An Indian Tragedy, An Indian Solution - Perspective of Managing Service Quality in Emergency Medical Services in India

An lndlan 1ragedy, an lndlan SoluLlon/MclnLosh eL al 1
www.jqbcs.lofo [ISSN 2159-6743 (Online)] !Cu8nAL Cl CLC8AL PLAL1P CA8L S?S1LMS/vCLuML 2, nuM8L8 1, 2012

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An Inuian Tiageuy, an Inuian Solution:
Peispective of Nanaging Seivice Quality in
Emeigency Neuical Seivices in Inuia
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India, the worlds largest democracy and second most populous country, is in the midst of an
economic boom with gross domestic product growth averaging nearly 8% over the past several
years despite a worldwide recession. The World Health Organization (WHO) has predicted that
trauma case related deaths in India will move from ninth position up to the third position by 2020.
The organization structure for an improved national trauma system in India will depend on a
national inclusive strategy supported by resources and funding within a service quality framework
to win public trust. This must include an integrated nationally coordinated approach to the
organization of pre-hospital care facilities, hospital networking and communication systems, and
the organization of in-hospital care.

Keywords: Management of complex health care systems, trauma, India



An Inuian Tiageuy, an Inuian Solution:
Peispective of Nanaging Seivice Quality in
Emeigency Neuical Seivices in Inuia
India has yet to establish an effective system of delivering trauma care and emergency services to a
majority of its citizens despite its economic success (Narayan, 2011). A recent example of this is that of
three big tertiary level hospitals in New Delhi allowed a patient to die for want of treatment. In the first
hospital, he was refused treatment on the pretext of non-availability of an intensive care bed. At the
second hospital (a trauma center), he was refused treatment because the ultrasound machine was
apparently not in a working condition. The third hospital refused treatment because the medico-legal
papers were allegedly not complete. He was transferred from one hospital to another but denied
treatment on one or another pretext. He died in an ambulance without getting any treatment (Hindustan
Times, 2010). As Garg (2012) stated, the death of this patient symbolized the breakdown of the
emergency medical services (EMS) in India (p. 49). Macro perceptions of medical systems require a
positive public perspective of service from a patient (Jabnoun, Al Rasasi, Jun et al., 1998) that in turn
drives patient satisfaction that ultimately increases trust in the system (Spreng et al, 1996).
The aim of this article is to review the state of medical services in India and to consider the marketing
concept of service quality to emergency medical services with recommendations on how services might
be improved from a patient perspective. For the purposes of this paper, emergency medical services are
generally considered to include cardiovascular emergencies, neurological injuries, and trauma related
emergencies. The focus of this paper will be on trauma care services specifically.

Method

The method applied within this paper involved critical review of the secondary literature. The systematic
review provided an exhaustive summary of literature relevant to health system in India. The first step of
the review was a thorough search of the literature for relevant publications. Publications were assigned
an objective assessment of methodological quality using a rating system. The researchers kept a log of the
search strings used and the results. The search string yielded more than 100 references. Additional terms
(keywords) were added to the string to focus the search more accurately. Next, the titles and the abstracts
of the identified articles were checked against pre-determined set of criteria for eligibility and relevance.
To ensure that the searches undertaken were consistent and comparable, the method applied involved
keywords and phrases derived from the research topic. These were then placed into categories and
assigned keyword numbers to allow their strategic combination according to researcher impressions from
a preliminary literature trawl: keywords-1 were to be paired with every keywords-2 once. These were
managing service quality and Indian healthcare respectively.
The initial search returned a high number of references (70 or more), the second search was further
refined by adding keyword-3 (outcomes) to the search string (for example see, Chambers & McIntosh,
2008). Search logs were compared between researchers to ensure that the terms had been applied
consistently (Saunders et al, 2007). This research was refined to 30 articles which directly addressed the
topic under consideration.

