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Article information:
To cite this document: Mosad Zineldin, Hatice Camgz-Akdag, Valiantsina Vasicheva, (2011),"Measuring, evaluating and improving
hospital quality parameters/dimensions - an integrated healthcare quality approach", International Journal of Health Care Quality
Assurance, Vol. 24 Iss: 8 pp. 654 - 662
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IJHCQA
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654
Received 11 November 2008
Revised 1 December 2008
Accepted 13 January 2009
Hatice Camgoz-Akdag
Department of Business Administration, Istanbul, Faculty of Economics and
Administrative Sciences, Kadir Has University, Turkey, and
Valiantsina Vasicheva
School of Social Sciences, Linnaeus University, Vaxjo, Sweden,
Abstract
Purpose This paper aims to examine the major factors affecting cumulative summation, to
empirically examine the major factors affecting satisfaction and to address the question whether
patients in Kazakhstan evaluate healthcare similarly or differently from patients in Egypt and Jordan.
Design/methodology/approach A questionnaire, adapted from previous research, was
distributed to Kazakhstan inpatients. The questionnaire contained 39 attributes about five
newly-developed quality dimensions (5Qs), which were identified to be the most relevant attributes for
hospitals. The questionnaire was translated into Russian to increase the response rate and improve
data quality. Almost 200 usable questionnaires were returned. Frequency distribution, factor analysis
and reliability checks were used to analyze the data.
Findings The three biggest concerns for Kazakhstan patients are: infrastructure; atmosphere; and
interaction. Hospital staffs concern for patients needs, parking facilities for visitors, waiting time and
food temperature were all common specific attributes, which were perceived as concerns. These were
shortcomings in all three countries. Improving health service quality by applying total relationship
management and the 5Qs model together with a customer-orientation strategy is recommended.
Practical implications Results can be used by hospital staff to reengineer and redesign creatively
their quality management processes and help move towards more effective healthcare quality strategies.
Social implications Patients in three countries have similar concerns and quality perceptions.
Originality/value The paper describes a new instrument and method. The study assures
relevance, validity and reliability, while being explicitly change-oriented. The authors argue that
patient satisfaction is a cumulative construct, summing satisfaction as five different qualities (5Qs):
object; processes; infrastructure; interaction and atmosphere.
Introduction
Healthcare satisfaction has gained greater importance, especially in developing
countries. It is both a service quality indicator and a quality component. Strong
healthcare systems enable healthcare providers to deliver better quality and value to
patients (Radhika et al., 2007). Improved health status and patient satisfaction
measures are ongoing concerns for hospital staff as quantitative and qualitative
techniques are applied in continuous process improvement cycles (Deitrick et al., 2005).
People are dying daily following uncontrollable events such as automobile accidents or
chronic disease, but deaths following medical errors are preventable and a nations
healthcare system must reach the point where no patient will ever be a victim (Radhika
et al., 2007).
Competitiveness among healthcare organizations depends on patient satisfaction,
which is created by responding to patient views and needs, continuous healthcare
service improvement and overall doctor-patient relationship (Zineldin, 2006). The
challenges achieving healthcare excellence are many and difficult. Trusko et al.(2007),
for example, report how errors are difficult to measure for several reasons such as
inadequate reporting and varied definitions. Further complications arise because most
errors are not a single act but a chain of events. There are structure, personality,
patient and provider problems to consider. Demographic changes, political
environment, healthcare quality social perceptions and information technology can
dramatically change healthcare. All this creates a complex situation in which we assess
healthcare by analyzing patient satisfaction what is valued by patients, how they
perceive service quality and how these can be improved.
Our aim in this article is to examine the major factors affecting patients perception
of cumulative summation. The factors included in this summation include: technical;
functional; infrastructure; interaction and atmosphere in Almaty hospitals, adopted
from previous research (Zineldin, 2006) in Jordanian and Egyptian hospitals. This
research contributes to previous academic healthcare sector studies and quality
management in two ways: Zineldins (2006) model, including patient-physician
relationship behavioural dimensions and patient satisfaction, will be reviewed and
analyzed; and we empirically examine major factors affecting cumulative satisfaction
to address whether Kazakhstan patients evaluate healthcare quality similarly or
differently than Egypt and Jordan patients. Results can be used by staff to improve
healthcare quality and patient satisfaction by setting healthcare quality strategies.
Kazakhstan healthcare
Kazakhstan is an independent, central-Asian republic. It neighbours Russia, which has
a long border to the north, China to the east and Kyrgyzstan, Uzbekistan and
Turkmenistan to the south. The population was estimated as 14.8 million in 2002
(UNDP, 2002). The main population is diverse:
.
Kazakhs (52 percent);
.
Russians (31 percent);
.
Ukrainians (4 percent);
.
Germans (2 percent); and
.
11 percent others (UNDP, 1997).
The Kazakhstan population has decreased during the 1990s owing to lower birth rate
(UNDP, 1997) and migration.
