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22ND MARCH, 2010

The Study was carried out by

Dr Cynthia Bannerman - GHS

Mrs Susana Larbi Wumbee -GHS
Miss Anna Plange - GHS
Mr Yaw Brobbey - GHS
Miss Nana Yaa Konadu - Ecobank
Ms Marina Osei National Service Personnel
Winifred Asare National Service Personnel
Comfort Boye National Service Personnel
Alberta Sarpong National Service Personnel

Chapter 1 Introduction and Background


The Ghana Health Service has been concerned with the recent public outcry of negative

staff attitude in its health facilities and has instituted a customer care program and other

strategies to help improve client services. Mystery shopping was conducted in twelve

purposively selected government hospitals and polyclinics in the Greater Accra Region.

The study will provide baseline information on customer care practices in these facilities

which will be used to review customer care training program and also to improve

customer care practices within health facilities as well as building on positive

performances observed

Mystery shopping is the art of obtaining information on customer service, It is designed

to capture the experience of customers and staff, and measure their satisfaction level

and performance. It helps to gain insights into their experience at various points of

interaction in a particular service environment (Wilson and Guttman 1998).


In recent times the word “customer care practice” has attracted much attention in the

service industry. The word “customer” has therefore been adopted for clients to give

credence and focus on their needs with the view of satisfying them. Customer

satisfaction has now become the priority of every service institution (Goodsell 1998).

The reason can be due to obvious competition among institutions offering the same

service. The customer in this perspective has a choice and would patronize the

institution that satisfies his or her needs.

It is not surprising that customer satisfaction has become the core goal in organizations.

This is because satisfying a customer enhances an organization’s reputation and

reduces loss of revenue because it is likely for the customer to return and even bring

along new ones. Exhibiting poor staff attitude can discourage clients from coming back

again. Poor staff attitude has created a bad public perception of health care workers in

Ghana. The evidence reflects in comments by the public following health staff rampant

strike actions, discussions on radio and television programs (Mmaa Nkomo) and reports

of service providers to their regulatory bodies by clients. Health service providers

explain that their work schedule is too much to allot them enough time to relate well with

their clients. Others have also cited long working hours and low incentives as some of

the reasons that hinder them to engage to come out with their best. These may be

genuine concerns but in spite of these the public reaction clearly indicates that their

confidence in health staff is eroding fast.

The Ghana Health Service is committed to the delivery of client focused, quality health

services. In the provision of services the clients’ needs and expectations must be met. It

is therefore important that health staff promote good relationship with clients, their

support persons, communities and even fellow health workers. Such an approach will

not only promote good customer relations but enhance the corporate image of the GHS.

It is based on these developments that the customer care program was launched. A

training manual, posters and video tapes for customer care training of all health care

providers within the Ghana Health Service outfit has been developed by a task team at

the headquarters with support from Ecobank. The training manual was pretested at

Tema General Hospital. However it is necessary to have some baseline study before

training is rolled out to the other health facilities. The information will be used to improve

the training program and customer care practices. It will allow for evaluation at the end

of the training in order to assess how the training has impacted customer care practices

at the health facilities.


One aspect of organizational performance that receives less attention in the actual

process of service delivery is customer care. The quality of customer service provided

by frontline staff to citizens should be important to administrators because “courtesy and

friendliness become important not as ends in themselves, but because customers

delight in courteous and friendly treatment and uses them to assess quality of service”

(Fountain 2001).

Poisant (2002) suggests that “to analyze customer, or citizen experiences, an

organization must put itself in citizens’ shoes and ask questions about how they are

greeted, the appearance of frontline staff, and the aesthetics of the office place”. Such

an approach is usually achieved by “Mystery Shopping”. Mystery shopper, or secret

shopper, is an independent contractor who visits your establishment unannounced,

interacting as a customer to provide objective quantitative and qualitative feedback

about the experience (Grove and Fisk 1992).

A mystery shopper makes inquiries and observations and notes specific details about

the reception, environment and the level of customer service provided. How much time

elapsed before the mystery shopper was greeted, and what was the tone of the

greeting? Was the secret shopper treated courteously throughout the visit? Were the

service providers knowledgeable about their work, and did they provide effective

assistance? Was the location clean, organized, and ready to welcome customers?

www.Beyondhello.com/services The literature on mystery shopping indicates that

organizations use it as customer surveys or a feedback technique that focus on the

process of service delivery rather than on the outcome of a service encounter.

