institute of Medicine (IOM) in 1990” (Buttell, Hendler, and

Jennifer Daley, 2007:62). According to the IOM, quality consists of the degree to which health

services for individuals and populations increase the likelihood of desired health outcomes and

are consistent with current professional knowledge (Lohr, et`al, 1992). For these writers,

provision of healthcare service is aimed enhancing the chance of desired health outcome for

populations. The service delivery is also needs professional knowledge.

2.1.3. Service Quality Management

Management is the control and making decisions in an organization (Crowther, Kavanagh and

Ashby 2006). leading, staffing, monitoring and evaluating of an organization`s activity are also

the element in management processes. Therefore, it is possible to conceptualize Service Quality

Management (SQM) as the management of the provision of intangible benefit (performs work or

supplies goods for customers) and the regulation and follows up of compatibility of services with

the pre-established requirements.

Furthermore, SQM is explained in the following manners. It is the activities that healthcare

organizations design and implement more effective organizational support processes to make

change in the delivery of care possible (Lohr, et`al, 1992). In the practice of SQM and healthcare

managment, Lohr, et`al, (1992) argues that, according to the IOM, setting performance standards

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and expectations is essential element to improving patient safety. According to QMO,2011),

health service quality management is the activity of managers and healthcare professionals to

plan, develop and implement successful continuous quality improvement/management programs

in their organizations and health care regions. The final purpose is to enhance the delivery of

quality health care services that are accountable to clients of the system, the government and the

public.

In general, the concept of SQM is refers to the management of safety, availability /access and

effectiveness of services as well as the process of ensuring to meet the established standard of

services.

2.2. Components of Health Service Quality Management

In regard to health service Quality Management components, the health quality framework of is

based on the six dimensions of quality that have been selected to encompass aspects of care

relevant to patients and providers of health services. These are safety, effectiveness,

appropriateness, consumer participation, efficiency and access. This arrangement is applicable to

other health institution located in developing and developed countries

The focus of health performance monitoring in recent years has been primarily on activity and

financial efficiency (NSWHEALTH, 1998:7). Clearly, activity and efficiency remain important

but these need to be matched with attention to the other dimensions of quality of healthcare, with

accountability for budget and quality being viewed as equal performance indicators of health

management (ibid).

In regard to health service, everyone connecting with the health system, including consumers,

policymakers, clinicians, and managers have an interest in the quality of care provided. What is

needed is an overarching, coherent framework for managing the quality of health care in a

systematic way in Black Lion Hospital.

According to Buttell, Hendler, and Jennifer Daley (2007), IOM’s Committee report outlined an

agenda to improve proposed six components of quality in healthcare as follow:

Safe: Avoiding injuries to patients from the care that is intended to help them. Effective:

Providing services based on scientific knowledge to all who could benefit and refraining

from providing services to those not likely to benefit (avoiding underuse and overuse,

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respectively). Patient centered: Providing care that is respectful of and responsive to

individual patient preferences, needs, and values and ensuring that patient values guide

all clinical decisions. Timely: Reducing waits and sometimes harmful delays for both

those who receive and those who give care. Efficient: Avoiding waste, including waste of

equipment, supplies, ideas, and energy. Equitable: Providing care that does not vary in

quality because of personal characteristics such as gender, ethnicity, geographic

location, and socioeconomic status.

Therefore, the management of Health Service Quality is emphasized on the planning,

controlling, monitoring, and etc the activities that are related to safety, effective, patient centered,

timeliness, efficiency and equitable.

NSWHEALTH (1998) adds that, effectiveness, appropriateness, consumer participation, and

access as the components of quality health care service. Consumer Participation in health care:

Not only do consumers have a fundamental right to participate in health care delivery, but such

input should have considerable benefit (ibid).

Access to services: Area Health Services should offer equitable access to health services on the

basis of patient need, irrespective of geography, socio-economic group, ethnicity, age or sex

(QMO, 2012). Appropriateness of care: It is essential that the interventions that are performed

for the treatment of a particular condition are selected based on the likelihood that the

intervention will produce the desired outcome. Essentially, the appropriateness of health care is

about using evidence to “do the right thing” to the right person, in a timely fashion

(NSWHEALTH, 1998).