Measuring
hospital quality
parameters
655
IJHCQA
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656
Kazakhstan possesses enormous fossil fuel, mineral and metal reserves. The
country enjoyed strong economic growth owing to the booming energy industry
(Euromonitor International, 2007). Industrial sector managers hope to develop these
natural resources, while new trade ties are being sought with markets outside the
former Soviet Union. Kazakhstan has a promising economic prospect, given its vast
natural resources (Kulzhanov and Healy, 1999). Economic growth led to rising
consumer incomes, which consumers them to buy expensive over-the-counter
healthcare products (Euromonitor International, 2007).
Kazakhstans health indices, since the 1950s, generally improved, but have
deteriorated since the 1980s (McKee et al., 1998). In 1996, over 30 percent of the
Kazakhstan population had incomes below the poverty line according to a World Bank
funded National Living Standards Survey (UNDP, 1997). Life expectancy fell against a
continuing rise in EU countries. However, life expectancy is higher compared to lower
middle-income countries such as neighboring Turkey (Kulzhanov and Healy, 1999).
An extensive healthcare system developed during the Soviet era was state-owned
and centrally planned. The key principles were that services should be accessible to
everyone and free (Kulzhanov and Healy, 1999). Before independence, the Kazakhstan
Ministry of Health administered Moscow policy through a centrally organized
hierarchical structure, from the republic level to oblast/city administrations, then to the
subordinate level (World Health Organization, 1994). In the 1980s, the system began to
deteriorate and its management problems became apparent. The health sector
traditionally had been assigned low priority compared to other productive
economies. As budgets became tighter, healthcare services could not meet demand and
facilities were forced to unofficially transfer costs to the population as user charges
(Kulzhanov and Healy, 1999). The Committee of Health lacked capacity and power to
implement a comprehensive national health strategy. Messages from President Nur
Sultan Nazarbayev set out broad goals such as Kazakhstan 2030 and Health of the
Nation. The Kulzhanov and Healy (1999) report concluded that service quality
improvements are not evident especially since retraining healthcare professionals has
only just begun, with healthcare staff still experiencing poor working conditions and
low salaries that are not conducive to raising standards.
Currently the United States Agency for International Development (USAID) is
working with the Ministry of Health to revise health service clinical practice guidelines
to meet international standards. Primary healthcare doctors are being trained in family
medicine and small groups from academic institutions are being prepared as family
medicine teachers for medical and nursing schools. The USAID quality improvement
efforts are continuing by training healthcare staff to improve clinical practices focusing
on maternal and newborn services, family planning and disease management (United
States Agency of International Development, 2007).
5Qs model
Service quality in the literature is commonly attributed to two dimensions: technical
and functional (Gronroos, 2000). Technical quality is what the customer buys and
whether services fulfill their technical specifications and standards. Functional quality
describes how service products were delivered; i.e. service-customer relationships. The
SERVQUAL model is multidimensional and its operationalization means that many
variables have to be considered (Zineldin, 2006). However, the 5Qs model is an
instrument that assures reasonable relevance, validity and reliability, while being
explicitly change oriented. The interaction process between service provider and
receiver is influenced by specific environmental atmospheres where both operate (Ford
et al., 1998; Zineldin, 2000, 2004; Robicheaux and El-Ansary, 1975). This is applicable in
a hospital, medical center or private medical clinics where patients and healthcare staff
work (Zineldin, 2006). The atmosphere can affect perceived service quality by
improving or by making it worse, which affects health. Healthcare service quality
depends on staff, buildings, waiting rooms, technical apparatus, etc. Healthcare quality
and patient satisfaction are more involved than just dividing service quality into
technical and functional. Zineldin (2000) expanded technical-functional and
SERVQUAL quality models into a five quality dimensions (5Qs) framework:
Q1. Object technical quality (what customers receive), which measures
treatment; the main reason why patients visit hospitals.
Q2. Processes functional quality (how healthcare staff provides core services). It
measures how well healthcare activities are implemented.
Q3. Infrastructure basic resources needed to perform healthcare services.
Q4. Interaction information exchange (e.g. percentage patients told when to
return for check-ups, time spent by physicians or nurses understanding
patient needs), financial and social exchange.
Q5. Atmosphere relationship and interaction process between parties are
influenced by specific environments where they operate. In developing
countries, unfriendly atmosphere explains poor care. Consequently,
atmosphere indicators should be considered critically.
Method
Our aim was to examine the major factors affecting patients perception of cumulative
summation. We tried to figure out whether there is any similarity among Kazakhstan,
Egyptian and Jordanian patients. This study concerns Kazakhstan inpatients. A
questionnaire, adapted from Zineldin (2006), was distributed. Our questionnaire
contained 39 attributes about five newly developed dimensions (5Qs), felt to be most
relevant to hospitals. The questionnaire was translated into Russian to provide a better
understanding, increase response rates and improve data quality. The sample size was
250, enough for statistical analysis. In total 195 usable questionnaires were received.
