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Journal of the Academy of Hospital Administration

Expectations of people from Quality Health Services in Metropolitan city of Delhi and to Propose a Sound Health Care Marketing Strategy for Private/Corporate Hospitals in Delhi

Author(s): Ambuj Bhardwaj*, D K Sharma**,R K Sarma***, P C Chaubey****

Vol. 13, No. 2 (2001-07 - 2001-12)

Today, the Indian healthcare industry is business driven and one sees entry of all sorts of service providers to be a part of this massive multi-crore business estimated to be around 73,000/- crore, growing at a rate of 13% annually. 81 The private sector Hospitals have come up to provide the health care in large way and this sector shares a major part of GDP (4.7 percent) compared to 1.2 percent of public sector. 78.4 percent of total expenditure on health is shared by private sector while 20 percent is accounted for by public sector.

The private healthcare network is spreading fast throughout the country. Delhi shows a much more enhanced and prominent private/corporate healthcare delivery system. Delhi ranks sixteenth amongst the world's 34 largest cities and from population point of view; it is the third largest city in the country.

The health care industry is today, facing the three C's: Competition, consolidation, and Consumerism. Since 1980s the proliferation of providers in the healthcare arena has been staggering, and the trend continues. The impetus behind this competitive surge has been the escalating cost of healthcare and the resulting response of payers - Consumers and employers.

The Need of Marketing in Health-Care Organizations

A great variety of health care Organizations are facing marketing problems, confronting a multitude of changing variables in the market place: increase regulation, decreased outside funding, more aggressive competition, a growing shortage of certain necessary clinical skills and an oversupply of others, a wave of entrepreneurial ventures by both Health care providers and non-providers, and a more critical consumer or patient population. With health care organizations currently facing some of their biggest changes and challenges, the need for tighter, more professional and forward-looking management is now greater than ever before.

Activities covered by marketing are

  • Monitoring the external environment (what is happening outside the organization and over which it has no control), with a view to identifying opportunities and threats.
  • Contributing to the discussion about the nature of and direction that the organization should pursue the customer groups that should be targeted and the competitive stance that should be adopted.
  • Determining the range of products or services that should be offered.
  • Influencing the levels of customer satisfaction that are to be aimed for.
  • Deciding upon the image that is to be projected.
  • Managing the elements of the marketing mix on a day-to-day basis. (The make-up of the mix is discussed at a later stage in the chapter)
  • Developing and implementing a system of feedback and control that is capable of providing a clear picture of just how well the organization is performing.

Definitions of Marketing

  • "An approach to management that applies to all types of organization, since it puts the customer at the very center of the operation and directs resources in such a way that the customer achieves a high(er) level of satisfaction in a cost-effective manner".
  • Marketing is the central dimension of any business. It is the whole business seen from the point of view of its final result, that is, from the customer' point of view (Peter Drucker).
  • Marketing is all about customer satisfaction and moving heaven and earth to achieve this more effectively that other organizations (Anon).
  • Marketing can be defined as the "analysis, planning, Implementation, and control of carefully formulated programs designed to bring about voluntary exchanges of values with target markets for the purpose of achieving organizational objectives. It relies heavily on designing the Organizations offerings in terms of the target markets needs and desires, and on using effective pricing, communications, and distribution to inform, motivate, and service the markets".

Marketing is also defined as "a managerial process involving Analysis, planning, Implementation, and control". Marketing can also be looked at as "a social process in which the material and service needs of a society are identified, expanded, and served by a set of institutions:

It follows from this that the marketing process consists of four stages:

The marketing process

It has three distinct elements:
  1. The pressures of the environments (and hence the nature of any opportunities and threats that currently exit and that are likely to emerge in the future).
  2. The demands, need or expectations of customers and how these are likely to change.
  3. What the organization is really capable of delivering?

Aim and Objectives

Aim: to assess the needs and demands of quality hospital services and to develop a sound marketing strategy for private hospitals in the metropolitan city of Delhi.

Objectives

  1. To assess the expectations and demands of people from hospitals in the metropolitan city of Delhi to find the market demand of the health services.
  2. To study and evaluate the Satisfaction level of patients in one of the selected private hospital in Delhi and to study the Marketing activities done by this hospital.
  3. Developing the approach for marketing the hospital services to meet the people's need in accordance with the quantum, nature and diversity of expectations from group of people studies.

Methodology

This exploratory research was conducted to gain an in-depth understanding of Health care consumer's expectations and their perception of service quality. This study is central to the marketing orientation of a large private, for-profit hospital in metropolis of Delhi. The study further aims to assess the views and experiences of the Consumers (patients) at the time of actual delivery of service in the selected hospital. For this purpose a large 500-bedded private (for-profit) hospital in Delhi was chosen. This hospital was established in early 1950's and has witnessed the changing consumer (patients) perspective over last five decades.