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CHAPTER THREE

3. THE STAKEHOLDERS AND SERVICE QUALITY

MANAGEMENT SETTING IN BLACK LION HOSPITAL

In this part, the issues of stakeholders` participation in service quality management and service

quality management setting in Black Lion Hospital are the major concern. Within this topic, the

questions of “who are the stakeholders and how the service quality management system of BLH

sets?” are answered.

3.1. Stakeholders in Service Quality Management of BLH

Successful management of a quality service system involves many different aspects that must be

addressed on a continuous basis. For this purpose, the prevalence of several participants of the

management activities from different sections of the departments of an organization is

imperative. The plurality of practitioners would provide the mirror to see different aspects of

Service Quality Management.

When we see BLH, the stakeholders in Service Quality Management (SQM) of are the officers

of the quality control office, the nurses, and the emergency section, laboratory and infection

prevention department1. The representatives of the above mentioned department and sections of

the hospital have tasked to assess the reality of their respect departments and contribute inputs

for the better quality of services. Each of the departments except the quality control office (that

has four representatives) has a single representative in the quality management committee. The

reports of each department have taken into account the key performance indicators that the

hospitals` quality management office sets. The committees that established in accordance with

Ethiopian Hospital Reform Implementation Guidelines (EHRIG) have a role in evaluating,

controlling and monitoring the service quality of the hospital.

1 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013

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As to the respondents to the interview and open ended questionnaires, the consideration of

customers/ clients as stakeholder in quality management system is limited. However, one of the

key indicators of performance that established by the hospital is customer satisfaction. According

to QMO (2010, 2011, and 2012), with the desire to examine the satisfaction of clients, the quality

control office has been conducting a number of surveys on patients who undergo triage within 5

minutes of arrival in emergency room, and total number of attendances who remain in

emergency room for more than 24 hrs. As to report of QMO, if the emergency service providers

presented the patients for diagnosis, or for another day pending for less critical illness within

short period of time, there is possibility of satisfaction.

The nursing service directorate director admits that, the participation of stakeholders in quality

management system has no continuity. The managing director of the hospital also argues that

there is high participation of stakeholders at office level. But the managing director has declined

to comment on the continuity of stakeholders’ participation. The cleaners, guards and are not part

of the quality ser control committee. Service starts from the reception room and all the

practitioners of services are in need to be presented in service controlling system.

3.2. Service Quality Management Setting in Black Lion Hospital

For the discussion of this section, both the primary data which was acquired from the

questionnaires and interviews, and reports of the organization (BLH) are used. The service

quality management and control system of the hospital is under the supervision of Chief

Executive Organizer (CEO) and the activities carried out based on the KPI/ Ethiopian Hospital

Reform Implementation Guidelines` (EHRIG) requirements. All the quality measurement results

as well as improvement measures and proposals are expected to be submitted to CEO2. The

quality management and control activity of BLH has been exercised by the committee embraces

eight individuals. In this committee, four employees are from the quality control office, a nurse,

one person from emergency department, one from laboratory and the remaining person

represents the infection prevention department (ibid).

2 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013

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The exercise of quality control is implemented on the basis of EHRIG`s standards that articulated

in its charters. In the standards of EHRIG, hospitals expected to establish committees from

several sections of the hospital. However, BLH sets only the infection prevention, nursing

standard, drug and diagnostics and patient enrollment committees (Ibid).

For the management of quality of the services of the organization, Black Lion Hospital

established Key Performance Indicators (KPI). These are hospital management, outpatient

service, emergency service, inpatient service, maternity service, and referral services, pharmacy,

productivity, human resources, financial service and patient satisfaction (QMO, 2010, 2011 and

2012). The establishment of the key indicators can be considered as the part and parcel of service

quality control of BLH. Most of these indicators are discussed below.

As to the report of QMO (2011), one of the key performance indicators called Hospital

M3anagement focused on the total number of EHRIG Operational Standards for Hospital

Reform meet, number of new and repeat outpatient attendances at public facility and number of

new and repeat outpatient attendances at private wing. When high number of EHRIG`s standards

meet and outstanding number of new and repeat outpatient get treated in regular and private

wing, we can say that the performance hospital management is praiseworthy.

