Ots 24 > Oac43-45 > Finalrep

1. INTRODUCTION “A responsive healthcare organization is one that makes every effort to sense, serve and satisfy the needs and wants of its clients and the public within the constraints of its budget and good clinical practice.” (Kotler and Clarke, 1987) The Vision of the H.M. Patel Centre for Medical Care and Education “We would strive to be a Centre of Excellence in all that we do; patient care or teaching, research or extension.” The Mission of the H.M. Patel Centre for Medical Care and Education To our patients, comprehensive and personalised health care with commitment and compassion at an affordable cost, to their utmost satisfaction, while keeping ourselves abreast of state-of-the-art technology. To our students, an environment conducive for excellent teaching and learning so that they become excellent health care professionals of the highest calibre, sensitised to the health needs of the less privileged and equipped to carry out ethical and value based practice. To the community, especially in the villages, deliver need based health programmes that lead to improvement in the health standards of all and also contribute to national health care policies and practices, and doing so by networking with other institutions having similar mission; and also conducting innovative and interdisciplinary research relevant to the community, striving always towards improving health standards and practices; To ourselves, a work culture that promotes a sense of belonging and accountability, leading to overall growth and development, both of individuals and the institution, maximising job satisfaction through job enrichment. While the sentiments contained in this mission statement are admirable, are they all simultaneously achievable? Can patients of all types be provided with personalized healthcare at a cost that is affordable for all? Can the hospital keep itself abreast of the stateof-the-art technology without charging a high rate for the services it provides?

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If the hospital is catering primarily to the needs of the rural community, is it providing its services at the level of their expectations? Or is it trying to maintain the excellent standards of corporate hospitals while charging the low rates of a charitable hospital? Is there a clash between the two goals which is finally leading to a “please all-please none” kind of situation? To determine whether the prime clients of the organization are being served in keeping with the mission and vision of the organization, a study to measure the level of patient satisfaction was conducted. 2. THE CONCEPT OF SATISFACTION “Satisfaction is a state felt by a person who has experienced a performance or outcome that has fulfilled his or her expectations.” (Kotler and Clarke, 1987) Satisfaction is measured against the expectations which the person availing of the good or service has, prior to experiencing the good or service. If the outcome exceeds the expectations, then the person would be highly satisfied, while an outcome falling short of the expectation level would result in dissatisfaction. A perfect match between the expectations and outcome would result in satisfaction. Satisfaction is an important element in the evaluation stage for a service provider. It refers to the consumers’ state of being adequately rewarded. Adequacy of satisfaction is a result of matching the actual past experience with the expected reward. Expectations are formed on the basis of past experience, statements made by friends and associates, and statements being made by the supplier organisation, which promises certain outcomes. An organization that claims that it can provide more than it is actually able to, would be heading for problems with dissatisfied clients. An organization downplaying what it is able to provide would not be able to attract enough users for its product or service. Therefore it is very important that the organization recognises what it is able to provide and markets its goods or services at that level. In the case of a healthcare provider, the organization has to be even more sensitive to the expectation levels of the clients who are using its services. This is because the client,

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henceforward called the patient, is in a frame of mind, where any dissonance between expectation and service is likely to cause him or her more irritation and dissatisfaction than when he or she is in a normal state of health. Patients form certain expectations prior to their visit to a healthcare provider. Once patients come to the hospital and experience the facilities, they may then become either satisfied or dissatisfied. Satisfaction or dissatisfaction refers to emotional response to the evaluation of service, consumption, and experience. It could be expressed as having five key elements. •

Expectations: The seeds of patient satisfaction are sowed during the pre-purchase phase when consumers develop expectations or beliefs about what they expect to receive from the product. These expectations are carried forward and again activated at the time of reusing.

•

Performance: During the usage of services the patients experience the actual service in use and perceive its performance on the dimensions that are important to them.

•

Comparison: It will be done after usage with pre-usage expectations.

•

Confirmation/Disconfirmation: Comparison of expectations with actual performance results in satisfaction or dissatisfaction with the service provided.

•

Discrepancy: If the performance levels are not equal, discrepancy results.

Every human being carries a particular set of thoughts, feelings and needs. The wishing list might be of value for those who want to know the real person within the patient. One must admit that there are a lot of things which could be altered. By getting to know the patients a little more to get their views on the care one ought to come closer to what the patients consider as good care. It can be said that there are five determinants of patient satisfaction: 1.Reliability: the ability to perform promised service dependably and accurately. 2.Responsiveness: the willingness to help the patients and provide prompt service. 3.Assurance: the knowledge and courtesy of employees and their ability to convey trust. 4.Empathy:

the

provision

of

caring

and

3

individualized

attention

to

patients.

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5.Tangibles: the appearance of physical facilities, equipment, personnel and communication materials. Excellently managed healthcare organizations have the following practices: •

The top ranking hospitals are patient obsessed. They have a clear sense of their target customers and their needs.

•

The best service hospitals set high service quality standards. The standards must be set appropriately high, to result in patient satisfaction.

•

Culture, subculture and social classes are important in determining satisfaction levels. Culture is the fundamental determinant of an individual’s wants and behaviour. It refers to a set of feelings of the patient or his relatives. Social class reflects sex, income, occupation, education, area of residence and recreational preferences, etc., which are important in determining satisfaction levels.

•

The patient’s behaviour is greatly influenced by social factors like reference groups, ideas, and beliefs. Reference groups here refer to peers, relatives, neighbours and friends. The family members influence the patient to a large extent.

•

The person’s satisfaction is influenced by the psychological factors such as perception, learning and attitudes.

Apart from the above, other factors that influences the patient satisfaction include availability of adequate staff, availability of physical facilities and equipment, design of the ward, cleanliness, environment, availability of clinical services, work load of the staff, behaviour of the doctors, nursing staff, paramedical staff, effectiveness of management functions, the leadership styles of administrators, communication channels, policies and procedures etc. Tertiary Hospitals cater to a wide set of patients. In a general hospital such as the Shree Krishna Hospital, the situation becomes even more complex because there is a wide set of patients distributed among different income groups, locations, educational backgrounds, and more importantly, with a wide range of ailments, ranging from the common cold to cancer, from a headache to a brain haemorrhage.

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3. SHREE KRISHNA HOSPITAL PATIENT PROFILES Who is a patient? Who are the patients of Shree Krishna Hospital? A patient is the client of the hospital. He or she is the person who uses the services of the hospital. The outpatient is one who visits the hospital for a short time and gets his problem attended to at an OPD or outpatient department. He does not require hospitalisation. An inpatient is one who is hospitalised. The patients of Shree Krishna Hospital are heterogeneous: •

The people from rural and semi rural areas surrounding Anand and Kheda district, and the urban population of Anand, Vallabh Vidyanagar and Karamsad. Apart from this it receives indoor patients from as far as MP and Rajasthan.

•

Educational level of the patients varies from illiterate to multiple post-graduate.

•

Occupations are as diverse as professional to agricultural labour.

•

Incomes vary accordingly.

Who is the target population of the Shree Krishna Hospital? Is there a target population at all? Going by the Mission Statement, the target population would be the rural community in the vicinity. But the patient profile shows that these form only 40% of the patients that visit the hospital. A large proportion of the patients in the hospital consist of industrial cardholders who come to the hospital for treatment because their companies have taken over the responsibility for the medical treatment for them and their families, and have tied up with the Shree Krishna Hospital to provide the requisite health facilities. 4. PATIENT PSYCHOLOGY

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Patient Psychology and Common Expectations A patient is the main user of a hospital. He is a person in distress. He expects from the hospital in order of importance: •

Cure

•

Care

•

Comfort

His distress is more if •

He is not attended to, but left alone or is made to wait for a long time, unattended.

•

The attending personnel do not ask him what his trouble is

•

The attending personnel do not listen to him when he is explaining his problem

•

His troubles (complaints) are not taken seriously (patients are some times told that they are exaggerating their problems)

•

He does not get quick relief from the problem

•

He is not told what is being done about him

•

He is not told what he can expect in terms of attention and cure

•

There is an atmosphere of pain and distress around him, particularly in general wards

•

There is an atmosphere of filth and neglect (unkempt surroundings, dirty linen, pests on the food and walls)

•

Mosquitoes or loud noises like talking and disturbance accentuate the discomfort of illness.

(Source: www.indmedica.com) The primary function of a hospital is patient care. The patient is the ultimate consumer for the hospital. Patient satisfaction is one of the yardsticks to measure the success of service that a hospital produces. The effectiveness of the hospital relates to provision of good patient care as intended. The patient satisfaction is the real testimony to the efficiency of hospital administration. As the hospital serves all the members of society, the expectations of the users differ from one individual to another individual because everyone carries a particular set of thoughts, feelings and needs. Hence determination of patients’ real feelings is very difficult. It is the responsibility of the administrator to infuse in the staff a feeling that 6

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the patient is all-important to the organization, very much in the same way as product related organizations uphold the maxim that “the customer is the king.” "Put yourself in your patient’s shoes," explains how to proceed with a patient. Though it is difficult, one can achieve this by using some tips such as listening to the patients, asking questions and seeking answers, by doing something extra for each patient, by admitting mistakes gracefully and taking corrective action. In service-oriented industries such as transport and hotel services, the staff is taught to deal with clients such that there is not a single indication of rudeness or irritation no matter how trying or irritating they may be. The hospitality industry staff often face a problem of exceptionally demanding clients, but their training is such that they have to deal with the situation firmly but with tact and understanding. In a hospital, this tact, sympathy and understanding are all the more important. It has been summed up in the word “compassion” in the mission statement of the Shree Krishna Hospital. Even if the cure is guaranteed to a patient, he is influenced by the environment around him and the extent of the care and comfort provided to him. Cure is something that all hospitals should be able to provide. This is because their main purpose is to cure their patients. Hospitals all claim to provide “excellent service”, “specialist doctors”, and the best medical equipment and diagnostic facilities. So healthcare providers have to differentiate themselves from their competitors by focusing not only on cure, but also on care and comfort. A patient who gets cured by the treatment at a hospital may not necessarily go back if he feels that he was treated without compassion, or his surroundings did not meet the expectations he had. Of course, if the patient does not get cured, his dissatisfaction reaches a much higher level. Keeping in mind these characteristics of patients, the study was operationalised as follows. 5. DECISION PROBLEM To assess whether the Shree Krishna Hospital is meeting its mission in providing quality service to the patients and how to further improve its health care services.

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6. RESEARCH PROBLEM To study satisfaction of indoor and outdoor patients and develop strategies to make services more effective.

7. RESEARCH OBJECTIVES The objectives of the study are: a) To assess the level of satisfaction among the patients and their relatives with regard to quality of services provided by the hospital in both In-patient and Out-patient Departments. b) To find the key areas of appreciation and complaints (in any) of the present services provided by these departments. c) To suggest measures to overcome complaints, if any. 8. SCOPE OF THE STUDY The patient satisfaction study was limited to the outpatients and inpatients of the Shree Krishna Hospital. Questions were addressed to both the patients and their relatives, if any. Only in the case of patients in the paediatric ward questions were addressed to the relatives alone. The inpatients and their relatives were interviewed shortly before their discharge from the hospital, after the billing processes had been completed. 9. RESEARCH DESIGN Preliminary insights were gained by interviewing patients in both outpatient and inpatient departments, to get an idea of the drivers to patient satisfaction. In the meanwhile, secondary data was also collected from journals and the internet about patient satisfaction studies in both India and other countries.

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For primary data collection, a questionnaire was prepared and pre tested on 20 patients. It was duly amended and the final questionnaire was administered to a sample of 240 patients.

10. SAMPLING PLAN The research was conducted by survey of both indoor and outdoor patients. The sampling plan was devised keeping in mind that there would be different patients loads for different departments. Also, we could not be sure of getting an exact quota of patients from a particular department according to the patient load, so it was better to assign the quota groupwise rather than department-wise. The 2 broad categories of patients were indoor and outdoor, of which an equal number was selected. The next categorisation was members belonging to the Krupa Arogya Suraksha scheme, and non-members. We also kept in mind that the sample had to have mixed views from all strata, rural and urban, illiterate and educated. Although these were not taken as sampling variables, judgemental sampling was used to get patients from different backgrounds. Table 1. Sampling plan for patient survey

Scheme Holder Type of patient Indoor Outdoor Total

Krupa 15 15 30

Non-Krupa 45 45 90

9

Krupa Non-Krupa 15 45 15 45 30 90

Total 120 120 240

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Department-wise allocation was done on the basis of the aggregate patient load on the indoor and outdoor departments for the past 2 financial years. This information was made available by the MIS Department of the hospital. The distribution is given as under, along with the grouping of departments. In the distribution, the psychiatry department was not taken into account since the patients from this department were not considered for the study.

