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Measuring
Quality award dimensions: health service
a strategic instrument for quality
measuring health service quality
363
M. Palani Natha Raja, S.G. Deshmukh and Subhash Wadhwa
Department of Mechanical Engineering, Indian Institute of Technology, Received 19 February 2006
New Delhi, India Revised 24 July 2006
Accepted 31 December 2006
Abstract
Purpose – The purpose of this paper is to describe research which compared quality awards and the
selection of criteria for assessing health care processes quality status, in private sector health care
institutions in India.
Design/methodology/approach – A comparison of quality awards was performed and criteria
were selected for assessing health care processes quality status. The relationships in the model, as
measured by the instrument, was the work’s main objective. Using the Malcolm Baldrige National
Quality Award, European Foundation for Quality Management and Kanji Business Excellence Model,
common factors were extracted to measure the quality perceptions of health care organizations and to
measure the relationships among the quality dimensions. The sample selected for this study
comprised healthcare stakeholders.
Findings – As a result of respondents’ knowledge, data provide unique insights into the
relationships among the dimensions that compose quality in healthcare organizations. Principal
component analysis was used to identify relationships among service quality dimensions in the
developed quality framework. Specifically, the relationship between leadership, resource
measurement, people management, process management and customer satisfaction.
Originality/value – The research shows that developing a measurement instrument is an important
step in assessing an organisation’s actual or perception of quality and assessing customer’s perception
is one way to improve service quality.
Keywords Quality management, Baldrige Award, European Foundation for Quality Management,
Health services, India
Paper type Research paper

Quality framework
Quality management has emerged not only as the most significant and long-term
strategy for ensuring the survival of organizations but also leads services to business
excellence (Rose et al., 2004). Many national quality awards originated after 1990 and
some are still at that stage of accumulating learned experiences through assessing
organizations on their processes. All the awards represent organizational efforts to
enhance international reputation in an increasingly competitive environment in
multi-national organizations (Puay et al., 1998). Assessment, which assists institutions
to define quality systems and customer driven quality objectives, indirectly helps
organizations to improve their quality in every aspect of their activities.
Most quality definitions, when applied to services, are customer-centered (Kanji International Journal of Health Care
et al., 1999). The Malcolm Baldrige National Quality Award (MBNQA), on the other Quality Assurance
Vol. 20 No. 5, 2007
hand, is a review of key quality management indicators, which can be quite insightful. pp. 363-378
The Baldrige Health Care criteria are well known and widely used by hospitals for q Emerald Group Publishing Limited
0952-6862
self-assessment purposes (Meyer and Collier, 2001). Although total quality DOI 10.1108/09526860710763299
IJHCQA management (TQM) provides a basic blue print for implementing quality processes,
20,5 the Baldrige award assessments are designed to establish an organizational baseline
and to point out strengths and areas for improvement (Mohanty and Lakhe, 2002).
Although the related Business Excellence Model is used as a measurement tool (Ruiz
and Simon, 2004), there is a need to develop a sound method and system to align health
care organization strategies with good performance management and measurement
364 (Chua and Goh, 2002). The best services will be those that are perfectly aligned to what
customers really need and want; therefore, service competitiveness strongly depends
on accurately assessing customer needs (CN) (Enriquez et al., 2004). Health care has
been transformed from philanthropic to business-oriented service in many countries.
Often, it is compared with professional finance services, since healthcare almost
always is seen as a cost to a customer because no services come free (Oxer, 2002).
Assessment and performance are intertwined. Performance, if it is to be improved,
must first be measured; and there are several reasons why new measures are needed;
for instance, poor application of information technology in hospital management
system (HMS) and the inability to focus managerial effectiveness (Crandall, 2002). In
the Philippines, an initiative known as the “Sentrong Sigla Movement” was created for
health care services, which defines quality as: “. . . the highest values we hold and
should be reflected in how we deliver health services” (DOH and MSH, 2000, p. 6).
Defined from the service provider perspective, health care quality is about:
.
providing a type of health service or procedure correctly the first time;
.
satisfying clients (the external customer) and ourselves (the internal customer);
and
.
achieving the highest level of quality at a low cost by ensuring everybody’s
commitment and cooperation.