To undertake mystery shopping it is important to identify the standards most important

to customers and most critical to the success of your organization. This is used to

produce a standard set of questions with marks allotted to each question. At the end of

the mystery shopping assignment, the shopper completes all information on the


Mystery shopping is not all about finding faults in performance and decor, so they can

be corrected, however capable and experienced the ‘shoppers’ it is also for what’s

being done right! That’s because it’s easier to build on positive performance (e.g.

smiling during conversations and personal interviews (Rouleu 2007). It can be used

anytime and at anyplace and considered as a performance evaluation tool over time. It

can therefore be re-used as appropriate to ensure positive customer care experience by

clients. http//www.Manufacturedhousing.org

Mystery shopping can be seen as a participant-observer evaluation method that can be

used to measure the quality of customer service provided by frontline staff (Grove and

Fisk 1992). Mystery shoppers can be thought of as participant evaluators who make

multiple, covert observations that focus on the service-delivery aspect of programmatic

effectiveness (Patton, 1990).

There are three schools of thoughts on who should be mystery shoppers. One aspect

says professional shoppers should be used because they are almost always capable,

experienced and motivated people. Others prefer to employ freelance personnel as

shoppers who are employed to work for realty fee. This is best done by staff who’ll take

the time to train and practice with a novice shopper. There’s also the “do it yourself ”

approach to mystery shopping this is less expensive, less detailed, far less effective, but

easier to schedule (Leeds, 1995)

Mystery shopping uses a trained observer posing as a client or customer to contact

agency offering service. The technique focuses on “activities and procedures that do or

do not occur rather than gathering opinions about the service experience” (Wilson 2001)

In addition to this fundamental training, the nature of mystery shopping requires

shoppers who are “objective, smart, and able to think on their feet” (Leeds 1995).

The validity of the mystery shopper technique hinges on the employee believing that

the observer is in fact a real customer, not an “undercover” evaluator. To both protect

the anonymity of the shopper and to increase positive interactions, mystery shoppers

may follow a script, or scenario, to solicit responses from the employee or service

providers. Immediately after the interaction, the shopper or evaluator rates the quality of

customer service received based on an established set of criteria.

Although mystery shopping is a valuable tool for assessing the quality of customer ser-

vice, its influence can be short-lived. Without an ongoing commitment from

management to reinforce service standards, “the novelty of being shopped can wear off,

leaving personnel complacent about their service and lacking motivation to take steps to

improve it further” (Wilson, 2001). The technique of mystery shopping perhaps works

best when coupled with other measurement devices, such as general customer service

surveys, and followed up with a concentrated training component for management and

staff alike.

The importance of quality customer service in the health sector cannot be overstated.

Because any given citizen only periodically comes into contact with health personnel,

those few experiences are greatly influential on that citizen’s perception on the quality of

care. For this reason, any Mystery Shopping program serves as a valuable

measurement tool for continuously assessing employee-customer interactions. If the

program is replicated, participants are encouraged to take responsibility for seeking

ways to use the data produced by the shoppers to routinely address areas needing




Customer care as a service discipline has not received much attention in health care

delivery in the country until recently when efforts have been made in health service

delivery to offer client focused services to clients. The problem of poor customer care

has to do with the professionally and technically oriented nature of the training of health

workers with little or no emphasis on customer care in the nation’s training institutions.

Thus the average health care worker is not exposed much to the principles of customer

care during training or even given adequate in–service training on customer care during

employment. This means that the average health care worker, though adequately

equipped with what (technical skills) it takes to deliver the service, they lack the

customer care skills of service delivery. This factor among many others is what has

contributed to poor staff attitude and bad customer care practices.