Emergency: Medical Services in India
Emergency medical services are the immediate care that needs to be delivered to an injured or suddenly
ill person. Such care should involve a well-coordinated network of services providing medical assistance
from a primary response care to definitive trauma care. This involves efficient pre-hospital care before
reaching the hospital and more specialized in hospital care thereafter and before discharge. Pre-hospital


care should typically be provided by an emergency medical team consisting of doctors trained to
international standards on trauma life-support techniques, nurses, trained ambulance personnel and
paramedic units requiring highly advanced skills and specialized equipment. Improving service quality
in emergency medical care will help to save lives and minimize disabilities in patients after recovery
(Rehberg, 2007). More important however, is to ensure that people are aware of the existence of the
emergency medical service. Garg, (2012) noted an EMS that people are not aware of is as good as
nonexistent (para. 7). Gargs notion is particularly relevant to the poor, indigent and illiterate.
The increasing rates of urbanization and industrialization in India suggest that providing efficient
post trauma care is an important area of concern in India. Current statistics are difficult to obtain but the
National Crime Records Bureau in India reported that in 2010, at least 10.1% of deaths were due to
accidents and injuries. A total of 678,326 cases of Un-Natural Accidents caused 359,583 deaths and
rendered 503,932 people injured during 2010 with a male to female victim ratio of 78:22. Most of the
victims of accidents were in the economically active group aged between 15 and 44 years. This group of
people accounted 60.7% of all persons killed in accidents in the country during the year. This is a major
area of concern and hence efforts need to be made effectively to prevent accidents, and secondly, to
increase the service quality of emergency medical services in India (NCRB, 2011). These statistics should
be treated with caution, however, because they underrepresent to reality on the ground; they do not
reveal the true picture. A Report of the Committee on Crime Statistics by the Social Statistics Division
of the Central Statistics Office in 2011, revealed Minimisation and Suppression of Statistics, Favours to High
Ups, Monetary Considerations, Under Pressure from goons, gangs, mafias or other influential sections as some
of the reasons for under-, or non-reporting accidents and injuries in India (CSS, 2011, p. 18-19).
Government policy focuses on the prevention of communicable diseases rather prevention of trauma.
There are no government agencies to plan, finance, or draft legislation to establish an efficient national
integrated trauma care system in the country. This is specifically lacking in rural areas where accurate
statistics may be limited and under reporting common (Joshipura et al., 2003). Furthermore, there is
limited provision of accident and emergency care unit systems in the major cities and towns (Garg, 2012;
Wegman, 1996). Meeting the golden hour goal (first hour after injury) and the platinum hour goal (first
ten minutes after injury) determines the effectiveness of treatment in the trauma patients that is
frequently missed in India (Medindia, 2012). Delayed pre-hospital care such as delayed first-aid
treatment, delayed inefficient transfer of the victim to the hospital from the accident site and medico-legal
issues can lead to deterioration of the patients conditions leading to complication (Gururaj, 2005).
Additionally a systematic triage system to evaluate the trauma victim is followed only by fifty-four
percent of the hospitals. This is compounded by resource shortages because state public health care
policy falls short for the majority of trauma cases that leads to inefficient trauma-care service to those
people who cannot afford the cost of investigations and the admission costs in specialized hospitals
(Joshipura et. al., 2003). Consequently, the poor and indigent are deprived of necessary post trauma care
and treatment because they cannot afford the treatment cost. Often the hospital where the patient may be
admitted depends on the hospital fees that the patients family can afford and not on the type of injury
(Joshipura et. al., 2003). The mortality rate among low-income group is as high as 63%, compared to 55%
among the middle-income group and 35% among high-income groups (Mock et al., 1998).
The better survival and functional outcome among injured patients in developed countries can be
partly attributed to high-cost equipment and technology (Narayan, 2011). Much of this high-end
technology is unaffordable and unavailable to victims to the poor. Improvement in the outcome of
trauma patients can result from improvements in the organization of trauma care services in the form of
focused systems in specific geographical areas (Sasser et al., 2006). Better organization of systems may
reduce the time between injury and the definitive treatment thereby reducing morbidity and mortality. In
India, such a trauma system is almost non-existent and even if present in some urban areas, lacks the
cohesive effort required (Joshipura, 2006).