Literature review
Quality management should focus on all activities and at all professional levels in
order to establish a continuous process towards improvement. The European
Foundation for Quality Management (EFQM) has a key role enhancing European
healthcare organization effectiveness and efficiency by reinforcing quality’s
importance in all activities, while assisting and developing quality improvement
(Naylor, 1999). The MBNQA has been accepted widely as a performance excellence
standard, measured along the lines of leadership, strategic planning, customer and
market focus, information and analysis, personnel, process management and business
results. Since 1999, non-profit organizations like those in education and health care
institutions were eligible for the award (Chua and Goh, 2002) and categories fit into a
framework composed of four basic elements (Prybutok and Cutshall, 2004):
(1) driver;
(2) system;
(3) measures of progress; and
(4) goal.
The EFQM model provides a goal-oriented and systematic measure of an
organisation’s strengths and areas on which to concentrate. It also provides the
escalatory growth and implementation of remedial and future action plans. The model
has many benefits and apart from self-assessment it can be considered a guide to Measuring
introducing quality principles and fundamental total quality management (TQM) health service
concepts (Bou-Llusar et al., 2005). However, some EFQM aspects need to be examined
in order to make the model more useful as a self-assessment tool (Eskildsen et al., 2001). quality
The relevance of performance measurement and evaluation has been explained in two
ways. Performance measurement has been defined as “evaluating how well
organizations are managed and the value they deliver for customers and other 365
stakeholders” (Moullin, 2004, p. 249). How health care is provided is a major concern in
many countries so Moeller and Sonntag (2001), for example, designed an excellence
model measuring method and scoring system to address health care issues.
Europeans have researched the scope and use of evaluation techniques in
international health care systems. The EFQM excellence model has been developed as
both a tool for organizational assessment and for strategic integration. German
healthcare organizations have started to apply EFQM by doing a self-assessment and
identified the strengths and weaknesses of each criterion (Moeller and Sonntag, 2001).
Consequently, a list of areas for improvement was generated:
.
dedicated staff;
.
a supportive organisational environment; and
.
sound leadership.

An area receiving much attention in the service quality literature is the health care
service industry. Gunawardane (2004), for example, explored the feasibility of applying
reliability engineering techniques to measuring and improving the consistency of
service operations in health care organizations. Healthcare service quality is linked to
activities, interactions and solutions to customer problems (Edvardsson, 2005).
Managing and measuring health care institutions’ performance, therefore, are
increasingly becoming difficult and complex as the health care system seeks greater
integration for economies of scale reasons. Many conventional quality tools, Pareto
charts, cause and effect diagrams, process flow diagrams etc., are being applied to
health care institutions. Most quality assessment tools provide a quality performance
measure but lack a monitoring capability for corrective feedback or performance
monitoring (Chua and Goh, 2002). There is a possibility of relating the quality award
criteria to measuring the healthcare services being offered in the various institutions
thereby improving health care institution quality.

Need for change in healthcare services


Healthcare systems are fundamentally interesting to all societies, which revolve
around their patients. Many healthcare organizations are beginning to recognize that
quality is needed for survival (Mohanty and Lakhe, 2002). Health care is about meeting
the physical, psychological and social needs of people who seek care (Rose et al., 2004)
but 60 per cent to 89 per cent of consumers are dissatisfied with hospital service
quality. Moreover, declining reimbursement, new incentive structures and increasing
competition are placing unprecedented pressure on providers to deliver health care
effectively and efficiently (Rad, 2005). In urban areas, doctors are facing competition
brought on by health care reforms and increasingly affluent consumers (Shemwell et al.,
1998). Quality criteria and related measures can improve patients’ health status and
their satisfaction. Health care needs strict professional standards, high customer
IJHCQA empathy and investment. Services offered by Indian private healthcare agencies, for
20,5 example, are characterized by over-prescribing, unnecessary injections, over
investigation and prohibitive cost. A majority of Indian states do not have laws or
standards governing private hospitals, and there is minimal monitoring or
accountability among private hospital managers and practitioners (Nandraj, 1999).
However, healthcare service quality indicators have been ranked for public and private
366 sector organizations:
.
professional and technical care;
.
service personalization;
.
environment;
.
accessibility;
.
patient amenities;
.
catering; and
.
price (Cammilleri and O’Callaghan, 1998).