The rampant corporate problem that destroys an organization’s reputation, morale and

services is poor staff attitude which often generates customer complaints. The

challenge is therefore to build a culture that uses customer concerns as an opportunity

for even greater service and loyalty, also creating team pride and an identity that

relishes excellent service. The health service encompasses different sectors, the

output of each area is crucial to maintain a good reputation. Poor work ethic is an

affront to an enthusiastic competent health service whose frontline staff approach their

work with a genuine desire to serve clients to ensure customer satisfaction. Mystery

shopping is a strategy that is undertaken to know whether services meets customer

needs. The results help to plan and evaluate effective customer care programs, improve

facility performance and tailor customer service training for employees.


• Assess customer care practices in selected health facilities

• Collect data to improve on GHS Customer Care Program for health care


• Provide a baseline to evaluate the effect of customer care training program on

customer care practices in the selected region


Twelve health care facilities was purposively selected for the Mystery shopping. They

are Ridge hospital, Adabraka polyclinic, La polyclinic, Kaneshie polyclinic, Maamobi

polyclinic, Tema hospital, Ashiama Health Center, Dansoman Health Center, Korle-Bu

polyclinic, Usher Fort Clinic, Amasaman hospital and Madina Health Center. The scope

of the mystery shopping was limited to the Out Patient Departments of these facilities.

The focus on the outpatient is because that is where majority of patients are seen.

A mystery shopper initiated an interaction with a service provider in obscurity at the

O.P.D. The anonymity of the mystery shopper was essential to get the right information

that depicts the reality on the ground. The encounter was to know how clients are

treated when they come into contact with service providers, in other words the details of

what actually occurs at the key moment of customer - health provider interaction. The

interaction afforded the opportunity to also examine the appearance of the facility.

A total of four National service persons were trained to undertake the mystery

shopping. One day training session was organized for them to know how to carry out

mystery shopping. Each trained mystery shopper visited six health facilities that was

not familiar to her as a sick person and went through the process on OPD consultation.

This strategy was to make the mystery shopping effective.


Purposive sampling was used for data collection. Each health facility was visited twice

a day that is morning and afternoon by different mystery shoppers. This approach was

to have a blend of what happens during the morning and afternoon at the Out Patient

Department. The mystery shoppers used a questionnaire that reflects the benchmarks

of the customer care. They reported back with detailed and objective information that

helped to determine how their experience measured up to the customer care service



Names of individual staff were not collected and findings not linked to individuals.

Data collected was available only to the research team. The immediate benefits will be

to improve customer care practices to patients/clients. It will also help improve content

and evaluate the customer care training program for staff and will contribute in the long

term to improve the image of GHS health facilities. The risks involved were negligible

with no harm to individuals or the facilities. The findings were not to be used to penalize

any member of staff or health facility.


The findings of the Mystery shopping are presented under the following headings

according to the questionnaire used by the Mystery Shoppers.

4.1 External and Internal Appearance of the Hospitals

The external appearance of the hospital compounds was generally clean; dustbins were

covered and placed at vantage points. However, in one or two of some of the dustbins

were not covered especially the small bins therefore those places were littered in other

places the dustbins were inadequate.

Most of the facilities have clearly visible directional signs to the entrance

The following were observed with some sign posts

• Fading

• Covered by tree branches or telephone pole

• Overshadowed by advert of the sponsoring company

There was sale of food at the entrance of a few facilities and in some instances

peddlers were selling toiletries.

With the internal appearance most of the floors, windows, counters and furniture were

clean. In only a few facilities were some furniture and windows found to be dusty. The

facilities have internal directional signs showing clients to service areas which are

labeled. A few of these signs had their writing peeling off

4.2 Registration and Waiting Areas

Patients were seen in the mornings and afternoons but in one facility after 1.20pm the

nurse asked patients to go to a nearby private hospital as the only prescriber on duty

was tired since he has been working from morning

There were two cards in use the old card and the new GHS folders. The fee schedule

for the various facilities and type of cards issued are shown in table 1.