Table 2: Sampling plan for outdoor patients Grouping

OUTDOOR PATIENTS Department Percent

Allocation Non Krupa Krupa 8 24 2 6

Group I

Medicine Dentistry

26 5

Group II

Surgery Skin & VD Orthopaedics TB and chest

8 9 11 2

2 3 3 1

5 8 9 3

Group III

ENT Ophthalmology OB&G Paediatrics Physiotherapy Emergency

9 9 8 7 2 4

3 3 2 2 0 1

9 10 6 6 2 2

100

30

90

Total

Table 3: Sampling plan for indoor patients Grouping

Group I

INDOOR PATIENTS Department Percent

Medicine Orthopaedics. ENT Ophthalmology

10

24 6 3 2

Allocation Non Krupa Krupa 7 21 2 6 1 3 1 3

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Group II

OB&G Paediatrics.

19 14

6 4

17 12

Group III

Surgery Trauma Care* TB and chest Others (Skin, Dialysis)

13 16 1

4 4 0

12 12 1

2

1

3

100

30

90

Total

*Trauma care patients were redistributed to medicine and surgery departments, since they would invariably be transferred after their condition had stabilised.

11. DATA REQUIREMENTS Firstly, it was necessary to know what are the different factors affecting the patient’s choice of healthcare provider. These factors were rated by the patient in terms of the importance attached to each factor in determining where he/she should go for treatment or medical advice. The hospital’s services were evaluated by the patients, under 5 different categories. The data requirements were categorized under the following heads. a) Information pertaining to the satisfaction level with the Hospital as a whole b) Information pertaining to the satisfaction level with the Staff (behaviour and efficiency) c) Information pertaining to the satisfaction level with the Services provided d) Information pertaining to the satisfaction level with the procedures involved in obtaining treatment (operational aspects) e) Information pertaining to the satisfaction level with the Krupa Arogya Suraksha scheme. For gathering the required information, a questionnaire was administered which contained both closed-ended and open-ended questions so that qualitative and quantitative analysis could be performed. (Refer Annexure1)

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12. SCALING AND MEASUREMENT TOOLS The patients were asked to rate the hospital on various attributes on a 1-5 Likert scale. For responding on questions regarding their choice of hospital, the scale measured varying degrees of importance attached to each attribute. For responding to questions related with satisfaction levels, the scale was used to measure the level of satisfaction or dissatisfaction. 13. ANALYSIS The data was analysed using qualitative and quantitative techniques. Indices were calculated for the responses on the Likert scale. The attributes or drivers to patient satisfaction were clubbed under 6 heads, and composite indices were calculated for each of these heads. Responses of the inpatients and outpatients were analysed and compared. Comparisons were made between the following categories of patients. For Outdoor patients: ♦ Krupa vs non Krupa ♦ Rural vs Urban For Indoor patients: ♦ Krupa vs non Krupa ♦ Rural vs Urban For Krupa patients alone: ♦ Responses on Krupa – specific questions – Indoor vs Outdoor. Comparison of composite indices for all indoor and all outdoor patients was deliberately avoided as the drivers to satisfaction differ between both categories. However, individual indices for the common drivers to satisfaction have been discussed in the report. Qualitative data has been grouped under various heads and also, different incidents which were related and observed have been made into small caselets to supplement the quantitative data. Suggestions given by the patients have also been incorporated wherever appropriate.

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Data has been represented by graphs and charts, wherever necessary, to make interpretation easier. 14. DISCUSSION OF FINDINGS 14.1 Choice of Hospital It was necessary to analyse what makes a patient opt for a particular healthcare provider, in a non-emergency situation. This pre-supposes that the patient has rationally chosen a particular centre for availing his or her treatment, based on certain criteria. How do patients choose a hospital? In the case of an emergency patient there is hardly any choice except the hospital which is nearest or most well known to the patient. In normal circumstances there are different criteria on the basis of which patients decide where they will avail of their healthcare needs. The main criterion would be the service that is provided at the hospital and the quality associated with it. Three of the major deciders in a non-emergency situation are: Physical Access: How is the hospital located? Is it easily accessible to the community? Time Access: During what hours are the services provided? How long does it take to access the service provider or what is the waiting time involved? Information Access: What is the reputation of the hospital? What do other people say about it? What does the regular practitioner, whether family doctor or GP or village level health worker say about the hospital? Do they recommend it? An analysis of the drivers to choice of a hospital gave the following information. 14.1.1 Outpatients For outpatients there was not much of a difference between importance attached to certain criteria for selection between the rural and urban patients. The following graphs indicate the preference that outpatients expressed for particular criterion compared to the maximum (100%).

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Fig. 1: Preference Criteria of Urban Outpatients

Preference Criteria of Urban Outpatients 120 100

Indices

80 60 40 20

Se rv ic e

Lo

sP

ro

vi de d ca tio W or E x p n d of ert M s H ou t ist h R .As e Va p u so l f tat i o In r M on fr a on e a Co nd y nv M en ed ie n Ef Sk ce fic ill ie Do nc c y m ed D Ad isc ve a n rt d Su fre p e Ae p o r st ts h G etic rie s va nc e

0

Criteria (Source: Patient survey)

For the urban outpatients, service tops the priority list, while infrastructure, convenience of having everything available under one roof (lab tests, X Ray, pharmacy, etc.), skill profile of doctors and the efficiency of the treatment are also very important. Lowest criterion for choosing is advertising, and second lowest, discount and freeship. This indicates that the urban outpatients are willing to pay more for better facilities. Word of mouth and recommendation from friends, even the family doctor, did not seem to be as important or crucial to the decision as the personal experience of going to a healthcare provider oneself. 14

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Value for money also received a lower score, as people mentioned that they wouldn’t mind paying more for “personalised attention.” (Refer Fig. 1)

Fig. 2: Preference Criteria of Rural Outpatients

Preference Criteria of Rural Outpatients

Pr Lo o... ca tio W o r Ex n d pe of rt M s H out is h Re t.A V a p u s so l f t at In o r M i o n fr o a an ne Co d y nv Me en d ie Ef Sk nce fi c il ie l D nc o y c m e D Ad d is c a ve r nd t Su fr e p e Ae p o r st ts G het ri ev ics an ce

Se

rv

ic

es

Indices

120 100 80 60 40 20 0

Criteria (Source: Patient survey)

Rural outpatients showed no difference from their urban counterparts. Contrary to our expectation that discount and freeship would be an important deciding factor for them, the score on these was very low. Many mentioned that their priority was treatment, and that the money matters would follow after that. Even if it meant taking a short-term loan it would be worth it for proper treatment. Many patients gave responses that ran in this way: “The patients of the Shree Krishna hospital do not come here because they are expecting to get free treatment. They come because the treatment is supposed to be the best here. When they are unable to pay, and they are made aware of the freeship facility they take advantage of it. However, that is not their primary motive in choosing this hospital.” (Refer Fig. 2)

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14.1.2 Inpatients For inpatients, the importance attached to some criteria varied considerably between the rural and urban patients unlike the outpatients, between whom there was only marginal difference. The rural inpatients gave much more importance to location in choosing a hospital than their urban counterparts. This would be because of the trouble and cost involved in transporting a patient in a critical condition a long distance. Although public transport is easily available in the urban areas, rural areas still face problems in this regard. Word of mouth and historical association (whether the patient’s family regularly comes to this hospital) also received higher importance scores from the rural inpatients, while the urban inpatients ranked reputation as more important. This reflects that the rural patients rely more on the first hand information from family members and friends, than what the general public say. Urban patients also keep in mind the “image” of the hospital. Convenience (meaning finding everything under one roof), discount, support facilities, aesthetics and grievance redressal also got higher importance from the rural inpatients. The urban patients do not mind getting medicines from outside if they are unavailable in the hospital, because transport does not pose a problem to them. Discount would be more important to the rural patients since they would be in a more vulnerable position money wise. Advertising received the lowest importance among both sets of patients, rendering it the most unimportant attribute for choosing a hospital. Grievance redressal system was not considered very important. Some patients mentioned that they would like to have a formal mechanism installed, but most patients felt that it would be better to make sure that there is no grievance, rather than set up a grievance redressal system. (Refer Fig. 3 & 4)

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rv es

ic Pr

ov Lo ide ca d t io W or Ex n d pe of r t M s H out is h Re t .A Va pu sso l f t at In or M i on fr o a an ne Co d y nv Me en d ie Ef Sk nce fic il ie l D nc o y c m e D Ad d is c a ve nd r t Su fr e p e Ae po r st t s G he t ri ev ics an ce

Se

Indices

Fig. 3: Preference Criteria for Urban Inpatients

Preference Criteria for Urban Inpatients

120 100 80 60 40 20 0

Criteria

(Source: Patient survey)

Fig. 4: Preference Criteria for Rural Inpatients

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Preference Criteria for Rural Inpatients

ov L o i de ca d ti W or Ex o n d pe of rt M s H o ut is h Re t .A Va pu sso l f ta t In or M ion fr o a an ne Co d y nv Me en d ie Ef Sk nce fic il ie l D nc o y c m e D Ad d is c a ve nd r t Su fr e p e Ae po r st t s G het ri ev ics an ce

Se

rv

ic

es

Pr

Indices

120 100 80 60 40 20 0

Criteria (Source: Patient survey)

14.2 Analysis Of Indices Computed Various indices were computed to capture the level of satisfaction of the indoor and outdoor patients quantitatively. The rating of different drivers to satisfaction was done on the basis of a Likert Scale. Composite indices were then computed from the individual indices for each driver. The composite indices were 5 in number and comprised the following drivers to satisfaction. 14.2.1 Outdoor Patients For outdoor patients, the 5 main composite indices were as follows: 1. Procedure and Finance Related: This included the efficacy with which the service was provided, expenses involved in obtaining treatment, billing promptness, clarity in showing expenses in the bill and the time spent at the various counters. Under time spent, there were further subdivisions for registration, pharmacy, cashier’s counter, duration for receiving test reports, and the time taken in obtaining a consultation with the doctor. 2. Doctor –related: This included the skill profile of doctors, the way in which doctors behaved with the patient through the course of the treatment, whether adequate information was provided by the doctor to the patient and to relatives, the way in which this information was 18

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provided to them (willingly or unwillingly), the diagnosis, the compassion exhibited by the doctor, personal attention to the patient, patience shown by the doctor in answering queries and doubts, and consultation with the doctor of one’s choice. 3. Infrastructure and Medical Facilities: This included three constituents: infrastructure, medical facilities, and technology. Infrastructure here pertains to the building, kitchen and support services, playground, etc. while the medical facilities refer to the range of facilities available at the hospital (for instance laboratory and radio diagnosis, scanning facilities etc). Technology refers to the level of technology available at the hospital, in terms of upgraded equipment, etc. 4. Comfort: This included all the aspects which would help to make a patient feel more comfortable during his visit to the hospital, though not related to the main purpose of his visit i.e. the medical attention that he was essentially there for. This included the location of the hospital, layout of various departments, comfort of surroundings (fan, seating space), ease in locating departments, general aesthetics of the hospital, privacy of consultation with the doctor, etc. 5. Support Facilities and Staff Related: This included all the support facilities provided by the hospital such as the pharmacy, emergency service (ambulance), nursing care, and the staff related behavioural aspects such as politeness and patience shown by the support staff. Results for the outdoor patients were compared between two different categories, 

The first was the patients subscribing to the Krupa Arogya Scheme vs. non-Krupa patients.



The second was the rural vs. urban patients. 63 urban and 57 rural patients were surveyed.

♦ Krupa vs Non Krupa An analysis of the Krupa vs. Non Krupa patient scores reveals that there was not much difference in the patient’s rating of the procedural aspects, or the infrastructure, comfort level, or support services and staff. The only area in which there was a significant difference between indices was that of doctors. This can be attributed to the preferential treatment that the Krupa patients expect from the doctors, as a corollary to their having subscribed to a

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scheme. Some of the patients under the scheme felt that they should not have to wait as long as everyone else for a consultation. Others said that they would prefer private consultations with the doctor rather than the panel consultation, which is a common feature in the more crowded departments such as Medicine and OB & G. (Refer Fig. 5)

Fig. 5: Indices for Satisfaction levels of Krupa and non Krupa Outpatients Outdoor

krupa

non-krupa

100 90 80 70

Indices

60 50 40 30 20 10 0

Procedure and finance related

Doctors related

Infrastructure and medical facilities

Comfort

Support facilities& staff related

krupa

76.44

76.85

90.44

78.41

79.09

non-krupa

76.92

84.74

85.4

75.52

74.52

Factors

(Source: Patient survey)

Outdoor Krupa patients gave the highest score to infrastructure at 90.44, while all the other scores fluctuated in the 76 –79 range. Outdoor non-Krupa patients also gave the highest rating to infrastructure at 85.44, but rated doctors a close second at 84.74. Remaining scores were lower, in the 74-76 range. Infrastructure is therefore the feature that the outdoor patients are most appreciative of, when they visit the hospital.