Good indicator evaluation is necessary to assign causality between program inputs


and outcomes. Monitoring and evaluation give meaning to the accountability
relationships between clients, policy makers and providers. A result-based monitoring
and evaluation system that joins information from more traditional monitoring efforts
with information from the service delivery framework can provide guidance on the
institutional reforms needed to improve service delivery. Even though the literature
provides insights into health care evaluation and performance, an integrated quality
model seems not to have been addressed.

Problem description
Healthcare in India is perceived as a business opportunity. However, services are
failing because they are falling short of their potential to improve outcomes. Social and
economic changes are witnessed in higher demand for health care services. Many
healthcare services are inaccessible and prohibitively expensive. Even when
accessible, they are dysfunctional, low in technical quality and unresponsive to
patients’ needs. Additionally, innovation and evaluation are rare. Prominent failures in
services are caused by a lack of access to unaffordable care. Rural area healthcare
institutions are not as popular with users, leading to minimal usage. Health workers
lack opportunities in rural areas where turnover is high owing to poor community
services (World Development Report, 2004).
Information on access, quality and efficiency is scarce in rural organizations and not
easily compared; for example, drug availability in healthcare facilities is an ambiguous
measure of quality. Services also fail when technical quality is low; that is, when inputs
are combined in ways that produce outcomes in inefficient, ineffective or harmful
ways. Rural patients have a choice to move out of their own area to visit urban
hospitals. Although outpatient clinics, autonomous hospitals and non-governmental
organisations run private clinics, they are concentrated in urban areas and not
distributed evenly. Consequently, healthcare services result in long waiting times,
inefficiency, low productivity, stressed staff and less satisfied patients. Long waiting
times for emergency care and shorter hospital stays after surgery are symptoms of
systematic imbalances in demand and supply in service providing organizations. Measuring
Healthcare quality deficiencies have been highlighted by Hwang et al. (2003) as a lack health service
of standardized approaches to satisfying patients, lack of an accepted conceptual
model of the patient process and lack of consensus within the medical profession on the quality
role that patient satisfaction should play in care quality assessment. Health care
organization quality evaluation is a multi-level effort. However, the rapid pace of
change in the health care system present challenges for health care managers charged 367
with delivering health services (Rad, 2005). Moreover, health sector reforms are
complex processes, affecting local systems in which individuals work – shifting
incentive structures, regulatory mechanisms and paths of accountability (Parkhurst
et al., 2005).

Method
Data collection
There is a need for research generally and instrument development specifically that
empirically contributes to the development of quality practices and framework for
assessing organizations. Therefore, a quality assessment instrument was developed
using MBNQA, EFQM and Kanji Business Excellence Model (KBEM) criteria.
Responses are marked on a Likert scale ranging from strongly disagrees to strongly
agree. Our comparison of quality award criteria relate to the development of a service
quality measurement instrument in health care institutions. Comparing quality award
criteria strengthens instrument validity (Raja et al., 2006), and all instrument items
were designed to reflect quality awards’ aspects. Quality experts and medical
professionals of privately owned institutions reviewed instrument content validity
during the pilot study. Many suggestions were incorporated and reviewed again by the
experts after the pilot study.
The MBNQA, EFQM and KBEM quality award models are used by several
healthcare organizations for continuous quality improvement. However, these models
are meant for delivering awards based on self-assessment. The aggregation of
assessment procedures could be implemented to improve the organizational and
process quality in general and for awards in particular. The idea of bringing out
common issues between the quality award models, extracting key ideas and
modulating the proposed service quality model is important. The proposed factors that
assist our understanding of the healthcare process and help us to analyze service
quality conceptual model are shown in Figure 1.