Table 1 Fee Schedule

Type of facility Morning Fees Afternoon Fees

Hospitals (folders) GHc4 (2), GHc 5.50 (1) GHc4 (1) GHc5 (2)
Polyclinics (Cards) GHc2 (2) GHc3 (1)

GHc 3.50 (1) GHc4 (1)

GHc 5 (1)

Polyclinics +HC (Folders) GHc5 (2) GHc5.05 (1)

The fees were not standardized across board and even in 2 of the facilities the charges

were different for the morning and afternoon visits. “The amount charged on registration

is GH⊄ 5.00 in the afternoon and GH⊄ 4.00 in the morning, receipts were issued”. Yet in

another facility the morning fee was GHc5.50 and afternoon fee was GHc5

Receipts were issued in all facilities. It was surprising to find that some of the receipts

did not tally with the amount paid. Unfortunately mystery shoppers did not check

immediately what had been written on the receipt, it was when they had reached home

that this was noticed “I was issued a receipt but on the receipt, GHC 5.05 was written

instead of ¢5.50p”.This happened in 2 different facilities and the circumstances at that

time did not indicate human recording error.

The mystery shopper who used her NHIS card did not pay any registration fee and was

not treated differently from fee paying patients

Another practice that was observed was the lamination of identity cards at the records

department. The lamination fees charged were GH⊄ 0.30p, GH⊄ 0.50p and GH⊄ 1, No

receipts were issued. These fees were optional or compulsory depending on the facility.

Record staff in a facility were buying second hand clothing and did not even
acknowledge the presence of patients.

4.3 OPD waiting room/ screening area

In most of the facilities, morning devotion precedes the day’s activities during that time

every activity come to a halt. After that a nurse gives health education talks and shows

the patients where they can locate the washrooms, lab, X ray etc.

There were bulletin boards in several facilities where posters on health education were

displayed however there were no health education leaflets for patients/clients to read

whilst waiting or to take home. Some posters were scattered on the walls and some of

them look very old and worn out.

Facilities also had television sets in their waiting rooms. The televisions were either

switched off or showing films.

Suggestion boxes were also present at the OPD but had no papers and pens.

Most facilities have their O.P.D crowded with poor ventilation. The place can be very

hot. They were delays at the OPD; Some OPD staff did not call patients according to

the queue as they favored some patients over others. This made waiting clients to be


There was an incident where the mystery shopper was not present when the nurse

called out her name, when she came back and informed the nurse, instead of her being

called with the next batch of patients she had to wait till the third. A batch consists of 10-

20 patients. In another facility where a man had reported at 7.00am with his sick child

and had not been attended to by 10.00am, when he complained was told to go away,

this resulted in a scene at the OPD. Yet in one facility when the mystery shopper

informed the nurse she was not around when her name was called out, she was

immediately asked to see the prescriber.

Some facilities charged Gh¢ 2.00 at the OPD for testing diabetes without issuing

receipt. Some of the facilities have laboratory attached to the OPD but most of them do

not work in the afternoon. In one of the facilities a staff directed one patient to go a

laboratory outside the hospital for his tests.

Patients also had to pay an amount of GH¢0.50p at some facilities before they could the


Some incidents that occurred at the screening area are described below. “When one of

us got to the screening room, she was expecting the nurse to ask her to sit before she

does so. Instead, she shouted at her and rudely asked whether she was afraid of her”.

“As the nurse at the screening area was taking my blood pressure, she was busily

chatting with someone which the afternoon patient later got to know to be the doctor on

duty. The doctor had moved from the consulting room and was sitting at the OPD

waiting area watching television and at the same time busily engaging the nurse at the

screening area in a conversation. My appearance did not even discontinue their

conversation. When the nurse told him there is a patient, he said “I am tired, I wish we

have closed. Take the lead to the consulting room; I will be with you soon”.

4.4 Consulting Room

During consultation some of the prescribers probed further after patient gave symptoms

of their illnesses and took their time to explain the patients’ condition to them whilst

some didn’t. Others seldom asked patients questions. One prescriber had time to draw

the abdomen using it to explain something for the patient. Most prescribers were

friendly but others were not polite and complained about work load. In some facilities

because of shortage of health staff, there were delays in accessing services at the

consulting room.

‘Being the 14th patient to see the doctor, it took 2hours, 30minutes before one of us

finally met the doctor because the consulting room was supposed to have two doctors

but one left to Accra. The one present was also busy seeing to “protocols” whilst we

kept waiting.

There were illegal chargers at the consulting rooms of some facilities. In some facilities

the amount charged was as high as GH⊄5.00 without any receipt.