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Expenses, as an individual index has received a poor score, resulting from a great dissatisfaction on the part of most of the patients with the high costs involved in getting treatment. The patients say that the registration fee of Rs. 15 is very low compared to the private clinics, where the fee is as high as Rs. 100. However, doctors frequently ask for tests to be performed even if the diagnosis can be made without the test report. Patients perceive the tests to be unnecessary and feel that they are being over charged for the laboratory tests and X Rays. Many have stated that they can get the same tests performed for 30 –40% less in the hospitals in Anand. Some patients have also complained about the costs of medicines at the pharmacy. Non-Krupa patients index for expenses is 67, while for Krupa patients it is 58. This is because most Krupa patients feel that the outpatient treatment should be covered rather than only inpatient treatment. They are dissatisfied with the discount of 10% that they get on the tests and the medicines because they say that it is made up by charging extra compared to other hospitals in the vicinity. Non-Krupa patients are less dissatisfied since their expectation level is lower. Another reason for the dissatisfaction of Krupa patients is that the information given to them at the time that they are applying for the scheme is not clearly understood and they expect to get outpatient treatment free. The dissonance between expectation and outcome leads to dissatisfaction. Many have claimed that the scheme is “not worth anything” since their chances of being an inpatient are minimal. Patients do not read the instructions in the booklet; Only 2 out of the 30 Krupa outdoor patients had gone through the terms and conditions stated in the booklet. Many of the applicants for the Krupa scheme are illiterate and form their expectations on the basis of what they understand from the Krupa staff. Another low scorer is the time spent at the pharmacy, which most patients mentioned was the only place where they had to wait for a long time in a queue. The patients of the Medicine, OB&G, and Orthopaedics departments mentioned that they had to spend a lot of time waiting for consultation. Those waiting to see some specialist in particular were not averse to waiting, but others expressed great dissatisfaction. Another area where time is a problem is the duration for receiving the test results. Laboratory staff were criticised by a small proportion of the patients for wasting time and talking among themselves and not proceeding with the work as soon as possible. This seemed to be more of an irritant than the actual time spent waiting for the results. Some of the patients mentioned that if they were given information regarding how long it would take for the results to come, they would not 21

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mind waiting. Both in billing promptness and clarity of showing expenses, the Krupa patients seemed better satisfied than the non Krupa patients. Both Krupa and non Krupa patients rated doctors high except on one dimension in which there was considerable difference between the scores; i.e. the diagnosis by the doctor. Krupa patients rated the doctors very high on this dimension at 95 while the non-Krupa score was 6 points lower. This could be because Krupa members are those who have already had several good experiences with the doctors and their treatment and have therefore signed up for the scheme. There is only very marginal difference between Krupa and non-Krupa patients in the indices regarding Infrastructure and comfort. However in all the support and staff related drivers the Krupa patients have ranked the individual drivers much higher than the then non-Krupa patients. There is no reason why the ratings should be so much higher, as the staff’s behaviour should not vary on the basis of whether the patient is a Krupa patient or not, neither would the support staff become more efficient based on that criterion. One explanation that can be offered is that the Krupa patients are those who have already been coming to the hospital for some time and would therefore be more accustomed to the level of the services provided at the hospital. The reason that they would have signed up for the Krupa scheme would be that they are satisfied with the services. The overall indices show that only the category of infrastructure and medical facilities has been given high scores. Non-Krupa patients have also given doctors a good score, resulting in an index in the 80s range. All the other indices fall in the 70s range, showing that while patients are satisfied, there is still scope for improvement. ♦ Rural vs Urban The indices for Outdoor Rural and Urban patients reveal that there is not much difference between the two categories in any of the composite indices. The maximum difference is less than 3 points, which leads us to conclude that the rural and urban consumers do not have any difference in expectations on the whole. Fig. 6: Indices for Satisfaction levels of Rural and Urban Outpatients

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OUTDOOR 90

Indices

85 80 75 70 65 Proced.& fina.

Doctors rel.

Infrast.& med.

Comfort

support serv.&staff

Rural

78.316

87.755

86.45

76.92

73.72

Urban

75.876

85.65

86.9

79.39

76.5

Factors

(Source: Patient survey)

Although it was expected that the rural patients would be more dissatisfied with the expense level at the hospital, it was noticed that there was not much difference in the score given to this attribute. This may be because the rural patients expect to pay more in a “big” hospital than they finally end up paying. Also, the rural people avail of more freeships than the urban, although the basis for deciding the allocation of a freeship is not the place where the patients come from, rather, it is their economic status. The urban patients may also be more aware of the competitor’s prices for laboratory tests and radio diagnosis, on the basis of which they would be able to compare the prices at Shree Krishna Hospital. Almost half of the rural and urban patients surveyed were covered under medical insurance given by their companies, and were therefore not in a position to comment on the expenses incurred except on a general level. (Refer Fig. 6) Similar to the Krupa vs. non-Krupa classification, infrastructure ranks highest in the indices, with doctors a close second. For the index pertaining to doctors, there was hardly any difference between the ratings given to the individual components by the rural and urban patients. This is as it should be, as it indicates that there is no differential treatment for rural and urban patients. On the other hand, does it indicate that this is where the hospital is losing out? It may not be catering to the urban patients who have more choices for treatment in private hospitals and who find no personalised treatment. In fact, as part of the qualitative research undertaken, and the image perception study, this issue came up several times. The respondents from Anand and Vidyanagar from the middle and upper classes said that it was 23

Dubey, Rose

very annoying for them to be treated like “everyone else” and that there was no personalised attention, unlike that in private clinics, where the patient can be assured of consultation with the same doctor, and can be confident that the doctor will remember his name, case history, and even a few personal details. In the index for layout there was a perceptible difference between the response of the rural and urban patients. The rural patients ranked the layout very low at 76.5 while the urban patients ranked it 20 points higher. This indicates that the rural patients are much likelier to get confused in a “big” hospital. They also have a problem reading the signs as they come from the poorer sections and many of them are illiterate. Constant questioning has made some of the staff irritable and they do not always direct the patients to the department, other than to indicate the general direction. As one urban patient said, “Aa baju”, when one asks for the location of a department is hardly the way to give directions. The doctors also refer patients to Dept. No. “x”. It is not the responsibility of doctors to direct patients around, but the nurses and attendants in different departments could be a little more proactive in helping people who appear to have lost their way. Rural patients have given the hospital a higher score for comfort than their urban counterparts, who have perhaps experienced the facilities of private practitioners, or have higher expectations. Some of the patients have complained that they are unable to sit comfortably in the crowded departments because of the absence of a fan. This is especially so in the OB and G Department, and the Medicine Dept. Rural patients seem to be less satisfied with the privacy during consultation with doctors. Some of the urban patients have also complained about the panel consultation where several patients are seated across the table from several doctors. Some object to the interference of interns. Some of the rural patients believe that the “trainee doctors” do the treatment on their own, and are more sceptical of stating their illness in the presence of the interns and medical students. Rural patients have given lower scores to the laboratory departments for the duration for receiving test results. This may be because they are more anxious to collect the results especially if they have to travel long distances back home. There is also a perception among the rural patients that the pharmacy gives “halka davai” which is different from what the 24

Dubey, Rose

doctors prescribe. Even if they are made aware of the different brands that produce drugs having identical composition, they remain sceptical. This came across from some urban patients as well during the course of the image perception study. Some of the patients say that the hospital has a contract with a particular pharmaceutical company and stocks only the drugs of that particular manufacturer. This leaves the patients with 2 options, if the doctor has prescribed a particular drug of a different company. Either they have to purchase this from outside, or take an equivalent from the pharmacy. Doctors and infrastructure and medical facilities have both resulted in indices in the mid 80s, while all the other indices are falling in the 70s range. The hospital would have to focus on these areas and try and pull up the scores on all these drivers.

Qualitative Aspects from Outpatient Survey Interns and Students Some outpatients are inconvenienced by the presence of the interns and student doctors, and resent the delay in their treatment due to the doctors teaching the students before treating them. One patient who visited an OPD in distress because of the pain that her ailment was causing her, said that she was made to wait for at least half an hour while her case was explained to the medical students in detail. Her objection was that she should have been attended to first and then she would have had no problem with the explanation afterwards. She was very irritated and mentioned that she would never visit the hospital again since they could not Fig. out whether they wanted their patients as clients or as merely live samples of some disorder.

Medical students can be a problem. They should at no time show any sort of frivolous behaviour when they are in the vicinity of the patients. One incident was of an uneducated man who had brought his baby to the surgery OPD with a finger injury. The doctor diagnosed something for the patient and the man turned to leave. As he left the room, he heard one student telling the other, “The doctor is such an

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idiot. He prescribed the wrong thing. God knows what will happen to that kid.” The man was very upset and resolved to have the child shown to a private doctor, no matter what the cost.

One of the members of the organisation related a similar incident. Doctors in a certain department had a consultation among themselves about which was the best way to treat the patient’s ailment. There was so much disagreement between themselves that the patient thought that they were confused and would not give him the proper treatment, He said that he preferred to go to one person who knew at once what to do, than show his problem to several specialists who could not agree on anything.

Some of the patients grumbled that in the OPDs they would go for a consultation once and be told that they had “such and such ailment” after which a course of medicines would be prescribed by one doctor. When they came back after a week or so, they would have to see a different doctor, who would cancel the findings of the previous doctor, as a wrong diagnosis and start a fresh course of treatment. This confused the patient who ultimately felt that none of the doctors were reliable and that he should go to a private doctor who would not keep changing his mind, or having other people interfere with the initial diagnosis. Another patient said that the residents should not be given the full authority to judge a case and that the consultant doctors should keenly supervise whatever they are diagnosing, since they are not experienced enough yet to be sure of their diagnosis. One of the patients pointed out that the doctors get diverted from the patient’s problem by the questions from the medical students in between the consultation. He advised that they should keep their questions till the end of the consultation between the doctor and patient. The result of interference is that the doctor often forgets to give the patient the detailed instructions that he would otherwise have had the time for. Privacy is less in a teaching hospital due to the presence of interns. One patient also suggested that the students should take the patient’s permission rather than poke their noses in directly, since personal problems are a matter of embarrassment for the patient.

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Time On one day, we found a man shouting very loudly at the Medicine department. On further investigation, it turned out that he had brought this mother for a consultation. 3 doctors, all talking among themselves, walked away with his mother, neither informing him where they were taking her, nor explaining to him what was to be done next. She had actually been called at 9:00 a.m. for a Doppler test. And after waiting till 11:00 a.m. the test had not been performed, neither had he been given any information how long he would have to wait. It turned out that the doctors had taken his mother for an X Ray, but without telling him where they were taking her. The nurse at the department said that she had no information and that he had better sit down quietly and not disturb her again. This was why he started shouting. We finally helped him locate her after making the inquiries. These information gaps can be very easily avoided and would spare a considerable amount of angst.

Although many patients feel that the time taken is much more, especially in the Medicine Dept, and the pharmacy, they feel that there is no solution and if they have to meet a specialist of their choice they would rather do that than meet anyone else. The doctors also say that it is impossible for the management to ask them to reduce waiting time for other patients. If one patient’s treatment is taking very long, they can’t help but make the other patient wait. “It is not a production line or an assembly line system here” quoted a doctor. However, patients feel that they should be informed at least what procedures will be undertaken. Health Plan Patients Waiting time is a problem with the Health Plan patients who complain that because they are put through the long waiting period at the Medicine department they are forced to sit with the regular patients, when all they require is a routine check. If all the Health Plan people can be called at one time in the afternoon when there is no rush at the OPDs and at the Labs then they would not have to wait so long unnecessarily. The Health Plan applicants are usually dissatisfied with having to wait along with the regular patients for the tests to be performed. They would like to come at a time when there is less rush of regular patients for tests such as chest X Ray and Doppler and ECG. They also

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feel that some staff should accompany them on the entire health plan from department to department since they will otherwise lose their way, while running around like the regular outpatients. Since they are paying a big lump sum they should be given some preferential treatment and should not be kept waiting when there are better ways of organising the checkups. Also, consultations should be one-on-one for the Health Check up patients at least. Locating the Right Department – a major contributor to wastage of time for the patient There should be clearer indications as to which department is on which floor. Often, the nurses and the doctors direct the patient to Dept. No. “x” but the patient has no clue where that department is. When they ask, the nurses often give directions like “aa baju” meaning “that side” which irritate the patient. Social workers would be helpful in directing people who appeared lost or confused. In the lab test department many of the patients get confused thinking that there are separate divisions for urine test, blood test, etc. Once they get to the lab, they get lost and confused and then staff lose their temper because they can’t Fig. out why the patient is standing in the lab and asking where they should go for the test. Maybe it is necessary to put up a board saying “blood test, urine test here”, and to guide those who are illiterate so that they don’t waste time losing their way wandering around inside the lab section. Another patient suggested that the numbers of the departments should be clearly indicated by means of a map or some pictorial description for the people who can’t understand whatever is written because they can’t read. There are no provisions for giving the information to patients about the procedure. Outpatients often get confused about what they have to do next, to get a detailed bill made or a test done. Good communication is needed from the staff. Personalised attention is very necessary, no matter how rushed the OPD is. Comfort – scope for improvement Some patients felt that the surroundings were not very comfortable especially in the crowded departments. One even asked that the hospital should be centrally air-conditioned. Another comment was that there are fans in some of the OPDs but none in others, not even the crowded OB and G Department, in which the women feel very uncomfortable in the 28