Leadership
Leadership is an overall hospital systems’ driver (Meyer and Collier, 2001). It is an
approach to quality management that focuses on giving value to customers by
building excellence into every aspect of the organization. Leaders allow and encourage
everyone to contribute to the organization by encouraging them to strive towards
continuous improvement in every process. Leaders emphasize process improvement
rather than individual accountability. It is a management behaviour that drives the
institution towards total quality. There are many leadership practices that are more
likely to improve performance (Pannirselvam and Ferguson, 2001) and the items we
considered for the leadership criterion, therefore, were thought clarity, administrative
style, motivation, trust, attitude, confidence, decision making and clinical competency.
IJHCQA
20,5

368

Figure 1.
Quality award
dimensions: a service
quality model

Resource management/measurement
Resource measurement is concerned with how staff manage information, materials,
technology and finance. It indicates how they plan and manage resources in order to
achieve the most advantageous end results (www.efqm.org). The items we considered
for this criterion were: staffing, infrastructure, tangible evidence, treatment cost and
employee motivation.

People management
This element concentrates on developing and managing people in the organization,
including training. It also refers to the quantitative aspects of workforce planning and
to the quality personnel policy. Leadership has a significant indirect effect on process
management primarily through its effect on human resource management. The items
considered for this criterion were: teamwork, skills, initiative, attitude and staff
training.

Process management
The element monitors how staff manage, evaluate and improve key processes to ensure
quality output. It emphasizes the way staff strengthen processes through improving
quality and operational performance. It reflects how staff design, operate and improve
processes that support policy and strategy and fully satisfy customers and other
stakeholders. The items considered for this criterion were: maintenance, job
involvement, setting standards, sincerity, effectiveness, values, commitment, job
nature, knowledge and optimal resource use.
Customer satisfaction Measuring
This element includes customer requirements, staff awareness, customer satisfaction health service
measurement and relationship with customers. It also reflects customer wishes,
expectations and professional needs. Every patient needs proficient and skilled quality
medical personnel for sound diagnosis, treatment and care. The items considered for
customer satisfaction, therefore, were: word-of-mouth for spreading the
product/service among general public, confidence, practical thinking, treatment cost, 369
displeasure, complaint resolution.

Sampling
The study population was large and unwieldy; contacts with the respondents,
therefore, had to be made in different locations. In order to achieve sampling
uniformity the researchers selected respondents as follows.
Stakeholders (nos):
.
Department heads (53).
.
Doctors (133).
.
Paramedical staff (57).
.
Patients (76).

Purposive sampling was used taking into consideration the following:


.
hospital locations;
.
willingness on the part of the institutions to allow staff to divulge information;
and
.
willingness on the part of the respondents to disclose data.

Members surveyed ranged from recently appointed to senior level doctors and
paramedical staff, nurses and patients. Out of 319 questionnaires distributed to 62
private healthcare organizations, 37 were returned incorrect or incomplete. In many
institutions, it was observed that there were no senior doctors to fill in the questionnaire.
Consequently, the most experienced doctors were considered as senior-level doctors.
Though some respondents occasionally left a response blank owing to their research
ignorance, most of the items had enough respondents. The limitations imposed by the
sample were not critical to this work because our intent was to identify the relationships
among service quality provided by healthcare organizations.

