Romanian patients' customer perception of healthcare quality.

Vasilache, Simona ; Dan, Mihaela

1. INTRODUCTION

Recent advances in healthcare management regard patients as customers, whose expectations have to be met by the quality standards imposed by the hospital. According to Walters and Jones (2001), the healthcare sector is a market, borrowing several characteristics of business markets. Thus, issues as customer retention and customer loyalty become significant for the case of hospitals as well, and their attainment, similar to business, depends on efficient quality management. The review in Komashie, Mousavi, and Gore (2007) presents, comparatively, the characteristics of quality management in industry and healthcare, respectively. They quote an almost fifty year old concern, still on the research agenda, that quality in healthcare is extremely difficult to define. One explanation for this intrinsic ambiguity of the concept may well be the fact that stakeholders have become more diverse, but less supportive (Fouler et al., 1989). Secondly, the degree of patient information and involvement in the process of care providing has dramatically modified over the last decades, driving a change in status, from that of follower of the medical prescriptions to that of active part in cure, which lead to an upgrading of standards, as far as quality is concerned. The patients clusters grow smaller, as their needs, based on their various lifestyles, begin to differ (Moumtzoglou, 2007). Thus, the concept of caveat emptor (let the buyer beware) is to be applied to healthcare markets, as well. Still, the customer comes to the hospital with the preconception that quality standards will normally be above his expectations, which will result in high levels of deceit, if the case. Then, if the buyer bewares, he will beware forever. There should be considered (Duggirala et al., 2008) the effect of physical and psychical discomfort of the patient on his perception, the contribution of the subconscious factors, the disproportion between the patient's level of understanding of what is going on in the hospital and his expectations, leading to a distorted image, in which every error is emotionally amplified.

In this context, errors in healthcare have more lasting and significant effects as compared with regular fields of business. According to Gowen, McFadden, and Tallon (2006), there are several sources of errors in healthcare. First to mention is the inadequate job design, caused by complicated hierarchies, in which administrative and professional competence interfere. That "take me to your boss" situation Julian Ashley tested two decades ago would be a Sphinx dilemma for almost every hospital. Subcultures, groups of influence, the quarrel between the cosmopolitans, medical professionals reporting to their professional bodies, and locals, administrators attached exclusively to the culture of the hospital they manage are unavoidable realities of all hospitals, to which Romanian healthcare system makes no exception. Secondly, errors in healthcare arise from poor equipments, or from lack of technical expertise in adequately using equipments, or from people having expertise not having permission to use equipments, which amounts to a disproportioned, irrational resources allocation. The study of the aforementioned three researchers points also at computer malfunctions and unplanned events. And, last but not least, the shortage of resources and the high costs accompanying high stakes, hinder quality initiatives in healthcare.

Patient safety, as a central issue in quality improvement initiatives (Zimmerman, 2004), relies on this perception of being well taken care of in a certain healthcare facility. Jackson, Chamberlin, and Kroenke (2001) propose several predictors of patients' satisfaction, in terms of unmet expectations, symptomatic improvement, and receiving enough explanations regarding the causes and duration of the current state of illness. Quality does not always cost more, in financial terms, but it certainly implies more relational costs and a difficult to manage partnership between doctors and patients. The idea of social acceptability, which WHO quotes in relation to healthcare quality, points precisely at this aspect, of taking the patient's side in discussing about how efficient and effective a healthcare system is. Issues like patient-doctor collaboration, which frequently involves disagreeing with the patient for the sake of defending his interest, particularizing significantly the basic rules of customer relationship management, the fair amount of guidance in situations when the "buyer" bears, finally, the risk, a persistent knowledge asymmetry (patients may be more informed, but not necessary more rightly informed), combined with the real need to incorporate patient expertise into the healthcare process, complicate the agenda of healthcare quality management.

The main limitations of our study arise from conceptual complexity, as it is difficult to catch, in only a few criteria composing a model, the delicate relationship between the patient and the physician, or between the patient and the hospital, as a whole. Secondly, the sample was a judgmental one, suitable for idea testing, but not for statistical representativeness.