Dubey, Rose

stifling heat due to the rush of patients. The Medicine Department has only a single fan and patients feel very uncomfortable due to the long wait. Privacy during consultation and tests Urban patients from the middle and upper classes were very dissatisfied with the arrangements at the departments where the X Ray and lab tests are conducted. They felt that there was no privacy whatsoever, and that lady patients should at least be sent in one by one, instead of having to undress in a common area. 2 upper middle class ladies complained that they were inconvenienced by the absence of any place to keep their clothes, and were appalled that during their Pap smear tests, there were people walking in and out of the room. A lady who had just emerged from the X Ray department seemed rather put out by her experience. When asked what was wrong, her response was as follows. “At the X-Ray lab there was no changing room and we had to undress in some kind of store-room and leave our clothes on a bench there. Not all women are comfortable undressing in front of others and we also have so many garments to take off and put on, that it becomes awkward. They should set up at least two cubicles like trial rooms in clothing stores - no need of a door, a curtain will do - with a couple of hooks to hang one's clothes on.” It sounds finicky but in comparison to the rural patients the urban people have higher levels of comfort expectation and any dirt or discomfort can cause them immense dissatisfaction. Patients complained of the dirty linen at the ECG and other testing departments also. To quote the complaint of one lady (translated from Hindi), “The worst experience I had in this hospital was at the Gynaecology department. Consultation was done by sitting across a long table from a panel of doctors. At least 4 patients are seated at a time. I don't appreciate revealing my intimate details in public.” One patient in the OB and G department requested that the husband should also be allowed in for the consultation if the wife were agreeable since more and more husbands are open to the idea of taking an active interest in the progress of the wife during her pregnancy. This would only be possible if the consultations are one on one so that other ladies would not be embarrassed. 29

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Afternoon OPD Patients in the afternoon OPDs find that they are badly organized and that there is no attention given by the staff to how the patients proceed in for consultation, unlike the morning OPDs. They feel that since there is a common OPD it makes things more complicated as several patients with varying problems have to wait to meet a doctor who will be able to handle their particular illness. There is also a popular perception that there are no specialists at the afternoon OPD and that the students are handling the OPD without any guidance from residents. This doubt should be clarified as the outpatients would be discouraged from piling up in the morning if they knew that there are equally qualified doctors at all times.

Partial treatment for friends and relatives of staff Some patients grumbled that others who were personally known to doctors or the nurses in the hospital bypassed them in the queue. This was also told to us by the friends and relatives of nurses and doctors themselves, as an advantage of coming to the hospital. They said that the service would never have been as prompt if they did not know someone in the departments who would push them ahead. Shuttle timings and frequency Some patients suggested that the shuttle timings should be adjusted to take advantage of the maximum flow of patients, so that the distance factor would be overcome. They said that if there was a continuous up-down of the shuttle as soon as there were enough patients for it to move, then it would make the hospital convenient to come to for even minor ailments and problems. 14.2.2 Indoor Patients The 5 composite drivers (detailed in the analysis of outdoor patients) were used to calculate the satisfaction indices for the indoor patients. However, some more attributes that were relevant for the inpatients were included.

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Among these, were the number of visits by doctors (in the doctor related group), facilities for the relative accompanying the patients and the information disseminated to them about the inpatient’s status (in the comfort group), kitchen food, regularity of ward staff, and cleanliness of ward and regular changing of bed linen, (under the support services group). Results for the indoor patients were also compared between two different categories. 

The first was the patients subscribing to the Krupa Arogya Scheme vs. non-Krupa patients.



The second was the rural vs. urban patients. 64 urban and 56 rural patients were surveyed.

♦ Krupa vs non Krupa In the comparison of Krupa and non-Krupa patients’ satisfaction levels, the Krupa patients gave 6 –8 % higher scores to the attributes efficacy, time spent and expense level than the non-Krupa patients. This was compensated by marginally different rankings on the other attributes so the final scores for the “procedural and finance related” driver to patient satisfaction were only 3 points apart. The Krupa patients would be better satisfied with the expense level because their treatment is free up to Rs. 5000. They would also be more accustomed to the time spent at the hospital and the procedures involved and would tend not to look at these with a critical eye. The attribute with the highest difference in points is time spent, leading us to the conclusion that the non Krupa patients find this much more a problem than the Krupa patients. Fig. 7: Indices for Satisfaction levels of Krupa and non Krupa Inpatients

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INDOOR Krupa

Non-Krupa

100 80

Indices

60 40 20 0 Com fort

support serv.&staff

84.89

85.7

80.47

85.56

79.85

81.41

Proced.& fina.

Doctors rel.

Infrast.& m ed.

Krupa

78.57

90.88

Non-Krupa

75.14

86.54

Factors (Source: Patient survey)

Krupa inpatients gave higher scores to the doctors on all 5 counts; diagnosis, personal attention, compassion, patience shown and the number of ward visits. The scores differed by 5-7 points, although the doctors’ rankings were all in the 80 –90 range, indicating a high level of satisfaction. Krupa patients would tend to see everything in a better light because of the discount on treatment, and also because they are visited by the Krupa staff periodically during their hospitalisation. (Refer Fig. 7) Technology was given a much lower rating by Krupa patients at 78 as compared with the non-Krupa score of 85. This did not affect the comparative scores of the driver infrastructure and facilities, due to the compensating difference for infrastructure. The driver that exhibited the maximum difference between Krupa and non-Krupa patients was “comfort”. In this group, the attributes comfort, lack of overcrowding, aesthetics, location, and information dissemination to relatives, 7 –8 % got higher scores from Krupa patients. This could be due to the association of Krupa patients with the hospital. It could also be attributed to the fact that persons availing of a service at a discount tend to have lower expectation levels than those paying the full price. The attribute with the highest difference was location, getting an index of 90 from Krupa patients vs.74 from non-Krupa

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patients. This may be due to the fact that Krupa patients are those who live nearby and therefore think it worthwhile to sign up under the scheme. Overall, comfort received an index score of 85 from Krupa patients as compared to 78 from non-Krupa. Emergency services were rated lower by Krupa patients, and so also the duration for receiving test results. In fact many Krupa patients felt that they should be given a priority in getting the test results as they had paid “special” fees. The index for test result duration was 10 points lower than that of the non-Krupa counterparts. Kitchen food was rated higher by Krupa patients. Overall scores for the driver “support staff and services” did not differ much. As can be seen from the Fig. 7 above, only procedural and financial matters and comfort for non Krupa patients have got an index below 80 indicating slightly less satisfaction on this driver as compared to the rest, all of which are above 80 for both groups of patients. Satisfaction rankings for the doctors were the highest among both Krupa and nonKrupa patients. ♦ Rural vs Urban In the analysis and comparison of indices there is no difference of more than 2-3 points between the indices, except in the behaviour of doctors, which has received an index score of 7 points higher from the rural patients. Urban patients are exposed to more choices and are therefore able to compare with the private practitioners who are able to give a lot more personal attention to the patients. This could be the reason for their satisfaction level being lower. Location has been rated better by the rural patients than by the urbanites. This is because the rural people who come even from far off take a bus or a shared auto and manage to reach the hospital, paying Rs. 5-6. Urbanites spend approximately Rs. 40 each way by auto. Also, they have access to private hospitals, which are much closer to their homes. There is virtually no difference in the main drivers to satisfaction ratings, and the rural and urban patients seem on the whole to have the same level of satisfaction with the inpatient treatment. As can be seen from the graph below, only procedural and financial matters have got an index below 80 indicating slightly less satisfaction on this driver as compared to the rest, all of which are above 80 for both groups of patients. Again, doctors have scored the highest for satisfaction level in both groups, rural and urban.

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Rural and semi-urban patients said that they were satisfied with the cleanliness of the hospital in comparison to the Civil and Govt. hospitals near their villages and towns. They mentioned that here the floors are regularly cleaned both in the OPDs and in the wards, and that the bathrooms are cleaned regularly. Fig. 8: Indices for Satisfaction levels of Rural and Urban Inpatients

INDOOR 90 85

Indices

80 75 70 65 60 55 50

Proced.& fina.

Doctors rel.

Infrast.& med.

Comfort

support serv.&staff

Rural

77.8095

87.22

85.83

82.02

80.94

Urban

76.23

86.42

85

81.25

81.743

Factors

(Source: Patient survey)

Qualitative Aspects from Inpatient Survey Requirement for Male Nurses Male patients in the Male Medical Ward and New Surgical Ward are dissatisfied with the lack of male nurses to hand them the bed-pan and take them to the bathroom in the absence of relatives to do the same. They feel embarrassed to have the “nursebens” performing such duties and many say that they would much refer if one of the ward boys could help them to the bathroom or hand them the bed pan instead of the nurses. This would require a ward boy to be on regular duty for this purpose exclusively.

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There is sometimes a shortage of wheelchairs outside the wards as a result of which patients feel inconvenience when they are being moved around. Perhaps it can be arranged that there is always one wheelchair left at the ward so that patients who are in the wards can use it to move around. Needless Hospitalisation One relative who felt that the patient had been unnecessarily hospitalised suggested that the hospital should cross subsidise the lack of patients in the IPDs with higher charges in the OPDs so as to recover the overall costs instead of forcing patients to stay in the hospital and causing loss of time and needless hassle to the family. He said that they would be willing to pay the equivalent of the hospital charges for 2-3 days in an OPD but was unwilling to undergo or put up with needless hospitalisation just to fill up the beds. He said that the rich would not mind paying a high price to recover quickly and be sent home rather than to be kept in the hospital interminably. Patients have also complained about the discharge procedure. They can only be discharged after the doctor in charge has signed the relevant papers, but the doctor himself will not show up until at least 2 days have passed, so that the hospital can make money on the bed charges. Needless tests to increase expenses Some patients insisted that the doctors unnecessarily prescribe tests such an x ray for a cut finger, and advise patients to take the AC room for simple ailments like giddiness. This undermines the patient’s confidence in the doctor as he feels that he is being ripped off by the hospital. Medicines and the pathology lab tests should be cheaper, say a lot of patients. Many say that they can get their pathology and x-ray tests done much cheaper at Emery hospital. Others say that the doctors ask for unnecessary tests to be performed so that the hospital can make more money. In direct contrast other patients swore that the doctors are 100% reliable since they make no personal gain from unnecessarily asking patients to be admitted or to take tests. Since they get a fixed salary they don’t have any incentive for increasing the expenses of the patient. In the private practise this often happens, with doctors advising patients to visit a particular lab for the required tests. The doctor then gets a commission from the lab for the 35

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reference. However, in this hospital, they would have nothing to gain by prescribing unnecessary tests. Relatives Some patients have complained of a lack of information from the doctors and nurses especially when the patient is in a critical condition and the family would like to know how he is. In fact in some cases, the doctors have failed to diagnose the problem in time and the family has not had any idea about what is happening for more than a week. Simple information (such as where the patients’ relatives are allowed to eat) would prevent a lot of resentment. Some of the relatives are reprimanded for eating inside or around the wards. They are not told that they can eat in the enclosure outside, so they draw the conclusion that they have to eat out in the open, and then they complain about the hospital and the discomfort that they have to undergo. The idea of having to pay Rs. 10 per night spent in the corridor is riling for most of the relatives. They say that they have to be there to relieve the one attendant who is allowed in the ward. But they should not be made to pay when they sleep in the corridor. And if they are paying, then they should be able to get some common facility which is easily accessible from the ward, in which they can sleep. Persons who come from far off places need more than one attendant, but are too poor to hire accommodation while the patient is in hospital. Tea and coffee and meals should be provided cheaply to the poor who come from long distances and stay for several days. They are not allowed to stay in the wards, and are charged for being on the corridors. The restaurant is too expensive. X Ray charges are high for the poor people. There should be an inquiry desk to clear the doubts of patients regarding direction, procedures, etc. Discharge Procedure and Legal Issues The discharge procedure has been found inconvenient in the sense that the patient cannot be discharges as long as the doctor in charge has not signed the discharge papers. The doctors sometimes do not turn up till the next day. If the patient does not have 1-2 relatives with him to do all the running around for fetching the medicines and getting the bills made and paid, then the patient would have to 36

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struggle between the OPD, the cash counter and the lab. For inpatients the admission and discharge procedures cause a lot of fatigue. Billing should be fully centralized so that patient’s relatives are not harassed with having to pay in bits and pieces. The patients are not informed of the amount that they will have to pay until the day that they are due to be discharge. In that case how will the family arrange that much money in one day? Another patient grumbled that the consent of the patient and the family is taken on every little procedure even for an emergency patient so that the hospital does not face legal problems later. This may be overdoing it a little, as many of the patients are only interested in getting better and are hardly likely to sue the hospital for having a tube or pipe inserted or an investigation done, if it is necessary and unavoidable. Lack of specialists round the clock Some patients feel that there is need for more specialists at the hospital. This is because in the event of an emergency, it is necessary for the specialist to be somewhere on call immediately. If he is only a visiting specialist, then there is a possibility that he may not be able to see the patient till the day he visits the hospital, or the patient will have to be shifted to the hospital where the specialist practises. Since this is not always possible, nonspecialists attend to the emergency patients and the patients believe that this may not be in their best interests. Deluxe rooms Deluxe rooms are often empty so it doesn’t matter that there are very few staff, but when it gets up to 5 patients then there are problems of there not being sufficient ward boys and nurses. Also, in the deluxe rooms patients feel that they should get priority in the order for tests and other facilities. Unsympathetic Treatment in the OB & G Dept. Although we were not supposed to highlight any particular department, some interesting observations were made and responses received in the OB & G Department. This department handles patients mostly from rural areas and has a high patient load in both inpatient and outpatient categories.