Data analysis
The questionnaire was piloted among those involved in service processes in healthcare
institutions such as department heads, doctors, paramedical staff and patients.
Validity and reliability testing helped to identify patient, nurse, technician and doctor
requirements. We designed the questionnaire to obtain information on:
.
leadership in the organisation;
.
processes and their importance;
.
quality performance and its resources; and
.
stakeholder satisfaction.
IJHCQA Data were subjected to comprehensive and detailed analysis. Principal component
20,5 analysis (PCA) was used to determine item groupings (factors) in each quality award
dimension, while descriptive statistics (means and standard deviations) were employed
on various constructs.

PCA
370 PCA is a multi-variate statistical method that analyses interrelationships among a
large number of variables (such as questionnaire responses) by defining a set of
common underlying dimensions, known as factors (Hair et al., 2003). This analysis is
predominantly used in the education sector; for instance, a researcher may intuitively
explain the reason for a person’s “intelligence” based on factors such as elementary
education, physical growth during childhood, parental care, exposure to books,
friendships, food pattern, love and affection, etc. Analysis, therefore, provides
relationships among constructs and extracts common “intelligence” dimensions. In our
study, PCA relates to each service quality dimension (leadership, process management,
people management, resource measurement and customer satisfaction) with their sub
factors. Further, it shows the way each construct is perceived by stakeholders such as
medical practitioners, department heads, paramedical staff and patients. Our PCA
helped us to group items into various components (Tables I-VIII). We used PCA to
analyze survey items as they related to service quality, which drive other factors.
Communalities are the proportion of explained variance for each variable, which range
between 0 and 1. Low communalities mean there is considerable variance unexplained
by factors extracted, which may mean extracting more factors is needed to explain the
variance.

Factor extraction
Factor extraction was carried out using the SPSS 11 correlation matrix. The solution
was rotated using Varimax with Kaiser normalization to aid component loading
interpretation. Communalities for the items are sufficient (the extraction accounts for at
least half of variance for every variable) and are shown in Tables I -VIII. There can be a
degree of subjectivity regarding the number of factors that should be extracted.
Common rules to reduce subjectivity include stopping extraction with Eigenvalues
below 1 (extracting four components – see Table I). Consequently, certain items were
removed because they did not load cleanly on any component (i.e. greater than 0.5
loading on one factor and less than 0.5 on others (Hair et al., 2003).

Results
Results obtained from various stakeholders are consolidated and described below.
Each service quality dimension: leadership, resource measurement, people
management, process management and customer satisfaction and their sub factors
are tabulated in Tables I-VIII.

Medical practitioners
The results indicate that medical practitioners perceive “Value” is the important factor
in the process management since doctors are more concerned about society and beliefs.
Regarding resource measurement, doctors perceive that “Tangible” is the critical factor
Measuring
Component
Items Mean SD 1 2 3 4 Communalities health service
Maintain 3.150 1.258 0.896 0.833
quality
Job involvement 3.037 1.202 0.881 0.871
Set to standards 3.518 1.401 0.915 0.862
Sincere 3.225 1.593 0.845 0.845 371
Effectiveness 4.052 1.269 0.812 0.681
Values 4.639 0.482 0.812 0.674
Optimal utilization 2.729 0.686 0.866 0.893
Flexibility in work schedule 2.473 0.658 0.741 0.851
Eigen values – – 2.564 1.546 1.397 1.010 – Table I.
% variance – – 22.856 22.002 20.151 16.455 – Construct: process
Cumulative % – – 22.856 44.858 65.010 81.465 – management

Component
Items 1 2 Communalities Mean SD

Human resources 0.898 0.561 2.805 1.177


Infrastructure 0.878 0.649 3.015 1.209
Tangible 0.806 0.808 3.511 1.374
Motivation 20.746 0.786 3.105 1.404
Eigen values 1.626 1.179 – – – Table II.
% variance 39.59 30.532 – – – Construct: measurement
Cumulative % 39.59 70.122 – – – of resources

Component
Items 1 2 Communalities Mean SD

Attitude 0.785 0.697 3.094 1.596


Competency 0.714 0.518 4.301 0.748
Teamwork 0.656 2 0.572 0.758 3.641 1.210
Confidence 0.630 0.409 3.905 1.333
Motivation 0.869 0.770 2.962 0.919
Decision making 0.644 0.642 2.226 0.912
Eigen values 2.387 1.406 – – –
% variance 36.582 26.641 – – – Table III.
Cumulative variance explained % 36.582 63.223 – – – Construct: leadership

for treatment owing to their preference for sophisticated and modern equipment
essential for speedier diagnosis.