The entire study was conducted in the following steps:

1. Review of literature

2. Informal discussions were held with teaching faculties in department of hospital administrations, department of
bio-statistics, Physicians, Resident Doctors and nurses working at all India Institute of Medical Sciences.

3. Questionnaire - the questions were directed at Expectations from various attributes of healthcare services
and were divided into three main categories depending on the functional location where the service was delivered:

  1. OPD services,
  2. Emergency medical services,
  3. Indoor medical services

4. Interview Schedule for admitted patients of this hospital to assess the patient's perception and views regarding the perceived Quality of healthcare service delivered at the actual time of its delivery. The questions were divided under following heads-

  1. Quality of accessibility/tangibles and Facilities
  2. Quality of interpersonal relationship
  3. Quality of technical care
  4. Quality of continuity of services
  5. Quality of administrative services

The interview Schedule was structured and framed on Likert scale, and the patients had five coded choices (1 to 5) ranging from highly satisfying.

5. Pilot Study done at the All India Institute of Medical Sciences, New Delhi. Patients admitted in general and Private wardsin AIIMS were chosen for the Pilot Study of interview schedule. For the questionnaire the attendants of patients admitted in general and Private wards were chosen.

The Marketing orientation of the hospital under study

  • Marketing in this hospital has been taken up two years back and is presently in the growing stage.
  • Marketing as a function was jointly attached to public relations and administration.
  • There is no separate designated department for Marketing.
  • There are two PRO's appointed in the hospital. One of them looks after the Internal issues, employees' welfare and patient's complaints, internal marketing information and research. The responsibilities of the second PRO include external marketing information, media relations and other such issues.

Internal marketing system and activities:

One of the PRO's as mentioned earlier has the full time responsibility of internal market research and intelligence activities. His area of responsibilities and nature of activities can be described as:

  1. Distribution of exit questionnaires
  2. patient complaint and suggestion system
  3. Analysis of patient complaints and maintaining database of these complaints
  4. Discussion and administrative meetings
  5. Employee welfare schemes

External marketing system and activities:

One of the two PRO's is assigned the job of looking after exclusively the external Marketing issues and media relations. The various external marketing activities conducted by the hospital are as following:

a) The hospital conducts various seminars and workshops on recent Development's and latest technological and advancement in field of medicine and other health related issues. Prominent and well-known dignitaries are invited for these sessions and extensive media coverage is given.

b) The hospital also circulates a bimonthly newsletter, which mentions the hospital recent achievements and elaborates on the hospitals vital statistics like average length of stay, hospital infection rate, total admissions, number of operations and percent occupancy.

c) To enhance market penetration the hospital has started a new facility for executives of Public/private sector companies. This facility has been named as comprehensive executive check up. To promote this the hospital has joined hands with various multinational companies and business groups.

d) Recently the hospital has offered affiliations to other secondary care hospitals in the capital.

e) the hospital is also undertaking an expansion plan within its existing premises in New Delhi. The plan involves setting up of an additional 200-bed seven-storied facility involving an outlay of Rs. 30 crore.

f) The hospital has a unique arrangement of managing physicians and hospital management relationships. None of the physicians are working full time for the hospital. The physicians are provided with well furnished chambers and working staff in the respective OPD slots. In return the consultant physician examines patients and the revenue generated is collected per physician. Out of this total revenue generated by the physician 23% to 33% is given to the hospital on monthly basis, the percentage of this share varies and is mutually decided between the respective physician and the management board. A similar practice is done in indoor cases also.

g) Hospital Website: The hospital recently has gone on line and has its own website.

The undefined activities practiced by this hospital seen from the marketing perspective do not impel the hospital management to devise an elaborate and well-defined marketing strategy or conduct a pro-active market research. The reasons perceived for the success of this hospital could be:

  • A sound and loyal Patient referral base, which has further expanded over years.
  • Positive word of mouth advertising by the physicians and consultants working in this hospital who tend to motivate and refer more patients to this hospital.
  • The top priority assigned by the management in capturing the media coverage has helped this hospital to build a unique and distinct image.
  • The management over years has diverted the major share of its profit in the up gradation of the existing investigation facilities and procuring the latest ones, assuring continuous competitive advantage.
  • In order to reach the poorest of the consumer groups the hospital provides regular services to jhuggi clusters through the mobile health scheme and also participates in health welfare programs organized by Delhi Administration.

Summary

This study is an attempt to assess the spectrum of expectations people have from health care services and the variation of these expectations among different demographic and socio economic strata. The study further aims at studying the marketing orientation of a selected private hospital in Delhi and the consumer's perspective of perceiving the quality of health care delivered in terms of the satisfaction/ dissatisfaction with different attributes of the service delivered.

- 80 patients admitted in the selected hospital were interviewed, among which 48 were from fully paying wards, 18 from the semi paying wards and 14 were from the general wards.