Framework of Service Quality Model of Emergency Medical Service
Services tend to be intangible, inseparable from their provider, perishable and inconsistent in their delivery
(Walker & Baker, 2001, p. 2). These qualities make services high in experience and credence qualities.
Patients therefore have greater difficulty in evaluating medical services generally and trauma services


specifically. Noting the unique nature of services, Levitt (cited in Gronroos, 2001) describes a service as a
promise of satisfaction (p. 3). As such, trauma services promise both implicit and explicit influence
patient expectations. Brown, Fisk and Bitners (1994) seminal work in clearly allied service satisfaction
with service quality, although the two do not share common definitions of terms nor is there clear
understanding in the literature of how the two relate.
Parasuraman (cited in Walker & Baker 2000), whose research has provided a framework for
measuring service quality in this paper, defines service quality as the gap between the consumers
expectations and their perceptions of how the service is performed (p. 1). Quality is therefore likely to be value
led in terms of perceived quality and availability of service to patients. It therefore follows that perceived
value in a trauma unit is a measure of the extent to which the medical service delivered meets the
patients expectations. The nature of a service means that the patient is physically present throughout the
care delivery process. Both the service outcome, as well as the service process influences the perception of
value. The perceived quality can be aligned with a continuum of unacceptable quality at one end and
ideal quality at the other with graduations of quality in between. This implies that prior expectations are
compared with actual service delivery and the service outcome and it is this comparison that leads to
perceived value. Thus, it is important that the management of the care service process occurs through
management of standards and controls be they regulatory or provider specific (Dorrian, 1996; Ghobadian,
Speller & Jones, 1994).
Quality is not a singular but a multi-dimensional phenomenon. It is not possible to ensure
organization specific quality without determining the salient determinants of quality specific to a service.
There are a number of models including those of Gronroos (1983), Lehtinen and Lehtinen (1991), and
Parasuraman (2002). Gronroos (2001) argues that service quality comprises three dimensions namely: the
technical quality of the outcome, the functional quality of the service encounter and the corporate image.
Lehtinen and Lehtinen also identify three dimensions namely physical quality, corporate quality and
interactive quality. They argue that it is necessary to differentiate between the quality of the process of
delivery and the quality of the outcome of the service (Ghobadian, Speller & Jones, 1994; Martin, 1999,
Walker & Baker, 2000). Garg (2012) further suggested that the reputation of a hospital often depends
upon the quality and promptness of its emergency medical services.
These attempts to identify the service quality determinants lack sufficient detail but are useful in the
separation of measuring both process and outcome in terms of quality. Other researchers such as
Parasuraman and Ghobadian, Speller and Jones have proposed more detailed quality determinants (e.g.,
see Ghobadian, Speller & Jones, 1994; Zeithhaml, 2000) wherein the importance and utility value of each
determinant is dependent on the nature of the service. Technical quality, functional quality and service
image form components of a service quality. Technical quality is the quality received by the patient when
the patient interacts with the service that leads to an evaluation of the service by that patient. The
technical outcome determines the functional quality that reflects the views of the actual service itself. The
technical and the functional quality of the service lead to building up of a service image in a broader
stakeholder context including those with no experience of the service delivery. Tradition, ideology, word
of mouth, pricing and public relation also contribute towards the building of that image (Gronroos, 1984).
Thus service quality is subjective and interpretative in the context of emergency medical services rather
than having an absolute clinical perspective.
An analysis in terms of the current state of emergency medical services, using the general model of
service quality structure as proposed by Parasuraman, et al. (1988), is shown as Figure 1. Emergency
medical services quality has impact on all the three phases of its interaction with patients. RATER and
the three phases of emergency care have been chosen for this review because of its simplicity and
appropriateness to the characteristic demands from emergency medical services. The dimensions of the
RATER Model include reliability, assurance, tangibles, empathy, and responsiveness (Nitin Seth, et al.,
2004).