Outpatient Service: this is concerned to the number of outpatient ‘waiting time cards’ completed,

outpatient waiting time (in minutes) and number of outpatients not seen on same day as

registration during the reporting period ( QMO, 2010). To say that this indicators is outstanding,

there should be outpatient who get service within short period of time (in card room, diagnostics

and treatment).

Emergency Service focused on the total number of attendances who remain in emergency room

for more than 24 hrs, number of surveyed patients who undergo triage within 5 minutes of arrival

in emergency room, and the number of deaths in emergency room from patients who were alive

(i.e. any vital signs present) on arrival (ibid). These several indicators can be the quality indicator

to rate emergency service of the hospital.

Inpatient Service: To appraise the performance of inpatient service, the quality management

office measures “the number of patients discharged alive (including transfers out), number of

days between date added to surgical waiting list to date of admission for surgery, the total

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number of patients who were admitted for elective (non-emergency) surgery during the reporting

period, average number of operational beds during the reporting period and total number of

major surgeries (both elective & non-elective) performed during the reporting period on public

patients” (QMO,2011:3).

Productivity: This can be measure based on the availability and services of average number of

full time equivalent nurses/midwives, average number of full time equivalent doctors and

average number of Full Time Equivalent (FTE) specialist surgeons (excluding

ophthalmologists).

Maternity Service: In this aspect, the number of live births attended in the hospital, the number

of women who gave birth in the hospital, the number of abdominal surgical deliveries, and the

number of instrumental or assisted vaginal deliveries as well as the number of maternal deaths

(any gestational age) are the major focuses (ibid).

Referral Services: The number of emergency referrals made and the number of non- emergency

referrals made are the basis to evaluate referral services. Both types referral expected to have

appropriate and timely treatment.

Human Resources: According to QMO (2011), the number of physicians (GPs and specialists)

who left the hospital during the reporting period, number of physicians (GP & Specialists)

employed by hospital at the beginning of the reporting period, number of physicians (GP &

Specialists) hired during the reporting period, and etc are the component to measure the

hospital`s human resources performance indicators. The hospital has attempted to give better

service by increasing the quality and quantity of the physicians Doctors (General Physicians &

Specialists).

Finance services: Total hospital operating expenses during reporting period, government

operating budget allocation for reporting period, total capital expenses during reporting period

and raised revenue budget allocation for reporting period and others the elements to evaluate the

quality of financial services of the hospital (QMO, 2012).

Patient Satisfaction: here, the focus is, number outpatient and inpatient surveys completed and

the rating score of the satisfaction (ibid). According to the reports, surveys were conducted to

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rate the satisfaction of clients. The findings of surveys are expected to measure the satisfaction

levels.

To sum up, the improvement of the sum total of quality indicators is synonyms with the

improvement of the whole service quality management setting of BLH. The introduction of BPR

in bringing radical reform to Quality Management practice is one of the changes that have

occurred after 2000. However, the entrenchment of Business Progress Reengineering (BPR)

practice in the management service of the hospital has little significance. There are official move

to realize the implementation of BPR but it is in the beginning stage. Since 2012, based on the

BPR study and performance appraisal of the employees of Addis Ababa University, high

numbers of new workforces have deployed in BLH. Most of the department of BLH have

occupied with the tasks of realizing BPR.

Furthermore, the response of administrative staffs and employees assert that, Balance scorecard

(BSC) system (a strategy performance management tools-semi structured financial and non-

financial report) has not yet exercised in the management of services performances of BLH.

In recent years, as to the Managing Director of BLH, the service quality control activities of the

hospital have shown significant progress. Similarly, according to (QMO, 2010, 2011, and 2012),

there are efforts to change the rudimentary system of quality control to objective and scientific

form. Further, the situation of service provision in BLH before seven years was backward and,

now there are positive changes although it is not enough to meet the needs and demands of

clients3. There is also diversification of services which introduced after 2000s reforms.

CHAPTER FOUR

4. DATA INTERPRETATION AND DATA ANALYSIS

All data are presented and analyzed in this chapter. The chapter is divided into two parts: part I,

which deals with general characteristics of the respondents in terms of sex, age, educational

3 Interview with Tinsae H/Michael ( GP), a third Year Student in Orthopedics( Specializing) and a Former Student

in BLH September 20,2013

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qualification and the service years of respondents. In the second part of this chapter the variables

of service quality management setting and the whole system of service quality management of

BLH.