Department heads
Our results show that department heads perceive that leaders should be “Competent”
enough to deal with medical problems supporting doctors are capable of doing things
in a better manner because of their knowledge, experience, skill and expertise in his
IJHCQA domain. Again, department heads emphasized that “Tangibles” such as blood
20,5 sampling, radiation facilities, body scanners are basic requirements for better
diagnosis and treatment.

Paramedical staff
Since the quality of hospitals depends upon leaders’ managerial ability, the five
372 element people management sub-factors were carefully analysed. Paramedical staff
perceived “Skill” to the prime factor for managing people rather than “Training”. Skills
can be improved by way of training and acquiring experience in the field. Regarding
process management, which has five sub-factors, “setting standards” scored highest

Component
Items 1 2 Communalities Mean SD

Infrastructure 0.916 0.907 3.094 1.147


Tangibles 0.910 0.861 3.867 0.855
Treatment cost 20.722 0.639 3.622 1.243
Sort things 0.969 0.942 2.83 1.396
Table IV. Eigen values 2.241 1.108 – – –
Construct: resource % variance 54.792 54.792 – – –
measurement Cumulative % 28.936 83.728 – – –

Component
Items 1 2 Communalities Mean SD

Team work 20.940 0.885 2.814 1.117


Skills 0.798 0.668 4.555 0.501
Initiative 0.904 0.855 3.907 1.545
Attitude 0.532 0.824 0.962 2.918 1.283
Training 0.708 0.724 2.777 0.501
Table V. Eigen values 2.492 1.603 – – –
Construct: people % variance 41.324 41.324 – – –
management Cumulative % 40.569 81.893 – – –

Component
Items 1 2 Communalities Mean SD

Commitment 0.926 0.858 3.407 1.764


Nature of job 2 0.855 0.870 2.629 1.278
Knowledge 0.714 0.551 2.018 1.227
Job involvement 20.895 0.826 2.111 0.634
Setting standards 0.824 0.709 4.870 0.339
Table VI. Eigen values 2.713 1.103 – – –
Construct: process % variance 43.128 33.177 – – –
management Cumulative % 43.128 76.305 – – –
whereas “knowledge” scored the lowest. Maintaining and setting standards in every Measuring
process of healthcare system is expected by paramedical staff – hence there should not health service
be any ambiguity in standards even during mundane activities.
quality
Patients
Six sub-factors responsible for customer satisfaction were identified from the
literature. From our analysis, patients said that “word of mouth” (i.e. goodwill, hospital 373
image) is a strong customer satisfaction indicator. That is, patients are bound to meet
well-wishers during their treatment and share experiences with relatives and
colleagues after treatment.

Hypothesis testing
The research hypotheses tested here provide a comprehensive evaluation and
performances proposed in the MBNQA, EFQM and KBEM quality award models.
These hypotheses address specific relationships between leadership, process
management, people management, resource measurement and customer satisfaction
that tests and results in healthcare performance lead to service quality.
H1. Leadership in a healthcare institution has significant positive impact on
service quality.