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The rural patients do not mind being spoken to roughly by the nurses or having personal comments made about them by the nurses doing the pre-operation procedures before surgery. However, urban and educated clients (especially women) are liable to react very unfavourably when nurses are harsh with them or make comments about them in Gujarati or even ask personal questions which are none of their business (such as a patient having a D&C being asked whether she was having an abortion). Maybe the nurses feel that asking the patient about their personal lives makes them feel more at ease, but they must distinguish between patients who like being chatted up, and those who just want to get the treatment over with so they can go home. This response came from an upper middle class lady who had been through a minor operation some weeks before at the hospital. She said that the nurses at the Gynaecology OT/ Labour Room where she was taken for the D&C operation were inhuman and unsympathetic. They were discussing her in crude terms in Gujarati and one asked her how many months pregnant she was, as if she was having an abortion, although this was not the case. The bathroom attached to the gynaecological ward had a broken tap and a broken mug and she had to scoop water out of a bucket in her cupped hands. There was no facility for her to change her clothes before the operation and they were just dumped on the floor while the D&C was done.

An experience at the OB &G OPD A rural patient at an OPD was responding to the questionnaire, based on her previous experience at the hospital. Even as she was responding to the questions about the nurses’ behaviour, the nurse at the concerned department came out and found all the footwear scattered at the entrance of the Department instead of being arranged on the stands. She lost her temper and kicked all the footwear under the chairs in the corridor, scolding loudly at the same time. I noticed that all the rural patients seemed to be very amused at this, and my respondent went on to give the OPD department nurse a score of 5 for behaviour on

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the 1-5 rating scale. At the same time, I noticed the look on the face of a middle class lady who was also waiting for consultation. She seemed dismayed, to say the least. Later on, when speaking to her she said that she found that there was nothing amusing in the nurses’ behaviour and that she had no right to behave in such a way with the patients. She could have instructed them to put their footwear on the stand instead of abusing and kicking it out of the way. (Berenice da Gama Rose)

This sort of harsh behaviour was observed during our ward visits as well. On one occasion, we were able to observe the duty nurse shouting at a patient who was not eating her lunch because she had severe abdominal pain. The patient was from what seemed a very poor background. Strangely enough, she too, didn’t seem too perturbed by the firing she had just received. Rather, she sat up in bed with a blissful smile and quietly ate her food. This led us to wonder whether constant interaction with stubborn and uncooperative patients from the lower classes has led the nurses to follow this kind of behaviour as a common practice. Before we criticize the nurse for the behaviour exhibited it would be necessary to analyse whether she would have got the woman to eat her food by any other means. However, if the same behaviour were tried on an urban educated woman, she would possibly not take it quietly. Even if she did not say anything, she would certainly not return to the hospital. The nurses would therefore have to carefully assess the nature of the patient and then deal with her accordingly. However, we still feel that there are better alternatives to screaming at a person to get them to do something.

14.2.3 For Krupa patients: Responses on Krupa – specific questions ♦ Indoor vs Outdoor The outdoor and indoor patients have differing perceptions about Krupa. (See Fig.9) Many of the outpatients do not realise that they will receive the benefit of Rs. 5000 treatment only if they are admitted in the hospital. They come for treatment, expecting it to be free, and then feel disappointed. Also, they do not go through the Krupa booklet, either because they are

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illiterate, or because they have not really thought it necessary. Members of Krupa complain that they are not told in detail all the intricacies of the scheme while they are signing up for it. Later they find out that certain diseases are not treatable under Krupa and they feel dissatisfied with the scheme. They are unable to read the booklet because they are illiterate. There is no post purchase information given to them. Fig. 9: Indices for Satisfaction levels of Indoor and Outdoor Krupa patients on Krupa specific issues.

D

O

Pr ic

e pt io ns M ed ia

oc um PR en T ta ti o Tr n ea tm D en ou t bt s Boo cl O k ar l th ifi et er c As ati s o on O ci th at er io St Be n af n fh e os fi ts pi ta l it y

100 90 80 70 60 50 40 30 20 10 0 In fo rm at D io is n ea Dis s e co u s c o nt ve re d

Indices

Satisfaction with Krupa

Factors

Outdoor Indoor

(Source: Patient survey)

This is why the outpatients have given lower scores on information and the diseases covered under the scheme. They have also given lower scores on the documentation and the quality of information provided in the booklet, although the rules are very clearly stated therein. Many of the Krupa outpatients felt that there was no big difference in getting a 10% discount off on a test costing Rs. 100 and they would prefer to be given preference in the queue to meet the doctors, and for getting their test results. Others said that they were satisfied with the discount and felt that it would be unfair to ask for preference in the queue for consultation. Perhaps the ideal situation would be to have a Krupa/non-Krupa queue and take in alternately one from each queue for consultation. Some of the outpatients felt dissatisfied with the scheme because they wanted to be linked to other hospitals also, like Mediclaim facility. Almost all the patients were satisfied with the Krupa office staff and said that they were polite and hospitable.

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There is a popular perception among the rich patients that the Krupa scheme is only for the poor people and that it is not necessary for them to sign up for it. Does this fit in with the image of Krupa? A wealthy businessman that we spoke to said that he had not availed of the Krupa scheme because “that is meant for the poor people who cannot afford medical treatment”. Industrial Card Holders The industrial card holders feel that since they are not paying directly for their treatment, that the doctors give them differential treatment. One comment was that the doctor should see the patient, not the income level before treating the patient. Some of them feel that since their treatment is “free” that they will get inferior service from the hospital. This may well be a misconception simply because they go there with an attitude that they will be discriminated against. Others say that they have to come here only because the Company is paying for their treatment here, but they would prefer to go to a private practitioner if they could afford it. An equal number of industrial card holders say that they would come to this hospital anyway, even if they did not get free treatment over here, because the services are good. This indicates a dichotomy among the patients themselves as a group. Coordination Problems and Rigidity in a Professional Bureaucracy The hospital lacks co-ordination between various departments. Doctors are not available sometimes. This puts off the patients who come to see a particular specialist who comes only on a certain day. If a doctor is not coming on a particular day, he should make sure that he informs the hospital in time for them to turn away outpatients before making them wait. If a patient is waiting with a fracture at the Orthopaedics Dept, then there is only one doctor to attend to him. Too much detail is given to procedural rules and the nurses do not want to take on the responsibility of anything that is outside their role. For instance, at one point, there was a diabetes patient whose toe was amputated and the medical students were called in to have a look. After undoing the bandages and examining the wound, which had not dried yet, the students went away. The patient called the nurse to re-dress the wound but she said that only the person from the dressing room was supposed to do the dressing and that she would

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call him. The person in question arrived after 5 hours to re-bandage the wound. The patient had a second surgical intervention recently, but refused to allow the medical students anywhere near him. Similarly, one patient who went to the Surgery OPD unit to have his finger dressed again was told to take the bandage off by himself. He explained to the doctor that he could not do it himself so he was instructed to have the bandage taken off in another department. He had already waited for 1 hour in the Emergency and Trauma Care Centre. By the time he located the place where he had to have the bandage removed, and returned to the OPD, it was an hour later and he had to wait again. The patient needed sutures that would cost Rs. 20. The person in charge of doing the sutures told him to pay the amount and bring the slip to him. The patient begged him to complete the treatment first and showed him that he had the Rs. 20 to pay, but the person was adamant. Furious, the patient blamed the hospital for its inefficiency and said that the residents, or some nurse in the OPD could easily have done the job instead of harassing the patients in this manner. Infusing confidence –appearing to be good is as important as being good! One respondent gave extremely low ratings to the doctor that he consulted. This was because his consultation lasted barely 30 seconds. He hardly sat on the stool when the doctor took a look and diagnosed the problem without hearing him out. The doctor immediately wrote a prescription and there ended the consultation. “Sab bakvaas hain”, was the comment. What kind of diagnosis can a doctor do in that much time?” he asked.

Good Behaviour - an important PR factor! One of the favourable responses we received was from a lady who told us the comparison between the Shree Krishna Hospital and the private hospital she used to go to in Baroda. She said that for them money is not a criterion and that they only choose by service. In the case of her daughter who is 9 months pregnant, the gynaecologist gave her mobile number as it was approaching the delivery due date so that she could be called in an emergency. To quote her response, “The nurses are kind, soft spoken and gentle. Excellent service has always been provided and that too, at rates which are ¼ of those in Baroda. Doctors’ behaviour here has a more personal touch also, which increases the patient’s attachment to the hospital and ensures that he remains a loyal client.”

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One patient was infuriated because the personnel in the department were not doing any work, but were talking among themselves and drinking tea. He was not called when the doctor became free for consultation, and he said that he felt like a fool. It is important that staff always give the impression that they are serious about their job, since the patient is likely to get irritated if he doesn’t see the staff busy. This leads him to believe that they are deliberately not attending to him quickly, out of a callous attitude. Patients have complained that the lab technicians and pathologists are usually talking in the department and give no indication about how long it will take for the test results to come. Neither do the patients get their results, nor do they see the staff working while they are waiting. This leads to a lot of irritation. At the Medicine Department, where there is a big rush for consultation, one nurse and one assistant handle the entire load, including the Doppler test department. As one patient observed, “There is only one nurse at the diabetes and blood pressure clinic and a big crowd so it is obvious that at some point she will lose her temper. Freeships And Concessions The staff are sometimes rough with the relatives of the patient when it comes to allotting free ships. Some of the relatives of indigent patients complained that they had been asked,” If you are poor, then why do you come here?” Cost is a factor for the people from the rural areas. Although even the poor come here because the treatment is good, rather than merely for the freeship or concession, they have the impression that poor people can get treatment at a very reasonable rate at this hospital and that freeships are also available for the economically disadvantaged. However, since the frequency of freeships has been reduced, many of the rural poor have found a dissonance between what they expected and the bill that they were asked to pay at the end of the treatment. Many of the poor people who are treated in the ICU have to apply for freeships and they say that procedure is tedious and sometimes even humiliating. “There should be some humaneness in giving freeships to poor people who land up in the ICU”, was the response of one patient. An interesting case was related wherein a boy had swallowed pesticide as he was 43

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unable to pay his debts. He was put in the ICU and recovered after a long period, whereupon he was presented with a bill of a huge amount, several times the size of the original debt. Some patients suggest that they don’t mind paying more but that cost changes should be explained to the clients, for instance what they are paying extra for and why. The other side of the coin Patients themselves will not let go of an opportunity to negotiate for a discount. A very well dressed man, working with the Bank of Baroda stated his income as Rs 5000 and asked if he could avail of some freeship or discount because the hospital treatment is very expensive. Compassion: A crucial Ingredient Our observation during one paediatric ward visit was that there was a patient in obvious distress. The nurse had left the room to do some work and the child seemed to be suffering from delirium due to high fever. The father looked around for help, but the two interns who were studying there, offered none. In fact, they continued reading from their textbooks. The situation did not require that they should prescribe something or use medical intervention. But a little bit of reassurance to the worried father and hysterical child would have been enough. The nurse arrived 5 minutes later and took the necessary action, but the father would have registered that “the doctors” were not bothered. A little compassion requires no formal qualification. What better training to be a doctor than to show some care and concern for a patient? Interns should also imbibe these qualities from the very start of their medical education.

The Much-maligned pharmacy Many patients complained about the inconvenience of the pharmacy counter and the long time that it takes to get the medicines especially when there is an emergency patient. They suggested that a small counter should be opened near the Trauma and Emergency Centre so that the immediate needs can be met. Also, some patients suggested that it would be more convenient if the inpatients were supplied everything and it were added to their bill at the end, rather than being told several times to go and wait in the queue for medicines.