The relevant data collected from the sample respondents of the questionnaires, the documents

and the information gathered from the interviews (with service quality management workers and

professional service providers) in BLH are analyzed and interpreted. Hence, the basic questions

raised in the first chapter were given appropriate treatment.

Out of the total 70 questionnaires 56 (80%) were filled and returned. From these total

respondents (TRs), 37 and 19 are clients and employees/administrators of BLH respectively.

Based on the responses obtained from the above sources, the analysis and interpretation of the

data are presented in the following tables.

4.1. Demographic Characteristics and Areas of work of the

Respondents

Under this part, democratic characteristics of respondents are analyzed. The respondents were

asked to furnish their personal demographic information and their types of work during the

study. Their responses have been summarized in table 1 below that depicts respondents’

demographic characteristics. The demographic articulation has two categories in which the

demographic presentation of clients and the employees of BLH have discussed. In addition, the

types work the employees engaged in and Service of Employees have also given emphasis.

Table-1(A). Demographic Characteristics of Respondent (clients) in BLH

Items Variables In number Percent (%)

A)Sex of Clients Male 20 35.7 % of Total Respondents(TRs)

female 17 30.4 % of TRs

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B) Age of Clients

12-25 11 19.6 % of TRs

26-35 13 23.2 % of TRs

36-45 6 10.7 % of TRs

Above 46 years old 7 12.5 % of TRs

C)Educational level

of Clients

Grade 4 to 8 5 8.90 % of TRs

Grade 8-10 7 12.5 % of TRs

Certificate &

Diploma

17 30.4 % of TRs

Degree 8 14.3 % of TRs

D)Types of Clients Emergency 10 17.9 % of TRs

Inpatient 13 23.2 % of TRs

Outpatient 14 25.0 % of TRs

Total Clients 37 66.1 % of TRs

Table-1(B) Demographic Characteristics of Respondents (Employees and

Administrators) in BLH

Items Variables In number Percent (%)

1) sex of Employees Male 8 14.3 % of TRs

Female 11 19.6 % of TRs

2)Age of Employees 26-35 9 16.1 % of TRs

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36-45 8 14.3 % of TRs

Above 46 years old 2 3.6% of TRs

3)Education Level

of Employees

Certificate &

Diploma

3 5.4 % of TRs

Degree 10 17.9 % of TRs

Masters and above 6 10.7 % of TRs

4)Job Description

of Employees

Management and

SQM

3 5.4 % of TRs

Physician & Nurse 13 23.2 % of TRs

Cleaner 3 5.4 % of TRs

5)Service of

Employees

1-4 years

6 10.7 % of TRs

5-10 years 4 7.1 % of TRs

Above 10 years 9 16.1 % of TRs

Total Employees 19 43. 9 % of TRs

As to table 1(A and B), the ratio of male and female respondents are equal. In the ratio of

respondents, there are fifty percent of male (35.7 % clients and 14.3 % employees) and fifty

percent of female (30.4% clients and 19.6% employees). Therefore, the proportion of both sexes

in the information of this research is highly considered. This implies that both sexes have

reflected their views in the data that are inputs for the research.

According to table 1(A and B), the clients and employees are 66.1 and 43.9 percent of the total

respondents (TRs) respectively. The above table (in item A and 1) shows the age groups of

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respondents and in which 19.6 % of the TRs ranged from the age of 12 to 25 (for clients) and no

respondents from the employees of BLH found in this age category. The age of 23.2 % clients

and 16.1 % employees of BLH are found in the range from 26 to 35. 10.7 % clients and 14.3%

employees are also 36 to 45 years old. The remaining 12.5 % respondents of service seekers and

3.6% workers of the hospital are 46 years old and above. From this data, we can conclude that

most of the respondents are capable to understand and analyze the condition of service that the

hospital delivered to them. Their age can enable them to give rational and constructive comment

and response to the questions stated in the questionnaires.

In regard to the educational backgrounds of the respondents, there are 35.8% Certificate &

Diploma holders. But, there are 21.4% respondents all of them are from the clients found in the

range between grades four and ten. 32.2% of respondents from both clients and employees are

degree holders. The other remaining 10.7 % respondents (employees) are in the level of Masters

Degree and above. Generally, nearly 80% of the respondents are professionals who hold

Certificate and Diploma Degree, Masters and above. Thus, the credibility of the response as well

as the rationality of the information they had provided are in a better position.