2. METHODOLOGY

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Using the answers of 50 Romanian patients having used, either directly or indirectly (as a carer), the services of ten Romanian clinics, in the last eight years (2001-2008), we analyzed their perception of each of these clinics based on three variables: competence of the doctors (doctors), competence of the nurses (nurses), empathy of the staff (empathy). Each of these variables was evaluated on a 1 to 5 Likert scale, where 1 = poor and 5 = excellent. The descriptive statistics for the three variables is presented in Table 1 below: Tab. 1. Descriptive statistics N Min Max Mean Std. Deviation doctors 50 1 5 3.92 1.217 nurses 50 1 5 3.81 1.509 empathy 50 1 5 2.67 1.155 Valid N 50

The perceptions of the patients in the sample are quasi-similar regarding physicians and nurses, rather positive, while the level of empathy reaches a below the average value. The reliability analysis for the three variables indicates a value of .724 of the Cronbach Alpha, which accounts for the positive average covariance among the items, supporting the reliability model assumptions.

The results of the PROXSCAL analysis are presented in the following section.

3. RESULTS

Patients' perceptions were expressed as proximities, which were analyzed using PROXSCAL (multidimensional scaling in SPSS). The final coordinates of the ten clinics in the common space are presented in Table 2 below: Tab. 2. Final coordinates Dimension 1 2 cl1 .432 -.547 cl2 -.070 .885 cl3 .566 -.058 cl4 .737 .142 cl5 .599 -.291 cl6 -.547 -.027 cl7 -.501 -.172 cl8 -.038 .633 cl9 -.503 -.337 cl10 -.676 -.229

The proximity of the points, in the bi-dimensional space, shows the similarity of the clinics, as expressed by their patients. Graphically, the patients' perception is illustrated in Figure 1:

[FIGURE 1 OMITTED]

It can be seen that clinics cluster according to their profile, which seems to dictate the similarities in perception, among their patients. If we compare the clusters, we conclude that while specialized hospitals tend to be very similar, general hospitals, for either adults or children, express a certain degree of dissimilarity, which may be explained by larger differences between various sections, or even between procedures in the same section, in general hospitals as compared to specialized hospitals.

4. CONCLUSIONS

Patient perception of the quality of the services offered in hospitals follows latent patterns, which cannot be adequately reduced to a set of variables, but can be approximated by multidimensional scaling.

Thus, hospitals which are similarly appreciated by their patients cluster closely together. By examining what these hospitals have in common, what are their best practices and how they can be transmitted, one can indirectly find out what is are the patients' expectations, as customers of the healthcare industry. Our analysis revealed that the profile of the hospital (general vs. specialized) influences the way the hospital is perceived, in terms of quality, and that there are differences, inside the clusters, the sample of specialized hospitals being more homogenous than the sample of general hospitals.

The results of the study may orient customer relationship strategies of the hospitals, and may lead to the proper differentiation of healthcare services, according to the specific profile of the hospital, seen as the most important factor of perceptual gaps among patients.

Further research may apply the suggested methodology on larger, representative samples, and may reach nation-wide conclusions, which interest decision-making in the healthcare national system.

5. REFERENCES

Duggirala, M., Rajendran, C. & Anantharaman, R.N. (2008). Patient-perceived dimensions of total quality service in healthcare. Benchmarking: An international journal, 15 (2), pp 560-583

Fottler, M.D., et al. (1989). Assessing Key Stakeholders: Who Matters to Hospitals and Why? Hospital & Health Services Administration, 34 (4), pp 525-546

Gowen, C.R., McFadden, K.L. & Tallon, W.J. (2006). On the Centrality of Strategic Human Resource Management for Healthcare Quality Results and Competitive Advantage. Journal of Management Development, 25 (8), pp 806-826

Jackson, J.J., Chamberlain, J. & Kroenke, K. (2001) Predictors of patient satisfaction, Social Science & Medicine, 52 (4), pp 609-620

Komashie, A., Mousavi, A. & Gore, J. (2007). Quality management in healthcare and industry: A comparative review and emerging themes. Journal of Management History, 13 (4), pp 359-370

Moumtzoglou, A. (2007). The future healthcare and quality. International Journal of Health Care Quality Assurance, 20 (4), pp 277-280

Walters, D. & Jones, P. (2001). Value and value chains in healthcare: a quality management perspective. The TQM Magazine, 13 (5), pp 319-335

Zimmerman, R. S. (2004). Hospital capacity, productivity, and patient safety: it all flows together. Frontiers of Health Services Management, 20 (4), pp 33-38