Figure 1. The RATER Model- Service Quality Dimensions Applied to Emergency Medical Services.
Note. Adapted from Parasuraman et al. (1988) and Nitin Seth, S. G. Deshmukh and Prem Vrat (2005).

Figure 2 illustrates the emphasis in managing service quality at each phase of emergency medical
services: Phase One being the awareness, trust and initial accessing the care, Phase Two being the in
hospital care and Phase Three discharge and rehabilitation.


Figure 2. Framework of service quality model of emergency medical services.
Note. Adapted from Nitin Seth, S. G. Deshmukh and Prem Vrat, 2005.

Discussion

There is no overarching national agency to coordinate an efficient trauma system, and no accreditation
bodies for trauma centers and physicians in India. Physicians in general suffer from poor education in
trauma life-support skills, inadequate resource allocation and poor infrastructure that limits access
(Joshipura, et al., 2003). There are gross disparities between trauma services available in various parts of
the country. Major industrialized cities and towns have developed trauma care centers have relatively
good infrastructure for hospitals and roads, but traffic congestion and poor organization of trauma care
have led to access problems. Rural towns and villages are isolated from mainstream systems, with little or
no access to clean water or electricity, let alone health care facilities (Gururaj, 2005; Narayan, 2011).
The organization structure for a trauma system includes the organization of pre-hospital care
facilities, hospital networking, communication systems, and the organization of in-hospital care (acute
care and definitive care) (Narayan, 2011). The trauma care system in India has to go a long way to ensure
integrated, efficient and functional emergency care to all the people in the country including those
residing in the rural areas. Key limitations for easy access of the emergency care in India include
insufficient doctors skilled in trauma life-support skills, inadequate resource allocations and poor
infrastructure. New policies and laws need to be enforced to accredit trauma care facilities in all the cities,
towns and villages. Legislative steps are the only ways of enforcing efficient emergency care units in the
country with supporting funding (Joshipura et. al., 2008).
Therefore, improvements in the field of trauma services are needed to ensure Golden hour and
Platinum hour compliance for all trauma victims as an achievable goal by coordinating activities
between pre-hospital care and specialized hospital care services (Medindia, 2012). A national strategy and
regulatory framework through which to achieve this, together with the physical resources for pre-
hospital care and communication systems are key factors. The management of care pathways across
service quality dimensions and measures from a clinical and a patient perspective requires well-trained
staff within an accredited framework at all levels of care from pre-hospital to definitive trauma care if


public trust, reliability and awareness of access is to be achieved. It follows that a regulated skill-based
training program for doctors as well as paramedical staff in emergency medical services procedures is
implemented to organize and integrate pre-hospital services with definitive care facilities (hospital) so
that a patient is shifted to an appropriate facility in the shortest possible time, regardless of the ability to
pay. A systematic triage protocol should be made mandatory in all trauma units (Joshipura, 2008).

Conclusion

From the above review, it has been highlighted that in India there is significant work to be done in the
fields of medical treatment and quality of patient care. The field of trauma care and emergency medicine
has not progressed uniformly in the country and it is still at a primitive stage. The importance of reliable
emergency medical services cannot be over emphasized, especially where the government has the
responsibility of caring for a majority of the population.
Service quality of the trauma care system in India can be improved by increasing resources available
for the treatment of the trauma victims. The technical quality should meet the functional quality of
hospital services thus enhancing image of the trauma care system and trust from citizens (Nitin Seth et
al., 2004). The United Nations General Assembly and the WHO have implemented an action plan A
Decade of Action for Road Safety 2011-2020 by member nations and thus the quality of emergency
medical services generally rather than road safety specifically, should be considered a high priority and
different mechanisms for its implementation throughout the country needs to be devised.



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