Concerning the clients` type, the table 1(A) (Item D) has three categories of clients which

include emergency, inpatient, and outpatient. Clients-respondents who are appeared in BLH for

only one day for emergence covers 17.9 % of TRs. This type of client may not observe different

forms of service delivery. Hence, the information they had tipped-off- has relatively less validity

but not irrelevant (because they can at least observe the single service quality). The other 23.2%

and 25% are inpatient (clients who take bed for inward treatment) and outpatient (patients who

come and go home for treatment for more than two times in BLH) respectively. These two types

of clients cover 48.2% of TRS and they have the chance to observe several aspects of the

healthcare service because they have stayed and appeared for several in BLH. Thus, the response

they had given during the research has more credibility.

Job Description and the position of employees in the sample respondents stated in table-1(B) (4)

and in which 23.2 %, 5.4 % and 5.4 % of TRs are Physician (GP) & Nurse, Management and

SQM staffs and cleaners respectively. This distribution shows that the presence of diversity in

19

occupations of respondents. Thus, they can observe different variables of quality serves. More

importantly, they are the practitioners of service system of the hospital.

In regarding to the service years of the respondents (employees), according to table 1(B) (5),

47.4% of respondent-employees or 16.1% of TRs are served in BLH for more than 10 years. The

remaining 10.7 % and 7.1 % of TRs are served from one to four and five to ten years

respectively. The majority of those sample respondents from the employees are seniors and

aware about the condition of service in Black Lion Hospital. This helps the research in acquiring

reliable information about the issue.

4.2. Assessment of Service Quality System of BLH

In this section several variables that are the attributions of quality have been discussed. The data

is gathered from both employees and clients of the hospital. The condition of quality service

delivery system, categories of observed problems continuity & improvement of supervision and

stakeholders’ participation in SQM Setting and others are the major themes.

Table-2:- Tabulation of Clients` Responses in BLH

Variables Levels and Options In Number In Percent (%)

I) Quality

Service

Delivery

Weak 14 25.0 % of TRs

Good 13 23.2 % of TRs

Very Good 8 14.3 % of TRs

Excellent 2 3.6% of TRs

II) Categories

of Observed

Inability Discharging Responsibility 10 NCC

Favoritism and lack of Openness 4 NCC

Material Shortage related Problem 16 NCC

20

Problems Lack Skilled Manpower 3 NCC

Unreasonable Delay of Service 11 NCC

Have No Observed 6 NCC

Total NCC 66.1 % of TRs

Key: - TRs denotes the Total Respondents of this Research and, NCC means Not Convenient

to Calculate

In this section, the assessment of service quality system of BLH is carried out on the basis of the

responses of respondents to the questionnaires (for both closed and open ended questions). These

data are also tabulated above in table 2 and below table 3 according to its convenience for

discussion and analysis.

4.2.1. Categories of Observed Problems

The data analyzed in this section is given only by clients of BLH. However, the administrators

and employees have had stated some problems for the open ended questions. In voting the

categories of observed problems, one respondent may state two or more problems according to

his experiences. That means he/she would states lack of skilled manpower and unreasonable

delay of service as a problem simultaneously. Thus, this condition constrained to calculate the

exact percentage of voters’ for a specific problem in terms of TRs. Numerically, 10 and 4

respondents observed the prevalence of “favoritism” and lack of openness and the inability of

employees to discharging responsibility irrespectively. High number of respondent (16) observed

or suffered from material shortage related Problems. Unreasonable delay of service is the other

problem of the hospital that admitted by 11 respondents. Some 5 respondents most of them are

new arrived in BLH for emergency services haven’t observe anything problem.

The above data shows that material shortage and related Problems, inability of service givers to

discharging responsibility as well as unreasonable delay of services are the major problems that

the clients faced in their stay in BLH. Under the violation of responsibility, client observed that

employees in card room, emergency section and other wards failed to execute professional ethics

21

(showing bad gesture, inability to give response, intolerance and unreasonable

boredom).Therefore, this conditions have a drawbacks in service system of the hospital that

patient would face additional psychological challenges. The patients may disappointed and feel

mal-treated.