‘At the consulting room, one of us was asked to pay an amount of GH ⊄ 1.00 which I did

not hesitate. Later, I asked two other patients who also went to see the same prescriber

who said they also did likewise. I then asked another patient who went to a different

consulting room and she replied no’.

Again, I questioned the lady at the revenue service point if patients had to pay for

consulting fee in the consulting room but she said ‘no’ and was ignorant about such a

practice. I then went back to the consulting room when the prescriber had left and

requested for a receipt from the ward assistant who was in house attire. To my surprise,

she said “there is no receipt for the money you paid, the money collected is just a token

for the prescriber. If you really want a receipt, then wait for the prescriber to come

back.” The doctor was so nice to me that, I could not wait to question her about it.

In one of the facilities, a prescriber agreed to see a patient who had jumped the queue

for a fee which was bargained, agreed on, and the amount paid in front of the mystery

shopper was then in the consulting room.

In another situation where the mystery shopper was asked to pay GHc5 in the

consulting room and she said she did not have money, she was allowed to go without


One mystery shopper had to buy and pay for some drug from the prescriber in the

consulting room.

It was observed that the shifts were not properly managed, prescribers sometimes left

even though their relievers had not come.

4.5 Staff Attitude

The staff in majority of the facilities did not wear name tags, some staff also wore mufti

to work.

Some of the staff showed good behavior. They were described as

Polite Courteous
Friendly Maintaining good eye contact

On the other hand some were also described as

Cold Rude
Shouting at patients Unresponsive to patients questions
Irritated when asked questions Disrespectful
Used impolite words Doing their own things instead of

seeing to patients
Buying second hand clothing

instead of working

In most of the facilities “greeting was a problem, patients had to greet about three times

without response”. Some staff were rude and impolite: When the ward assistance was

mentioning the names of the first ten patients to see the doctor, some cards fell but she

did not organize the cards in the right order. A lady patient got annoyed and tried to

draw her attention to that but the ward assistant spoke rudely to her “should I stop

mentioning the names”, she said it amidst chewing gum.

“We also encountered some negative attitude at the records and waiting area. Two

young nurses in mufti attacked a patient, who thought they were laughing at her. This

created a scene at the OPD.”

A doctor showed no compassion when he was informed that a patient with

Haemoglobin of 3gms had been brought to the facility in an ambulance. He was

annoyed and asked why the patient was brought without prior phone call to the facility

and for that matter the accompanying nurse should take the patient back and phone.

This he said would teach her a lesson. But for the intervention of the consulting room

nurse who begged the doctor and took it upon herself to go and look for a bed this

patient might have been turned away. All this happened in the consulting room in the

presence of the mystery

Complaints/Information desk

There were complaint desks in most of the facilities but they were not manned In one

facility security men manned the desk, apart from this facility that has complaint forms

all the other facilities did not have complaint forms. They had registers

A member of staff got irritated when asked for direction to the complaints desk

Notable incidents

These are presented in a verbatim report of the Mystery Shoppers

1. The nurses were attending to their favorite who came in late at the expense of
the other patients when we were waiting at the OPD waiting area. For instance,
the morning patient got to the clinic by 7:00a.m and later met this calm man with
his sick daughter of about five years of age at the OPD waiting area. She did not
meet them at the records, so it meant they had come earlier than she did. It was
almost 10:00a.m and the child had not been called for screening. Some people
we witness holding their cards and had just passed by were attended to all in the
name of “protocol”. Occasionally we witnessed the “khaki nurse” go through the
cards in the box and removes particular ones and called them to them to be
screened. In fact, it became too much though few truly needed that immediate
attention, the gentleman had to approach the “pediatric nurse” since his child
was also very sick. She did not hear exactly what he told the nurse but she
asked him to go away. The man got angry even though he did not insult the
nurse; he wanted the other nurses to hear him out. It took the intervention of the
senior nurse (in green belt) and a patient to calm the situation. The scene was
2. A nurse was able to convince a doctor to admit a patient referred from Pantang
hospital and whose HB was 3.0. The doctor had wanted to punish the nurse who

accompanied the ambulance since he did not follow the lay down procedure to
refer a patient to the hospital.
3. Delay in change over.
4. Mystery shoppers felt prescribers were few during this period therefore patients
waited longer before seeing the prescriber.