- The findings reveal that 37.5 percent of the patients had come to this hospital of their own and the choice was based on the way they perceived the hospital's image, while in 36.3 percent cases friends and relatives of the patient suggested them this hospital, and another 26.3 percent of the patients were referred by their family physician.

These patients had selected this hospital as per the Perceived image and various other attributes which in order of importance assigned and the majority that opted for them are:

  • Highly Qualified Doctors
  • Advanced Investigation Facilities
  • Large Hospital
  • Cleanliness
  • Courteous Behavior of the Hospital staff
  • Easy Accessibility

The physicians refer a little less than a third.

By and large the patients were satisfied by the parking facilities, refreshment Facilities, and the availability of safe drinking water.

  • However patients from General Ward complained that the refreshments were too costly and out of their reach, and suggested some cheaper and affordable alternative.
  • Many of the dissatisfied patients also wanted that no parking fees should be charged.
  • In fully paying and semi-paying wards the patient's are provided with televisions and facility of newspapers and magazines, while in general wards none is provided.
  • Around eighty percent of the patients were satisfied with the behavior of reception Staff, but those who were not associated this with the overall dissatisfaction and were reluctant to use the hospital again.
  • One of the major dissatisfiers was the convenience of registration process in the hospital. Less than 50 percent of the patients were satisfied with the registration process while more than 20 percent of the patients were highly dissatisfied and complained it to be highly inconvenient and cumbersome.
  • Only one-third of the patients rated the waiting time as short and appreciated it, the rest were dissatisfied or did not answer positively. One-fourth of the patients rated the rating time to the intolerably long.
  • There was a differential trend noted in the response of patients regarding the ward comfort. The fully paying wards were maintained well by the hospital and none of the patients admitted in these wards complained. While the general appearance and comfort were unappealing and dissatisfying for patients admitted in general and semi paying wards.
  • Patients were generally satisfied with the maintenance of Hygiene and sanitation in the hospital with more than 70 percent finding it to be clean and Hygienic.
  • Compared to the over all maintenance of Hygiene and sanitation in the hospital relatively lesser number of patients (two-thirds) were satisfied with the maintenance of toilet and bathing Facilities in the wards. A further ten percent of the total sample was highly dissatisfied in this context.
  • In the delivery of dietary services again a differential trend significant enough to stand statistically was seen. In the general ward it is evident that optimal quality is not taken care of and as high as 43% (more than 14% complaining it to be terribly bad) of the patients were dissatisfied with the diet supplied.
  • The statistical association between the availability and accessibility of the doctors and the type of ward clearly indicates a gradual increase in the level of dissatisfaction as the revenue generating capacity of the particular ward type decreased. It appears that there is an obvious difference in the way doctor's deal with patients in the general wards and those in the paying wards.
  • A similar trend but with even higher variation was seen with the accessibility and availability of the nurses in the ward.
  • As regards to the time spent by the doctors and nurses with the patients, more than 80 percent of the patients were satisfied or highly satisfied.
  • The information displayed in the hospital was only in English which a large proportion could not understand.
  • Besides the variation among the wards this chance of changing the physician in future was very strongly related to the way patients perceived other non-clinical attributes. Patients wished to change their physicians on account of being dissatisfied by the behavior of the reception staff and the problems they faced due to inadequate inter departmental coordination in the hospital.
  • Patients assigned great amount of importance to these non-clinical attributes in defining the total quality of health care received, and dissatisfaction with any of these reflected on the overall rating of the clinical care and future decisions regarding reuse of the hospital services.
  • Thus it can be said that from the patient's perspective not only the clinical care but also the ease, convenience and the perceptions regarding the behavior of the staff were important attributes defining the overall satisfaction or dissatisfaction from the service provider.

Responding to the probability of patient utilizing the services of this hospital more than 65 percent said that they would surely use this hospital again. The response to this question was related to a number of non-clinical factors, which were found to be more significant determinants in deciding the future use besides the satisfaction or dissatisfaction from the clinical part of the service. These factors are:

  1. Behavior of reception Staff
  2. Duration of time spent by doctors and nurses
  3. Ease of Registration process
  4. Behavior of nurses and hospital Staff
  5. Accessibility and availability of nurses in the ward
  6. Did you get value for money?

The statistical analysis of this interview study revealed the extent of satisfaction or dissatisfaction perceived by the patients regarding various attributes of health care service at the actual time of deliver of the service at the selected hospital. However to be successful in satisfying consumer needs it is essential for a health care provider organization to learn and understand the prospective consumer's viewpoint of looking at the service and expectations he has from it before he actually consumes it. To assess these expectations a questionnaire study was done dealing with various aspects of the quality health care service.