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Some of the patients feel that the poor people and the industrial card holders are denied medicines of good quality at the pharmacy since they are not able to afford better tablets. The pharmacy palms them off with “halka davai” was the complaint of some of the poor patients. Another point of view is that the hospital has a contract with one particular company for the supply of medicines. As a result, if the doctors prescribe the drugs of another brand or company, the same are unavailable at the pharmacy and patients are given the equivalent of that brand in the contracted company’s range of medicines. When we spoke with the Purchase Manager he mentioned that there was a contract with 25 pharmaceutical companies. Another misconception is that the medical students treat the poor patients and qualified doctors treat the rich patients. Since there is no differentiation between the consultants, residents, ad interns, the patients automatically assume that if they are poor that they will get second-class treatment. This response came from one patient, who said that the concessional rates at the pharmacy were hardly anything less than the regular price. “Medicines are sold at the MRP or only slightly below that. The poor can’t afford it.” Nurses – maintaining a delicate balance Nurses are perceived to be very busy with the procedural work of filling in the files and documents and are therefore sometimes not able to respond to the patients on time in the wards. The nurses in the OPDs are sometimes overburdened with the crowds of patients who keep coming up to inquire when their turn is coming, or those patients who stream into the waiting hall outside the consultation room without their number having been called. Many do not keep their footwear outside as required to do and even if they do, then it is not kept on the stands. Nurses sometimes show irritation in these circumstances. However, not all of the patients are able to see things from an objective point of view and they immediately conclude that the nurses are rude. Another complaint was that the nurses do not tell patients exactly how long they will have to wait. This causes patients problems since they are not sure when their turn will come up. When we observed the situation in the OPDs it would be impossible for the nurse to determine how long it would take to see a doctor, since there are several doctors and not everyone wants to see one doctor in particular. Also, consultation can last from 2 minutes to 45 minutes, and therefore the waiting time cannot be determined, What is needed is something to distract the patients from the fact that they are waiting, such as a TV 45

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screen showing Hindi or Gujarati movies. Some of the patients were sympathetic towards the nurses and said that it was not their fault that they lose their temper sometimes. Others were very critical of them and said that they were unnecessarily harsh. Nurses must also remember that they are in the hospitality industry and like airhostesses and hotel staff, they often have to deal with demanding and uncooperative clients. This is just one of the job hazards and they will have to learn to respond with patience at every juncture, no matter how difficult it may seem at the moment. Sometimes the nurses talk very loudly in the wards, causing disturbance to the patients, although they mean no harm. They should be always conscious of the patient’s comfort, even if it means moderating their voices, talking less among themselves, etc. The patient, after all, comes first. A very positive observation was that the ward nurses all knew every patient by name. Many were observed to be very gentle with the patients. 14.4 All Indoor and All Outdoor Patients The ratings for the outdoor patients are lower than those for the indoor patients resulting in lower index values. While indoor patients have given low scores on procedure and finance related aspects, the other indices are all above 80, across different categories of patients. This is indicates that the outdoor patients have to be convinced that the services of the hospital are in keeping with their expectations.

Fig 10. Comparison for outdoor vs. indoor aggregate indices.

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Inpatient vs Outpatient Satisfaction

100 Indices

90 80 70 60 50

Proc and Fin

Doctors

Infra and Fac

Comfort

Support & Staff

outpatient

77.16

85.07

96.67

76.19

75.03

inpatient

75

86.85

85.39

81.59

82.58

Satisfaction Drivers Outpatients are very satisfied with the infrastructure and other technological aspects of the hospital, more so than even the inpatients. Outpatients are also not entirely satisfied with the comfort level and support services of the hospital. However, this explanation does not support the fact that outpatient load is relatively the same, while inpatient load has fallen drastically in the past few years. Also, if indoor patients were so satisfied why would they prefer to go to the private practitioners? One reason would be that outpatients who were unhappy with the services would certainly not come back to get admitted in the same hospital. In several instances, there are patients who have been severely inconvenienced by the loss of time due to the delay in receiving the results of a test, or due to staff being inattentive. These things would add up in the long run. Also, competition has increased tenfold. Now there are speciality hospitals in Anand and VV Nagar, dealing with specific problems, and offering highly personalised service and the highest degree of comfort and care. This made us aware that the problem might not always be within the organization. It could be outside. Shree Krishna Hospital has tried to provide every comfort to the patients. But it has only focussed on improving itself. Neither does it have a PR department, nor does

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it have the money to advertise. Is Shree Krishna Hospital looking closely enough at the competitors in the healthcare segment? Why are they thriving? What are they doing better? In order to study all these things, an image perception test was conducted in Anand and VV Nagar, the results of which will be dealt with in a later section. 15. BRAND REPOSITIONING STRATEGIES Shree Krishna Hospital has been at the helm of many activities, which constitute providing health care facilities to the patients at the Shree Krishna Hospital and also assisting students of Pramukhswami Medical College by giving quality education. Thus, it is of utmost importance that it provides quality medical services to the patients so that it builds an image and which will also help it in getting enough patients. This will also help it in setting an image of a quality service provider not only for patients but also for getting the required funds from donors. Since it is a charitable organization, which stands for the betterment of the rural community, it is imperative that it builds an image so as to cater to the needs of the community apart from giving the best medical services. The crucial question is also related with finances, which are necessary for catering to the rural community needs. Most of the patients who come from the rural communities are benefited in the form of cheap services. Apart from this those patients who have no money at all to support them, are provided with freeships. The total expenditure on this goes up to the extent of the about Rs. 1.25 crores. The fund for the above generally comes from donations. Apart from this, capital expenditure is also financed from the donations or taking short-term loans for which donation is planned. Regarding freeship there have been many attempts in the past to make it more effective and serve the purpose but in some form or the other the main objective has not been achieved. Moreover it has not led to any substantial incremental benefit as far as image building is considered. Apart from freeships there have been other attempts in the form of extension programmes e.g. tobacco cession programmes, awareness programmes about cancer etc. so as to benefit the community in large. But at present the most important question is how to improve the image of the hospital so as to gain a brand image. What is a brand? 48

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There are many definitions of the brand but we can take it in one of the simplest forms, as explained by advertising planner Paul Feldwick who says: “At its simplest, a brand is a recognizable and trustworthy badge of origin and also promise of performance.” Brand also transforms experiences and provides a means of differentiation. Organizations often communicate their brand messages through a variety of conduits. The process is multi-faceted. It is about interactions with people, what we see in the advertising, the content that appears on the Web site, the quality of the services and the efficiency in providing them. The organization may try to control all these outputs but is only the visual presentation that is truly policeable. Content is not. In the present world one cannot create an Orwellian world where every employee thinks and talks in the same way. Significance of Brand  The power of a brand lies in giving employees the freedom to use their imaginations within the constraint set by the organization’s values. So, the message is clear that organization can try to communicate its brand through signs and symbols; there is no guarantee that consumers and other audiences will read them in the intended way. It is just impossible to prevent people from using their different personal and cultural experiences to decipher what they see.  When we choose to buy a product or a service, both positive and negative reasoning influences us. The degree of consideration given will depend on the complexity and the size of the purchase but the factors will tend to be similar.  The first factor is functionality. Is the service the same as what I need? 

The second is emotionality. It means does it tap into my needs and desires and sense of self?

 The third is differentiation. What is the context for this service and how is it different from the other service providers that I could substitute for? It tries to address in a sense what it is not.  Strong brands tend to be opinionated. They tend to stand for something and provide a positive reason for choice.

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Image Perception Study An image perception analysis was conducted through a household survey of 60 households in Anand and 60 in Vidyanagar, to get an idea of the urban perceptions of Shree Krishna Hospital. (Refer Annexure 2) The findings are detailed in the following sections of the report. Reason for going to a particular health care centre In the survey conducted in the surrounding areas of the Shree Krishna hospital the prime reason for going to any health care centre in particular has been the following:  The first reason, which came out from the survey of 120 respondents in Anand and Vallabh Vidya Nagar area, came out to be services.  Location and time were the next important categories. As far as Anand is considered locational disadvantage has been one of the major factors for the patients for not coming to this hospital.  The last category has been the specialization, price and association with the hospital or doctor over a period of time. (See fig.: 11) Fig 11: Reason for choosing a particular hospital Reason for going to health care centre 73

Spec

Factors

Price Assn

68 20

Location

96

Tim e

98 112

Serv ice

Preference (Source: Household Survey)

Familiarity with Shree Krishna Hospital The survey conducted in Anand and V V Nagar has showed that maximum (approximately 65 %) people in and around the cities don’t have much knowledge about this hospital. This clearly indicates that a major proportion of the population still is not clear

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about the service being provided and its facilities. Out of total surveyed only 8 per cent know very well about it and 27 per cent know a fair amount. The rest either know a little bit or have just have heard about it from others. (See Fig. 12) Fig.12: Familiarity with Shree Krishna Hospital FAMILIARITY WITH SHREE KRISHNA HOSPITAL

8%

1% 30%

Never heard of Heard of

27%

Know a little bit Know a fair amount Know very well 34%

(Source: Household Survey)

Out of this in Anand area 30 percent of the people have considerable familiarity about it as compared to V V Nagar where about 40 per cent people know better about it. (See Figs.13 &14) So, the implication is that there is vast majority of the population which has to be attracted towards this hospital. This can be done by following a market-based approach of focusing on customer and focusing on excellence in services provided. Fig.13: Familiarity of Shree Krishna Hospital in V V Nagar

Familiarity of SKH in VVN

8% 2% 22%

25%

43%

Never heard of

Heard of

Know a little bit

Know a fair amount

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Know very w ell

Dubey, Rose

Fig.14: Familiarity of Shree Krishna Hospital in Anand

Familiarity of SKH in Anand

8%0% 35%

32% 25%

Never heard of

Heard of

Know a fair amount

Know very well

Know a little bit

(Source: Household Survey)

The survey conducted in Anand and VV Nagar shows that Hospital image has to improve drastically. This is evident, as out of total approximately 27 per cent of the respondents had either somewhat or very favourable image in their minds of this hospital. Out of the rest, 30 percent were indifferent and the remaining 43 per cent fell in the category of having an unfavorable image. (See Fig.: 15) Fig.15: Favourability image of Shree Krishna Hospital FAVOURABILITY IMAGE OF SHREE KRISHNA HOSPITAL 8%

Very Unfavourable

10%

19%

Somewhat unfavourable Indifferent

33% 30%

Somewhat favourable Very Favourable

52

(Source: Household Survey)

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As far as Anand and V V Nagar are individually considered 25 percent and 36 percent of the respondent are indifferent respectively. (See Figs. 16 & 17) So, the hospital can approach V V Nagar and surrounding areas for its image-building exercise. Fig 16: Favourability image of Shree Krishna Hospital in Vidyanagar

Favourability image of SKH in VVN

10%

V er y Un fa v ou r a ble

8%

18%

Som ew h a t u n fa v ou r a ble In differ en t

28% 36%

Som ew h a t fa v ou r a ble V er y fa v ou r a ble

(Source: Household Survey)

Fig 17: Favourability image of Shree Krishna Hospital in Anand

Favourability image of SKH in Anand

7%

10%

20%

38% 25%

Very Unfavourable

Somew hat unfavourable

Somew hat favourable

Very favourable

Indifferent

(Source: Household Survey)

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15.1 BRAND PERCEPTION Fig. 18: Importance Performance Ranking Performance ranking 1 00

Indices

90

80

70

60

50

Im por t a n ce Per for m a n ce

Ex pen ses

Doct or s

In fr a st .& fa cilit ies

Com for t

su ppor t ser v .&st a ff

1 00

1 00

77

86

1 00

1 00

1 00

86

7 9 .5

78

Factors (Source: Patient survey)

From the survey, the main findings have been that the prime importance in the eyes of patients coming to Shree Krishna Hospital is given to 5 drivers ~ Expenses, Doctors, Infrastructure and facilities, Comfort and Support services and staff. On these parameters as per the ratings given by the patients, they are more satisfied with infrastructure and facilities and Doctors as compared to support staff and comfort being provided at the hospital. The area where it has to concentrate more is expense, which is not that satisfactory. (See Fig.18) The qualitative insights of the survey are discussed below: The rural patients and the urban patients have different expectation levels and different choices. The rural patients come to the hospital thinking that it will give them excellent service since it is a BIG hospital and they tend to associate big hospitals with big illnesses. They have also heard stories of the freeships that are available here and that they may get something off on the bill. Also they have heard that it is much cleaner than the civil hospitals and that the facilities are better, the staff are better, and in general, they have more chances of getting well. Therefore, when they are presented with a hefty bill at the end of the

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treatment they feel that they have been let down and that the hospital has not lived up to its expectation. In fact, the Shree Krishna Hospital is perceived as a “better civil hospital” than the one in Anand, and not as a trust hospital. So the poor expect better treatment at the same rates as they would pay in the civil hospital. The rich, on the other hand, would not go anywhere near the Civil Hospital because they know that the quality of service over there does not match their requirements. They go to the Shree Krishna Hospital expecting customised service and the quality that they would get in a private hospital at a lower price. They get the lower price, but no better service than the rural people get. In fact, they face problems such as a lack of privacy in consultation, long waiting hours (especially problematic for working people) who don’t want to waste a whole day getting a minor illness attended to. Further, they find that they are not treated with the same level of comfort and hospitality that they would find in a private establishment. So they are dissatisfied. Others, in the upper classes, do not go to the Shree Krishna Hospital at all, because they perceive it to be a nice hospital set up specifically to cater to the rural poor. Middle class people, for whom money is still a criterion, do not go there because the distance outweighs the other advantages. The amount that they pay in transport is more than what they save in the lower registration and consultation costs. One patient gave this response, “There is no brand value and positioning should be the core at present to compete with other places which have advantages of locality. There are no private rooms for the middle class people, who would also want privacy and comfort without luxury.” The upper classes and better-educated people also feel that since the hospital does more treatment for rural people that they have no specialists and are merely a general hospital. Other hospitals in the meanwhile have strongly dinned into the public that they have specialists and super specialists available for consultation and they hold special camps to build goodwill, (such as the free cardiac problem camp held by Emery hospital). People who attend these camps are immediately convinced that these hospitals are providing excellent service, and they become loyal patients of one hospital. 55