The minor number of respondents has also faced problems that resulted from lack skilled

manpower and favoritism and lack of openness in service delivery of the mentioned hospital.

Here, as to the respondents, justification for their response that students are made try and error on

patients and personal relations is the prerequisite to get prior service respectively. If it is so, the

condition has a severe impact in the service quality of BLH.

Furthermore, the respondents from employees to open ended questions asserted that sampling,

diagnostic and treatment materials (including some low cost machines) are unavailable.

Therefore, patients are obliged to attend another hospital for diagnosis or sample tests. For the

same respondent, the problem that resulted from the failure to discharge the given responsibility

is undeniable.

When the referees from other hospital send to another private hospital for complementary

diagnosis and or sample check the patient may not afford to pay for the diagnosis/ laboratory

services. Consequently, they would leave the hospital untreated. It has also costs their time and

the condition is the anti-thesis of the principle of efficient and timely healthcare service.

In responding the open-ended questions, both clients and employees say that, water shortage,

electric power cut and hygiene problems are the common circumstance. According to my

observation, the problems are common in the city of Addis Ababa and other hospitals and thus, it

is the resulted in another health complication for patients. But there are expectations that

hospitals are life saver institution and for this purpose they should have to have different water

and electric lines to guarantee the day to day availability. To ensure the availability and supply of

electric power and water, the availability of Generator and high volume water tankers are the

prerequisite in opera\ting hospital serves.

As to the clients, the challenges/problems to patients started in Card Room and the extents have

widen in diagnosis and treatment service as well as in service to give bed for in patients. A

number of respondents argue that after the arrival in BLH by referral, the hospital re-send them

22

to get diagnosis and to give sample in private hospital. The chance to get bed for inpatient is also

too narrow and long time pending is a ubiquitous act. This is disappointing but normal

phenomenon in BLH. When referral hospital sends the referees to other private hospital, the cost

of attending complementary treatment in private hospital is a challenge for patients. Therefore,

long time pending, additional cost for supplementary and complementary treatment in private

hospital as well as the material shortage, bureaucratic, and ethical problems in side BLH would

disappoint clients. Leaving the hospital without treatment would be possible. The general

observation of respondents affirms that due to the above mentioned challenges and other several

reasons the accommodation capacity of BLH and the demand for service are incompatible.

Table-3 Responses of Respondents from BLH Employees

Variables levels In number In (%) in Terms of TRs

A) Quality of BLH Service

Delivery

Weak 4 7.1 % of TRs

Good 10 17.9 % of TRs

Have No idea 5 8.9 % of TRs

B) Continuity &

Improvement of

Supervision

Weak 7 12.5 % of TRs

Good 10 17.9 % of TRs

Have No Idea 2 3.6 % of TRs

C) Stakeholder

Participation in SQM

Weak 4 7.1 % of TRs

Good 10 17.9 % of TRs

Very Good 2 3.6 of TRs

Have No Idea 3 5.4 % of TRs

23

D) Practice of Balance

Scorecard

Not yet practiced 15 26.8 of TRs

Have No Idea 4 7.1 % of TRs

Total 19 43.9 % of TRs

Key: - TRs denotes the Total Respondents of This Research

In this section, quality of BLH service delivery, continuity and improvement of supervision of

SQM, stakeholders` participation in SQM setting and the practice of Balance Scorecard are the

major subjects. Problem articulation, the other critical variable that is vital to discuss the

condition of services is discussed above.

4.2.2. Quality Service Delivery

According to table 2 (1) and 3(A), 32.1 % (25% clients and 7.1% employees) of the respondents

said that the delivery quality service in black Lion Hospital is weak. In the same table the

responses of 41 % (23.2% clients and 17.8% employees) of respondents asserted that the service

quality of BLH is good. 14.3% and 3.6% clients termed the service quality of the stated hospital

as very good and excellent respectively. The remaining 8.9% of respondents, all of them are

employees have refrained from saying something about the quality of services in the mentioned

hospital.