The analysis revealed that 63.8 percent respondents favored private hospitals, while 26.3 percent opted for the government hospitals. Attributes used by the respondents in choosing the hospital:

  1. More than 75% of the respondents assign highly qualified doctors and easy accessibility
  2. Maintenance of cleanliness
  3. Availability of the advanced investigation facilities
  4. Waiting time and courteous behavior of the hospital staff

Summarizing the preferences opted by the respondents it can be concluded that people principally looked for a faculty of the experts available to take care of the disease which is the prime concern of going to the hospital, and after satisfying this condition they further looked upon the other aspects of the patient care which relate to the convenience and being treated with dignity in a clean and conducive environment.

OPD services

  • More number of people in working age group preferred a telephonic system of appointment, which is expected due to the busier life style of the group. Similar preference was noted in the older age group.
  • Around sixty percent of the respondents expected the waiting time at the registration counter to be less than five minutes.
  • It was seen that around two-thirds of the respondents preferred their registration numbers to be displayed on a flashboard and disagreed with names being called or displayed, while only one-seventh of them agreeing to either being called by their names or else by their registration numbers.
  • The more educated people were found to be more selective in their choice and expected a higher level of privacy and better mode of communication.

About one-third opted that "May I help you counter" was the best way to guide patients in OPD, While another third of them wanted the hospital to display self-explanatory layout maps and signboards.

Emergency services

  • 3/4th of the total sample size expected the waiting time in the emergency to be as less as 1-5 minutes, while as another 20% of the respondents were ready to wait for 5-10 minutes.
  • The majority (almost 94%) of the respondents wanted the doctor to divulge the information regarding disease to the patients' and a minority settled for a nurse or a medico-social worker doing so.
  • Money charged for emergency services - 36.9% - money should be charged only for the medicines used and investigations performed in the emergency, 23.1% - for medicines alone, 21.9% - emergency services inclusive of the consultation fees for the physician, 18.1% - no money what so ever should be charged. It was also seen that the subgroup willing to pay more for health services was also willing to pay for the emergency services.
  • 40 percent of the respondents preferred the doctor to take care of the anxiety and queries of the relatives and, a third of them preferred medico-social worker to divulge the information, while another 23.1% of the respondents preferring the staff nurse.

Indoor Services

  • 50 percent of the respondents favored the doctors to make at least two rounds-morning and evening.
  • 40 percent wanted the doctor's rounds to be taken thrice.
  • Students and professional subjects were more demanding in nature and expected rounds to be taken thrice or more.
  • Similarly the younger age group expected more frequent rounds while the older age group was contended with less.
  • Here again the respondents favored the doctors to divulge the information to the patient.
  • 45% of the respondents favored the stay of patient's relative in the ward area, while as 38% of the respondents said that the relatives should stay in the waiting area.
  • 75% of the total sample size said that the waiting time at the investigation lab for an admitted patient should be below ten minutes. Better paying class expected the waiting time to be less. (In the high-income group more than 95% wanted that the investigation should be done with in 10 minutes) a higher level of expectations and a demand for a prompt service was also noted with younger age group in this regard.
  • Half of the respondents said that they should be given the freedom to choose from the diet menu in advance. While another one third wanted an opportunity to choose from combination packages.
  • Two-thirds expected the linen to be changed daily and a minority of 16 percent on alternate days. Younger age group was again found to be keener about the cleanliness regarding the linen and demanded more frequent change.
  • One third wanted the toilets and floors to be cleaned thrice daily, forty percent twice a day, another third four times a day.

75% of them demanded separately defined parking space for patient, patient's relation and doctors and other hospital staff.

The study brought out a variegated picture of the levels of expectations as desired by the people at large which is more or less in contrast to what is being provided by the health care providers. This actual gap between what is being expected and what is being delivered from the health care consumer's perspective was reflected clearly in the findings of the study in terms of expectations and the various sources of satisfaction/dissatisfaction levels with the chosen hospital.

The crux of this study is that the healthcare providers should closely monitor the delivery of care and customers needs, simultaneously being able to retain a favorable position within an increasingly competitive market by developing a more satisfied consumer base. In order to be successful in today's competitive health care environment the health care provider should deliver the services tailored to consumer needs and must actively review the changes in these demands and expectations in context to time and the socioeconomic strata of the community being served. It is imperative for a health care organization to use concepts and principles of marketing in conducting research of its markets and accordingly plan and modulate its strategies as per the changing needs, demands and preferences of the consumer on a continuous basis.

* Dy. Med. Supdt. Sir Ganga Ram Hospital, New Delhi
** Assoc. Professor Deptt. of Hospital Admn. AIIMS
*** Addl Professor, Deptt. of Hospital Admn. AIIMS
**** Prof. & Head, Deptt. of Hospital Admn. & Medical Superintendent AIIMS, New Delhi
Correspondence Dr. Ambuj Bhardwaj

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