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For the working class, the most important thing is to get treatment which is fast, and effective. They find that it is better to go to a specialist clinic by appointment and get the problem attended to in a way that will save time on consultation, and also on the period that it takes them to recover. Many complaints were received about the doctors at Karamsad prescribing drugs that took a long time to have remedial effects. At the same time, the private doctors do not advise them to have unnecessary tests and there are no procedural delays. They prefer to pay the extra money at a private clinic for this reason. Whether rich or poor, no one likes to be admitted to a hospital unless he thinks that he is feeling sick enough to remain there. Many patients have complained that they were unnecessarily admitted in the hospital and kept there for ailments as small as an insect bite, and fractures of the arm or leg, when they could have been allowed to go home. Patients have also complained that they were kept in the ICU although they began to feel better and had asked to be shifted out into the regular ward. This builds the perception that the hospital is trying to fill its beds by keeping patients there without any cause. This deters other patients from coming to the hospital, because they feel that they will be held back for more time than will suffice. The very rich are willing to pay any price as long as they get preferential services and their lives are made convenient. Therefore, when they take a deluxe room, they would want a ward boy to be on call at any time of day or night, and that the patient should have preference for the medical tests to be performed. They feel that the service that they get in the deluxe rooms, apart from the comfort of the AC and a fridge and TV, is not very different from the patients in the wards. So why are they paying so much extra? What do they really want? Not the fridge or the TV so much as the 24 hours care and attention that make them feel special. Thus the hospital does not end up pleasing anyone. Price differentiation would make a big difference but then customised service would have to be given to those who were paying more. The hospital would then have to go slow on the image of being an “affordable for the poor man” establishment, and just concentrate on the image of providing excellent service to all. Why segment the market, and select a target market, when it would reduce the choices for the hospital and needlessly discourage another segment through false perceptions? Also, it has to follow a strategy for attracting back the people who had bad experiences several years ago and have never been back since. Many 56

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patients mentioned that since “AMUL Madam” took over there have been several improvements, while in the image perception analysis, several persons quoted that they had bad experiences as many as 8-10 years ago and never went back to Shree Krishna Hospital because of that. The hospital has to win back the confidence of these people and focus on highlighting and marketing all the improvements that have come about in the last few years. Patients who visit the private hospital OPDs say that the difference is that there, they are able to make an appointment, they do not have to wait for a long time to see the doctor, he personally calls them in for the consultation, they get one-on-one attention from the doctor, without the distraction and the embarrassment of students standing around and taking notes. The atmosphere is nicer, they say, as there is a TV in the waiting room, comfortable sofas and magazines. The doctors are extremely courteous, and the patients feel that since they get complete privacy that the doctor is able to devote his full attention to them. Also private doctors do not waste time chatting with their colleagues or going out of the clinic, as for them time is money. The more patients they treat, the more money they make. In addition to this the private doctors show great personal attention and interest and do not hassle or hurry the patient out of the consulting room, despite the fact that “time is money”, because they know that a certain amount of PR is necessary to retain the patient. Patients who are satisfied swear by the hospital. They say that the tests are cheaper than the private hospitals, the service is better than the civil hospitals, and that this hospital forms the perfect in-between, giving the excellent service of a private establishment with the affordable price which the rural people can afford. The services of the doctors are unquestionably the best available in Anand, and these are backed up by excellent aesthetics and support services. The administration is convinced that some of the doctors in the hospital themselves refer patients outside, but this feedback has not come from any of the patients themselves. Private doctors do not give their patients a favourable referral for the Karamsad hospital since they get no commission from the hospital, neither has the Shree Krishna Administration tried to build up goodwill with the private practitioners so that they will refer patients here. As a result, patients who normally get influenced by word of mouth, (more so from their family doctor), do not go to the hospital, and form a bad impression about the place without having ever seen it. 57

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There are still stories from the past 10 years which people who have bad experiences relate, and in general the perception among some of the public is “When people come here, they get a direct passport to heaven.” Because it does not have a history of excellent treatment, it will have to double efforts to attain the goodwill of the people. A very large proportion of the patients of the patients come from among the GIDC industrial card holders, and those who have some friend or relative among the nursing staff in the hospital. Some of the doctors also recommend that patients who come to visit them at their OPDs in Baroda and expensive private hospitals should come here for their treatment especially if they need to run a series of tests which would otherwise work out very expensive for them. No patient said that the consultant doctor had asked them to see him privately or at some other place where the doctor would be practising on other days of the week. Thus the falling patient load is not because there is any persuasion against coming to Shree Krishna Hospital. There is not enough persuasion to go to Shree Krishna Hospital. People’s reasons for not taking treatment at Shree Krishna Hospital. •

Bad experience in the past

•

Poor services

•

No personalised attention

•

Loss of time and unnecessary delays due to lack of coordination between departments

•

Community level attachment to another hospital (eg: Zakaria Hospital)

•

Costly with no reason and no extra services or benefits

•

Distance (transport costs and hassle involved in getting there negate the cheaper service charges at the OPD)

•

Very few specialists and even fewer doctors with a good reputation.

•

Training doctors who interfere or treat the patients themselves so nobody wants to risk it. People are scared of being treated by a trainee.

•

The treatment is done at their own pace, and since it is a teaching hospital all they want is to get the students’ priorities right, not the patient’s.

•

The hospital doesn’t have specialists and the doctors keep referring people to Baroda for big operations So people go to Baroda directly.

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•

Specialists are available in Anand so there is no value addition in going further to Karamsad unless there is a very big ailment requiring hospitalisation.

•

Image is better when one goes to private hospitals.

•

Private doctors treat well, and build a rapport. They don’t forget the patient and give personal attention, water, and good comfortable facilities at the clinics.

•

One patient had heard that under the Krupa scheme they hospital offers free treatment of Rs. 5000 and so they keep people in the hospital as inpatients until the 5000 is used up so that they can then reclaim it from whatever fund they have.

•

It is a “civil” hospital so there are prestige issues involved.

•

It is a hospital for the poor. It does not have any coordination between departments and is prone to delays

•

Doctors always try to admit the patient

•

No integration and responsibility and the doctors are not good.

•

No reliability: Wrong diagnosis

One respondent related an incident which took place with his mother, where the wrong diagnosis was given after his mother had been kept in the ICU for 3-4 days. The problem was actually that of angina, but it was diagnosed as a pulmonary disorder and the patient’s family invested in 2 respirators for the purpose of her treatment. After 2 months they found the treatment to be ineffectual and had her shown to a doctor in Baroda who diagnosed the problem. She has been under his treatment ever since and says that she would not consider ever going back to the Shree Krishna Hospital Positive Feedback Surprisingly some of the patients have travelled from as far as MP to seek inpatient treatment here because they have been in Anand during the camps held and have decided that the hospital offers excellent treatment. Still others come in from Baroda even, because they say that “Karamsad Civil” is much cheaper than at Baroda….approximately ¼ the price, and much better service, cleaner surroundings and better patient care. The point is, do the rich perceive the hospital as “Karamsad Civil”? Brand building exercise

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The brand building exercise for the hospital can be done by reinventing the mission and its core values. This would need decentralization in the process of the thoughts and also in its implementation to the ground reality. The core values can be as follows: Innovation: 

Intellect, imagination and creativity our credo;



High-impact ideas and achievements our basic reason of existence;



Value creation our way of life.



Patient satisfaction paramount;



Integrity in all we do;



Quality without compromise;



Outstanding execution always;



Accountability for our action.



Commitment to deliver all the time;



Strong work ethic the norm;



Focus on winning for everyone;



Our results speak for them selves.

Excellence:

Urgency:

Community: 

Teamwork by all;



Open and honest dealings;



Recognition and achievements;



Leadership at every level;



Caring for others;



Trust



Respect for the individual;



Everyone an owner, empowered to succeed;

Spirit:

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

Non-political meritocracy;



Fun environment;



Courage to be different.



Personal and professional opportunity;



Teaching organization; learning and knowledge, sharing a way of life;



Mentoring and guidance for all;



Open minded to new ideas.

Growth:

The vision and values thus above detailed and a description of the organization culture can feature on the organization’s web site so that any would be donor, employee, partner or patient has a clear expectation of the Charutar Arogya Mandal brand. These values can form a part of the organizations selection process. The goal at this stage is to determine whether there is a match between the individual and the organization’s values. We propose that there can be an employee induction programme, which should be built around these core values with the inputs from the different departments. The name can be “SPARK” (the acronym stands for - Shree Krishna Hospital: Performance, Achievement, Results; Knowledge). Making Shree Krishna a Brand for long time Brands are founded on the principle of certainty – the idea that the service one gets this week will be available in future also, is often hard to achieve. It is not often possible to order people to behave in an entirely predictable way. The situation is exacerbated as the organization grows in size and then the certainty becomes more fragmented. Generally, the driver for defining values is organizational growth. While a founder or founders can influence the organization when it is in its infancy or if it is small or medium in size, personally, when the organization grows over a period of time it becomes difficult to

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sustain that influence. The ideas of the founder become less pronounced and subsets of vision and values start to emerge within parts of the organization. This leads to lack of consistency in the presentation of the organization and consequently a lack of continuity of experience for customers. This inconsistency is often exacerbated once founder leaves the organization. This necessitates the initiation of a branding programme so as to save the ideas or values of its propounders. The brand idea can be a glue to hold different parts together. This does not create a world of rulebooks but rather a common set of ideas that can steer attitudes and behaviour. The assumptions and values that guided the founders and their decisions, can, if they are well articulated, become the assumptions and values of the employees. With respect to Shree Krishna Hospital it is necessary to start the process of making the values and mission permanent by projecting them in the form of a brand image. This is necessary as the organization is growing very rapidly and has increasing departmentalisation with more subsidiaries coming up. It is expanding in size and it is of utmost importance to permanently settle the idea and vision of the chairman and other visionaries in the minds of the people belonging to the organization.

Networking the Brand Branding is more complex at the strategic level. Shree Krishna Hospital has not only to manage its relation with patients but it has to take into account other stake holders such as donors, media, government, suppliers, buyers and employees of the organization. Each of these will have a different expectation and understanding of the brand. (See Fig.: 19)

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Fig. 19: Networked Brand

Marketing Communicatio n Donors

Competitor s

Partners

Consum ers (Patient s)

Physical Experienc e

Employee s

Retailers Digital Experience

People Consumers are not target markets devoid of any persona, they are individuals, some of whom act in similar ways when encountering a brand. The relationship between employees

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and consumers is therefore at the heart of the brand experience. Just as in a successful relationship, the employee/ patient relationship needs honesty, openness and a unity of interest. When the unity is intuitive with employees and consumers and they share the same passions, it is particularly powerful. For the organization to move to a stance where the consumer is the focus of its attention does not require archery target charts with the word ‘consumer’ in the middle. It necessitates an orientation where everyone thinks and acts like the consumer. This humanistic approach seems to have been lost in the often-militaristic jargon of professionalism and the abstraction that seems from ever-large organization. So, the outcome is that it is the need of the hour that all the functional departments and non-functional department work in unison to create something different. It can only happen when all the employees think in the same direction. The means can be different but ends should be the same. The Brand Model If the hospital focuses on the restructuring of its image and building a brand around it, it will involve in its purview not only the patients but also internal factors. It can be well explained by putting the Hospital in a Brand Model. The model demonstrates several important facets as to how branding works:  The identity of the organization will be formed by its personality, culture, philosophy, values and mission. This is the core of what an organization is.  This identity of the organization is transmitted to outside in terms of ‘brand idea’, which is the articulation of the unique attributes that make the organization what it is. The formulation of this brand idea can take different forms, but it is defined by the identity i.e. once SKH identifies its mission and core values the brand will be designed around them or it will reflect that.  The ‘brand idea’ is itself communicated through three key mechanisms: the nature of marketing communications, employees’ interpretation of the identity and the nature of the services. Although we can see that only one box is represented by the employees, the point to note is that service is also delivered by the employees. This clearly explains why it is important to integrate all the aspects of the organization’s system and processes so that there is a unity in the way the brand is presented.