To analyze the condition, this response tells us that significant numbers of clients and employees

(32.1%) have suffered from the weak service delivery practice of BLH and therefore, the hospital

has lacks some required quality services. The respondents that recognized the prevalence of

quality service are exceeding 50% of the respondents. Therefore, although there are some

weaknesses in service system, there are improvement and satisfactory condition in the whole

system. Similarly, the responses to the open ended questions asserted that there is gradual

improvement of service quality in BLH.

Finally, the some employees were reluctant to give response for the questionnaires although I

had get permission to questioned them and inform the purpose of the questionnaire. The

24

reservation to slam or approve on the presence of quality service may be also resulted from fear

of the consequence criticizing the system.

The interviews and some answers for the open ended questions informs the research that there

has been newly introduced services, quality improvement, and the application of information

technology as well as new way of performance measure. This is marked by the reform activities

of BLH after 2000s4. Hence, this condition has value in enhancing quality services.

4.2.3. Continuity and Improvement in the Supervision of SQM

Regarding the continuity and improvement in the supervision, the questions in the questionnaires

are forwarded only for employees of BLH in view of that they are the direct practitioners and

subjects of the supervision. According to table 3 (B), 7 out of 19 respondents termed the

continuity and improvement of Supervision in the hospital as weak. Out of 19, 10 respondents

asserted the prevalence of good continuity and improvement of Supervision of service quality.

The remaining two respondents have no idea about the Issue.

To see the implication of the responses, the simple majority of the respondents (employees)

recognized the presence of good quality of quality supervision and improvement. Thus, although

it is still less satisfactory, the continuity of same practice would help the further improvement of

service delivery. However, BLH has some drawbacks in controlling and supervision activities of

the health care services5. The weakness that observed by a seven respondents is a challenge to

ensure clients` satisfaction.

In general, the service quality, the supervision and the system have brought change after the

2000s continues reform activities. The reports of QMO of BLH have supported the above claims.

Currently, the hospital stared to implement the system of Business Reengineering process with

the aim to ensure worth mentioning service quality. The condition shows that there are praise

worthy activities but not sufficient.

5.2.4. Stakeholders` Participation in SQM Setting

4 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013

5 Interview with Anteneh M(GP), First Year Student in Specializing Radio and a Former student in BLH, September

29/2013

25

The stakeholders of the SQM setting are different departments of the hospital include, nursing

department, QMO, infection prevention office, pharmacy, emergency and laboratory sections6.

The responses of Administrators and QMO staff members to the open ended question have

asserted the above composition of stakeholders in SQM setting.

Concerning the levels participation of the stakeholders, the data is gathered from only the

employees. As stated in table 3(C), according to 4(21% of the respondents) out of 19

respondents, the practice is weak. From the same number of total respondents, 10 (52.6% of the

employees-respondents) of them rated the level of the stakeholders’ participation as good. Two

respondents asserted that there is very good implementation of stockholders` involvement in

service quality system of BLH. The remaining three respondents have no idea about the issue.

Based on the above data, we can state that the mentioned stakeholders` participation in service

quality control system of the hospital is in a better position. However, there are stakeholders that

ignored in the system. Hence, the participation of representatives of janitors, guards, clients and

others have given less emphasis.

4.2.5. Practice of Balance Scorecard (BSC)

Although the federal government of Ethiopia has given great concern for the implementation of

BSC, BLH has lag behind in introduction the system. According to table 3 (D), the absolute

majority of the respondents (15 out of 19) have affirms that the system of BSC has not yet

practiced. The interviews with the concerned guys have also asserted this claim. There are 4

respondents out of 19 that do not have knowledge about the system at all. This has also an

impact in obtaining objective financial and non-financial report to measure the performance of

service quality. The administrators have also informed me that BSC will be introduced and

implemented.

6 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013

26

FINDINGS, CONCLUSION AND RECOMMENDATIONS

Summary of the Major Findings

The main objectives in undertaking this study were to know the service quality management

system of BLH; to identify the changes and continuity in SQM system of the Hospital; to

identify the stakeholders and components of service quality management and to articulate the

challenges in providing quality service.

Accordingly, in the attempt to achieve the above objectives the study tried to find solutions for

the following basic questions. What is the system of service quality management? What are the

changes and continuity in SQM and related issues? Who are stakeholders and components of

service quality management of BLH? How and why the inability to provide adequate services

BLH?