The Mystery Client study has brought out a lot of information about customer care

practices in the selected health facilities. There are positive performances that have to

be reinforced and negative attitudes that should be worked on

It is encouraging that facilities are keeping their external and internal environments

clean and attractive, however more covered dustbins should be made available at the

OPD and hospital grounds and patients educated to put their general wastes in these


The Outpatient departments were found to be crowded, hot and poorly ventilated. Most

of the facilities are old and have inadequate space for expansion. The introduction of

national health insurance in the country has removed financial barriers and increased

access to health care thus the high patient load at the OPD. The large numbers of

patients in poorly ventilated areas may pose potential threat for spread of respiratory

infections particularly in this epidemic of H1N1. Whilst very little can be done about the

infrastructure, improving work processes and some reorganizations and introducing

innovations may help to reduce to reduce the volume of patients at the OPD

. Some staff were friendly and polite while others were rude. Most had no name tags,

this is difficult for them to be identified with any untoward incident. There were variations

in the amounts charged at the records unit for registration at the same facility.

Although collection of money is dissuaded in consulting rooms some prescribers were

charging money to the tune of Gh¢5.00 before attending to a patient. Others sell drugs

which should have been done at the pharmacy unit with National Health insurance

especially for those who have registered. It was found out that some clients were

referred to private health facilities which is questionable, it was not known whether the

facility has any arrangement with the private hospital. This would have been important

because patients usually pay more in the private health facilities. Information desks in

majority of the facilities are not manned, in such an instance where and how do patients

channel their concerns, there were no complaint forms.


In facilities where available covered dustbins are not enough, it is recommended that

additional bins should be provided to help maintain a clean environment. Also even

though most facilities used in the study, have sign board directing people to the facility

some are fading and should therefore be changed for easy identification of the facility by

newcomer to the facility.

Based on the findings of the study, it is recommended that name tags should be

provided for all health workers for easy identification. This will help to deal with the

negative attitude of staff, since they would be easily identified for any untoward


The study found too much delay in the health delivering process an issue which should

as a matter of urgency be addressed so that more people would be attended to and on

time. Need to look at the flow of patients, the mystery shoppers spent about 2-5 hours.

There should be reorganization of the service areas to make access to them faster to

save some time, other strategies must also be considered.

There should be a way of staff to run the shifts effectively to prevent situations where

health professionals leave when the replacement is not ready, causing a lot of delays.

They study found that most facilities visit have no staff manning the information desk,

thus patients have nowhere to go to make enquires.

It is also recommended that the Institutional Care Division of the Ghana Health Service

should design complaint forms for use in all health facilities so that patients who have

complain can write them and such complains when received should be acted on

immediately. Also health brochures and leaflets should be made available at the OPD

for patients to read as they wait for services. Instead of the patients watching films of all

kinds GHS should develop DVD on health issues for the OPD’s. It is again

recommended that trained supervisors are assigned to consistently observe activities of

the OPD and attend to customer care practices. Staff who demonstrate good customer

care practice should be rewarded, those who exhibit contrary behaviors should be

sanctioned. All health workers should be trained in customer care, since most health

staff have the technical knowledge required to effectively carry out their work but lack

the customer care skills to be able to satisfy their patients completely.

Finally and most importantly, mystery shopping should be done in all health facilities

and be part of the Customer Care Training program. Trainers can use the results to

review their training contents and include some of the positive and negative incidents as

case studies during their training sessions.


The mystery shopping carried out in twelve selected health facilities in the Greater

Accra Region will form a baseline data to inform the content of the customer care

training programme soon to be rolled out is all health facilities in the country and also to

evaluate the customer care training programme.

In most facilities where the study was carried out, both the external and internal

appearance of the facility were clean. Some staff encountered in the course of the study

were polite and friendly, others on the other hand were rude. Certain negative incidents

were reported including collection of illegal fees to which no receipts were issued.

The study therefore recommends that customer care training should be organized for all

categories of health workers to sharpen the customer care skills of all staff to be able to

satisfy the clients completely.


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