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I I I UNPLANNED COMMUNICATIONS

IDENTITY

IMAGE Spontaneous governing council feedback

Org. Culture

Org. Philosophy

Employees View of Identity

Services Organization mission

Spontaneous governing council feedback

UNPLANNED COMMUNICATIONS

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Donors

Government Media Influential Groups

ACTIVITY

Feedback

Suppliers

Local Communities INTERFACE

Core values

Brand Idea

Patients

COMPETITORS

Feedback

Marketing Communication Strategy

IDENTITY IMAGE

Org. Personality

The three boxes inter-relate with each other, which stresses the overarching role of employees and also indicates the importance of internally marketing, externally marketing communications. Employees will not be able to support the public relations messages if they do not understand them.  As well as the planned communications of the organization, unplanned communications are also transmitted. These moments of truth are again determined by the identity and employees’ understanding of the brand idea.  The goal is to create an appropriate and effective image among variety of the stakeholders or in this case donors and community, which over time creates a favourable image or reputation for the organization.  There is ongoing feedback to the organization. The image and reputation will impact the identity and the way the employees see themselves.  The interface between identity and image is seamless, partly because of the fast flow information these days. The two-way flow indicates that the barriers that used to exist between the organization and the people have broken down and there has been more direct interaction. This will be enhanced by the introduction of online system in the hospital and more easy flow of information. The extranet being developed will also enable more effective communication with the professional audience such as suppliers and patients. So, it is clear from the model that although it is important to invest in the technology and building infrastructure it is more important to put focus on the people and the need for a clearly defined brand idea that engages employees and creates the right sort of image with relevant audiences. 16. SOCIAL WORKERS Very few of the patients could distinguish the social workers, as all the workers in the hospital, from the nurses to the kitchen staff are “ben”. As a result, a clear role definition of the social worker was not perceptible. The social workers had mostly been seen by the people attending the daily lectures at 11:30 as the “bens” who were organizing the health program. Other than this they are perceived to be an inquiry counter for information about the Krupa scheme.

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17. GRIEVANCE REDRESSAL When asked about the Grievance Redressal system, the patients replied that it was not really necessary because they could easily solve the grievance with the person right there on the spot, be it the nurse or the doctor, instead of going to someone with their complaint and having someone else investigate the matter. They felt this would take unnecessary time and that the Grievance Redressal personnel would in any case take the side of the hospital staff in the case of a dispute. 18. DESIGN OF A PATIENT SATISFACTION MODULE In order to carry out patient satisfaction studies in the future also, a module was designed for the Shree Krishna Hospital as a means to periodically evaluate the status of their performance as regards the patients. (Refer Annexures 3, 4 and 5) 19. SWOT ANALYSIS The SWOT analysis was performed to get an idea of what the hospital can bank on as its strengths, and what it will have to work on as its weaknesses. The opportunities and threats indicate how the immediate environment will affect the hospital. Strengths:  Good connectivity and accessibility  Single general hospital of such size in the area  Almost all minor treatment from beginning to end under a single roof  Modern equipments, labs and wards  Qualified mainline staff and diligent support staff  A good pool of professionals to choose from  Generous aid and donation  Quality OPD service  Affordable  Ability to respond to any obsolescence quickly  Dynamic and influential leadership

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Weaknesses:  Delays  High turnover of experienced doctors  No specialised services  Few linkages with other speciality hospitals  Weak promotion and marketing  Lack of empathy and customer care  Poor relation between management and doctors  High unutilized capacity  Poor past reputation  Dependence on external funding  Poor location  Bureaucratic functioning and adherence to procedures Opportunities:  Linkages with specialists and specialized bodies  Influencing government to maintain a quality check on private practitioners  Special packages for urban and niche segment  Generating a corpus fund from wealthy prospective donors in the area  Gaining autonomy as a medical college  Generating large number of nurses for self, internal and external market  Constantly upgrading the technology  The new Cancer project being marketed as the speciality of the hospital Threats:  Doctors leaving for private practice  Private lab technicians  Village quacks  High proportion of high risk referred cases  Decreasing disease incidence in the area

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 Running a 500 bed hospital in low disease prone area  Superior PR campaigns by competitors 20. CONFLICT AND COOPERATION There are 3 very important sets of people wherever a hospital is functioning. These are the doctors, the management and the patients. 2 of the 3 sets of people usually find it very difficult to get on with one another, especially since they are both qualified professionals. The doctors are the soul of the hospital. The slightest feeling that the management is not giving them enough freedom as professionals, or that they are being monitored by target setting and evaluation, leads to intense dissatisfaction and resentment. As professionals, doctors also have an ego that has to be respected and not trodden on, but also not allowed to get beyond a limit of acceptability. Management has to do a tightrope walk in order to keep the doctors within a frame of discipline while still giving them enough freedom to function without feeling suffocated. Unlike professionals in other bureaucracies, who are able to work according to targets and accept quantitative evaluation and monetary rewards, doctors often depend on intrinsic motivation for satisfaction and abhor having to work within set timings, and according to targets. In fact, a simple issue like the amount of time taken by a patient waiting for consultation could be considered a problem by the management and the patient. The doctor may feel that if the patient has come specifically to meet him, that he will not mind the wait, so long as he has the assurance that the treatment will be done properly. Doctor-management stress gets escalated in healthcare organisations that do not have a medico at the top management level. The management takes care of all the functional and support functions, leaving the doctors to do their clinical and teaching practice unperturbed by administrative issues. However, this sometimes leads management to think that the doctors are dependent on them for the proper functioning of the establishment. A little bit of callousness creeps in, and the doctors begin to feel that they are being treated as dispensable. The doctors then begin to perform exactly the way they would if they had been in a bureaucracy. They go strictly by the rules and if they are asked to do anything extra. They 69

look at it in terms of what they will get out of it. If they have the choice of doing something a little outside their usual scope of duties, they immediately say “That’s not my job,” and walk away. The management is also professional in its outlook. The management does not look upon the freedom which the medicos wish to have, as being healthy for the organisation. Management feels that it would be very easy for the whole system to go haywire if the doctors are allowed to exercise too much freedom. Doctors, like artists, consider themselves to be beyond the trappings of rules and regulations, and feel that there should not be hair splitting when it comes to their exercise of duty. To give a practical example, if a doctor works through his lunch break because there is an extra load of patients on a particular day, he would take the next hour off to compensate. If he were observed to be “off work” in that extra time, and that were taken into account by the management, the doctor would obviously be extremely frustrated. The third party is that patient. This set of people gets caught between the doctors and the management. Finally, as the main consumer or client of the hospital, he realises that there is some dissonance between them and that he is caught in the middle. There is also a certain feeling that patients/ clients in any service provider would like to get, that everyone in the organization is geared to serving him as best they can, and that they are working in harmony. Take the case of a 5 star hotel. The cooks and the waiters would not make an effort to deliberately get in the way of each others’ work because they would know that a combined effort was required of them to satisfy or please the client. This comes across strongly to the client, as he gets good food and good service. Similarly in a hospital, the patient wants cure, along with care and compassion. The latter can only come when the doctor himself is at peace so that he can focus solely on his patient’s well-being. The support staff would also have to learn and understand this. There is no such thing as “This is not my job”, unless the person is not qualified to do it because it is a medical procedure. If it just means sparing the patient some trouble, then why not go out a little extra way to do that? It is the extras that the organization provides which build customer loyalty. Today everyone can provide healthcare. Shree Krishna Hospital should look at what extra it can provide. Already, there is quite a bit of emphasis in this direction. It just needs to be implemented further.

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Conflicts which we have watched in the hospital are detailed below as an example of the sort of incidents which would keep recurring in the organization. A way has to be found for dealing with these in an amicable manner, with honesty between all parties involved. Doctors criticise the administration and the management for forcing the poor people to cough up enough money to meet the bill. The management says that it will go bankrupt if it continues to hand out largesse to all and sundry without at least making them pay the maximum that they are able to. The doctors then try ways of hoodwinking the management by changing the diagnosis, as in the case detailed below. The management accuses the doctors of manipulating the truth. The patients in the meanwhile are no fools. Even a PO in the Bank of Baroda gave a response that his income was just Rs. 5000 and that he wanted a discount on his bill because the charges were expensive. The poor say, “it is such a big hospital, they get donations, they get fees from the medical students, they can afford to give us something off on the bill.” Mithulbhai, an infant of 2 years suffers from acute asthma. His father had registered him under the Krupa scheme. Soon after, Mithulbhai had an attack and was hospitalised. Although asthma is a chronic ailment and Mithul was ineligible for any discount since Krupa does not cover chronic diseases, the boy was given completely free treatment. This happened a second time. The third time, the boy had an attack with more complications and was put in the Paediatric ICU where the charges mounted. He was there for over a month. The Krupa staff denied any further benefit as the amount of Rs. 5000 had almost been exhausted from the earlier incidences of the attack. The doctors then changed the diagnosis to some ailment that would fall under the benefit of the scheme so that at least the remainder of the amount could be met from the Krupa scheme. The administration was helpless. The doctors refused to budge and said that this was the final diagnosis. The benefit was given without further ado. However, it is incidents such as these, which give rise to bad feeling between the doctors and the administration. Both parties should be honest with each other and work in the best interest of the patients, while finding a way round such problems. There should be no deceit between the parties, not even for the benefit of the patient. This is because the patient will move out of the hospital in a while, but the bad feeling between the doctors and management will remain and prove a problem in future cases. It would have been better if

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both parties worked together to collect funds for the boy’s treatment through a collection from students, employees and the community. After collecting a certain amount from within the hospital, a feature on how the Mandal had collected some part of the amount could have been arranged. A request could be made to members of the community to donate the rest of the amount. This would have acted as a marketing gimmick and also attracted the goodwill of the community. Procedural Rigidity or Communication gap A lady from a wealthy background had to have a hysterectomy after which it was necessary to be given a unit of blood. Before the operation she had specified that she would only agree if her son’s blood were used, as she was reluctant to have a transfusion from any one else’s’ blood. The Blood Bank refused to allow this and insisted on giving only stored blood. As a result the lady was very upset. This might have been because the stored blood had been treated and brought to the correct composition for transfusion, whereas the freshly donated blood would take some time to be treated. However, this was not explained to the family, as a result of which there was quite a lot of bad feeling from their side. The administration blamed the Blood Bank staff for being too rigid. The Blood Bank staff blamed the administration for being ignorant. No one explained the necessity of taking the particular course of action. 21. CONCLUSION If we summarise the study we find that there exists a gap in relationship between the professionals and this affects the services and thus it fails in serving that extra which is needed to give the organization the image and repute of being a centre of excellence. If we focus on fig. 21 we observe that the patients are at the top of the triangle because they should be supreme in this organization. This is because the hospital cannot survive without patients. Fig. 21: Doctor-Management-Patient Triangle PATIENT Cure and compassion

Comfort and Cooperation

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DOCTOR

MANAGEMENT

Trust, Respect and Honesty, Participative decision making

Within limits of reason, the patient’s every requirement should be catered to. Doctors and management are together at the base of the triangle. This is because they are equally indispensable for the smooth functioning of the hospital. Any friction between the two and the triangle will collapse. So it is their responsibility to hold up the patients with concerted effort. So, in the above respect the study firstly focussed on trying to figure out the critical factors affecting the patients when they come to hospital. Next, it tried to identify the present status of the services and approach being followed as per the stated mission and objectives of the hospital. It came out that when the patient comes for the first time to the hospital he/she gets good impression given the good infrastructure and other support facilities. But, there is inconsistency in providing services, which is mainly because of coordination problems. This coordination problem could be in between departments or even within a department. One thing that should be kept in mind is that this is a service provider with a social significance, which makes the provision of timely and efficient services imperative. As far as the image is considered the study focussed on analysing the present image and then suggesting measures to position the hospital as a brand. Since the hospital is a general hospital having no specialised branch, there is no any unique selling proposition for the hospital. From the study it came out that the urban patients mostly go to the specialists for getting the treatment. As against them the rural patients primarily depend on local available doctors due to time and location factors. This generates the requirement that hospital should reposition its image and firstly focus on its output i.e. giving quality services rather than focussing on any target segment. Due to not having inward approach towards this goal it is losing its focus and ultimately failing to cater to any of the segments. Thus, keeping the above situation in mind, some of the recommended strategies which hospital should follow to reposition its image are:

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 Focus up on is improving the coordination between both the administration and medical staff. This is of utmost necessity and importance to give patients quality service.  There should be a committee comprising of the members from all the divisions and regular monitoring should be done of the activities and in case of any discrepancies a solution should be found out taking in viewpoint of both the management and medical staff rather than of any one section.  For brand repositioning the hospital should have some departments where speciality services are provided. This will give it an image of a speciality hospital with good general services. Once it is known of having some expertise it will be easy to spread out good word of mouth. The new cancer project would be a very useful opportunity for implementing this strategy.  Since, it is also very essential that employees should also be committed towards the mission of the hospital; there should be a well-designed induction programme, which would orient new entrants towards common goal and will instil a sense of responsibility.  The hospital should also take regular customer feedback. For this an excel sheet has been prepared by way of which the responses against different factors can be taken and entered. This will automatically give them regular feedback indicating where improvements are required

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