To address the established questions, I reviewed relevant and related literatures, designed and

employed descriptive survey research method, collect data from the samples of BLH by taking

representative sampling through the accidental, stratified and random sampling techniques. The

data gathered from questionnaires, interviews and documents analyzed and based on the analysis,

the paper stated the following major finds.

The service quality management system of BLH is has hierarchical arrangements that

the committee on service quality management submits all the reports to the chief

executive organizer. The committee has embraced representatives from several

sections of the hospital like, laboratory, pharmacy, emergency and others. The QMO

has key indicators of quality includes, inpatient and out patient measurement, finance,

referral, pharmacy service and a number of others.

Regarding the changes in SQM system of the Hospital, after the continuous reforms

in 2000s, there are newly introduced services, quality improvement, and the

27

application of information technology as well as new way of performance measure.

The structural organization of BLH and some cultural-routine service delivery

practices are among the continued element of the system. The organization has also

determined to get rid this and other weakness.

The stakeholder of the SQM setting are different departments of the hospital include,

nursing department, QMO, infection prevention office, pharmacy, emergency and

laboratory sections. There is limitation in Stakeholders participation. The

participation and consideration of customers/clients, cleaners in BLH, supportive

staffs as key stakeholders have given less emphasis.

In health institutions, effectiveness, efficiency, safety, accessibility, productivity,

appropriateness and consumer participation are the dimension or components of

service quality management. In this aspect, BLH has been working on several

components of service system with employing KPI.

In BLH, the research proves that there are challenges as well as problems in the

provision of quality service. These are “favoritism” and lack of openness, the

inability of employees to discharging responsibility, Material shortage (electric power

cut, diagnostic and sampling machines water shortage) related problems and

unreasonable delay of services. Furthermore, lack of required man power and the

inability of the hospital to accommodate the patients requesting healthcare services

are the observed challenges of the delivery of quality services. It is undeniable that

these problems are the manifestation of weak service quality and therefore BLH has

been facing this.

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Conclusion

Black Lion Hospital is one of the few referral hospitals of Ethiopia and it is the treatment and

educational centre. Since 2000s the hospital has attempted to bring outstanding changes in

service delivery for its clients. For this purpose, it has undertaken a number of reforms. There

was effort to increase the number and the skill of specialists, and general physicians. It has also

been working to introduce Business Reengineering Process for the sake of bringing radical

reform in the whole system. But there is still problem in service delivery system.

Concerning to the service quality management setting of BLH is has hierarchical arrangements

that the executive organizer are the highest decision making person with taking into account the

reports (inputs) that several departments of the organization submit to him. In respect to quality

service, the committee on service quality management submits all the reports to the chief

executive organizer. The committee has embarrassed representatives from several sections of the

hospital like, laboratory, pharmacy, emergency and others. These are also the stakeholders in

quality service control and management settings of the hospital. The QMO has key indicators of

quality includes, inpatient and outpatient measurement, finance, referral, pharmacy service and a

number of others. The coming of new service quality indicators has also brought change in

service delivery system. The changes are reflected in the increment of the number of clients who

get service and the types of services that the hospital delivers.

In contrary to the positive changes, the research has discovered some problems like the inability

of employees to discharging responsibility, material shortage (electric power cut, diagnostic and

sampling machines water shortage) and unreasonable delay of services. The lack of

accommodation capacity the patients requesting healthcare services are also challenges in the

delivery of services.

29

Recommendations

Based on the findings the paper forwarded the following recommendations.

Healthcare organizations and the professionals affiliated with them should make continually

improved patient safety a declared and serious aim by establishing patient safety programs with

defined executive responsibility.

In the quality service management system, the participation of stakeholders including the

cleaners, clients, food provision section of the hospital and others are the basic tasks which need

to be done.

The electric power cut, diagnostic and sampling machines water shortage lead to question the

efficiency, effectiveness, appropriateness as well the quality of services. Thus, BLH has to work

in improving the mentioned weaknesses.

As educational and service institution the hospital has to work on building man power who can

give priority for professional ethics and values in discharging the required duties.

The recommendation of employees and clients coincided that BLH is in need for purchase the

machines that are vital for diagnostic, sampling and treatment services. Furthermore, the general

service provision system has limitation and recommended to be improved.

30

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