We used frequency distribution, factor and reliability analysis to analyze our data. One
variable (expressed as percentages) was considered at a time to obtain responses
associated with different values. As frequency distributions are a descriptive, we show
how respondents perceive each attribute related to healthcare quality. WE used factor
analysis to transform original into new, correlated variables called factors (Malhotra,
2007), which are used to identify key points emerging from questionnaires. Factor
analysis is an interdependent technique where all independent relationships are
examined. It identifies how patients perceive hospital quality and major points where
hospital staff need to improve. Reliability tests were used to examine the extent to
which scales produce consistent results if measurements are repeated. Reliability tests
were applied to all 39 attributes. In short, factor analysis discovers which 5Qs
dimensions are perceived important in Kazakhstan.
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Factor 1: Infrastructure
The highest loading factors were rooms appearance and hospital cleanliness the
patients biggest concerns. Forty-one percent said rooms were average; 25.6 percent
said it was bad and 11.8 percent said very bad. Almost 31 percent rated hospital
cleanliness average; 26.2 percent bad and 12.3 percent very bad.
Factor 2: Atmosphere 1
This factor related to staff attitude towards Kazakhstan inpatients. The highest
loading factor was nurses politeness; second was other hospital staff politeness and
third was physician politeness. Almost 35 percent said that nurses politeness was
average and 25 percent said it was good. Hospital staff politeness was perceived as 37.9
Component
Table I.
Rotated component factor
matrix (only significant
components are
displayed)
0.742
0.636
0.709
0.658
0.710
0.742
0.629
0.666
0.766
0.752
0.640
0.681
0.661
0.746
0.721
0.659
0.688
0.705
0.601
0.650
0.670
0.740
0.673
0.809
0.877
0.833
0.645
0.800
0.761
Factors
Factor 1
Factor 2
Factor 3
Factor 4
Factor 5
Factor 6
Factor 7
Factor 8
Factor 9
percent average, 19 percent good and 19.5 percent bad. Physician scores were 31.3
percent average and 30.8 percent good.
Factor 3: Interaction
Waiting time for refunds had the highest loading. Time staff spent understanding
patient needs was second. When refunds were the subject, 40.5 percent felt it was
average and 27.7 percent bad. Staff understanding was rated average by 41.5 percent
and 22.6 percent said it was bad.
Factor 4: Process
The highest loading was speed and ease of discharge. The second highest loading was
given to the component related to time between admission and getting into your room.
Discharge was judged average by 39.5 percent and bad by 26.7 percent. Time between
admission and getting to rooms was 35.9 percent average and 29.7 percent bad.
Factor 5: Atmosphere 2
Even though atmosphere was mentioned in the second factor, it occurred again to
stress its importance in hospitals. The highest loading was family sleeping
accommodation, which was perceived as 21.5 percent bad, 20.5 percent very bad
Measuring
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parameters
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Table II.
5Qs model attributes and
corresponding factors
IJHCQA
24,8
and 38.5 percent average. The second highest loading was room pleasantness and
appeal; rated 40.5 percent average, 21.5 percent bad and 19.5 percnet very bad.
660
Rank
Dimensions
Question
Critical Percentages
Infrastructure
Visitor parking
Process
Atmosphere
Process
Infrastructure
Food taste
Atmosphere
Interaction
Atmosphere
Infrastructure
10
Infrastructure
Food temperature
staff concern for patients needs, parking facilities for visitors, waiting time for refunds
and food temperature were all common shortcomings for patient satisfaction in all
three countries.
A strategy to improve Kazakhstan hospital patient satisfaction is focussing on
infrastructure (Q3) and atmosphere (Q5), which are also concerns in the other two
countries. Zineldin (2006) felt that Egyptian and Jordanian patient satisfaction data will
be helpful for Kazakhstan hospitals because the most critical healthcare shortcomings,
which lead to patient dissatisfaction, are the same. Healthcare service improvement is
achieved by applying total relationship management (TRM) and the 5Qs model with a
customer orientation strategy. According to TRM, improving quality and patient
satisfaction requires good atmosphere, infrastructure and relationships between
physicians, nurses and other hospital employees. All health service personnel should
be included in developing guidelines and measuring standards (Longo, 1994).
We used the 5Qs model to measure patient satisfaction with medical care; also used
in the Egyptian and Jordanian studies. The 5Qs model encompasses technical,
functional, interaction, infrastructure and atmosphere qualities and services. The
results can be used by hospital managers to reengineer and redesign their quality
management processes. This model is just a short-term initial improvement step. For
long-term benefits, service quality should be continuously measured and improved.
Our study focuses on service quality measurement. However, cost measures, physician
and nurse performance, and salary distribution might also be measured in detail.
References
Deitrick, L., Ray, D., Stern, G., Fuhrman, C., Masiado, T. and Yaich, S.L. (2005), Evaluation and
recommendations from a study of a critical-care waiting room, Journal of Healthcare
Quality, Vol. 27, pp. 17-25.
Measuring
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Table III.
Most critical healthcare
shortcomings
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