Component
Items Mean SD 1 2 3 Communalities

Word of mouth 3.447 1.226 2 0.817 0.772


Confidence 2.328 0.946 0.773 0.697
Practical thinking 2.868 1.181 0.806 0.687
Treatment cost 2.710 1.421 0.738 0.624
Displeasure 3.092 1.443 0.764 0.679
Economic prosperity 2.618 1.082 0.716 0.531
Eigen values – – 1.376 1.354 1.262 – Table VII.
% variance – – 22.928 22.570 21.026 – Construct: customer
Cumulative % – – 22.928 45.498 66.524 – satisfaction

Component
Items Mean SD 1 2 3 Communalities

Clarity of thought 3.210 1.268 0.745 0.573


Administrative Style 3.408 1.480 0.731 0.613
Motivation 3.460 1.427 0.684 0.663
Trust 2.447 0.998 0.840 0.797
Attitude 2.789 0.868 0.805 0.771
Competency 2.565 1.099 0.915 0.838
Eigen values – – 1.635 1.506 1.114 –
% variance – – 26.199 25.543 19.168 – Table VIII.
Cumulative % – – 26.199 51.743 70.911 – Construct: leadership
IJHCQA To test H1, we grouped all the positive replies to various questions. Our study showed
20,5 that leadership had a significant impact on service quality (t ¼ 6:5, df ¼ 11, p , 0:05).
It is inferred that leadership has a significant positive impact on service quality.
H2. Resource measurement will positively influence service quality in healthcare
institutions.
374 Our findings showed that resource measurement had a significant impact on service
quality (t ¼ 4:57, df ¼ 10, p , 0:05) so the null hypothesis is rejected.
H3. Process management positively influences service quality in health care
institutions.

Our findings show that process management had a significant impact on service
quality (t ¼ 4:71, df ¼ 12, p , 0:05) so H3 is accepted.
H4. Customer satisfaction with the health care institution has a significant
positive impact on service quality.
Our findings show that customer satisfaction had a significant impact on service
quality (t ¼ 6:24, df ¼ 8, p , 0:05), so the null hypothesis is rejected.
H5. People management positively influences health service quality.
Our findings show that people management had a significant impact on service quality
(t ¼ 6:93, df ¼ 10, p , 0:05) and H5 is accepted.
Each of the five hypothesized relationships is supported by the quality award model
that drives systems that create service quality. This guides our assumption that an
integrated quality model, which provides the direction of each of the five specific
hypotheses, exists. The elements in Figure 1 and Table IX test these research
hypotheses, which verifies the integrated quality award model theory.

Inference
It is inferred from the patients’ perspective that superior doctor leadership “inspires
and motivates” staff to contribute and improve the healthcare institution. Supporting
paramedical staff expect that certain “skills” are indispensable for better treatment.
Also, paramedical staff need “standardized” processes that are harmonized and
consistent for all healthcare activities (i.e. food management and routine
administration). Senior doctors’ perspective, on the other hand, is more about
“competency” – clearly reflecting their ability, expertise and know-how. Senior doctors
also are more concerned about “tangible” resources that need to be measured and
managed in a more effective way. It is inferred that medical practitioners respect

Degrees of 5% level of
Construct Mean Std dev. freedom (n-1) t value significance

Leadership 37.92 19.23 11 6.54 2.20


Measurement of resources 39.82 27.56 10 4.57 2.23
Process management 55.30 40.63 12 4.71 2.18
Table IX. Customer satisfaction 40.22 18.20 8 6.25 2.31
Dimension summary People management 39.27 17.92 10 6.93 2.23
human “values” and “concepts”, which are fundamental to healthcare processes – Measuring
these should be established in the hospitals. health service
As far as quality award dimensions are concerned, there is no significant difference
in the importance assigned to leadership, resource measurement, people management, quality
process management and customer satisfaction in the healthcare institution. The five
hypotheses that link quality performance were similar and all five alternate hypotheses
were accepted. These inferences are similar to the findings from previous research that 375
test quality management and its performance (Stewart, 2003). From the quality award
dimensions and constructs, it is inferred that they influence health service quality.
Indeed, we have statistical evidence that many of these features are observed in Indian
hospitals.

Discussion and conclusion


Quality award criteria emphasize the need for an organization to make substantial
progress in its pursuit of quality. We conclude that customer-driven quality, fast
response, communicating the mission statement, solving problems, continuous
improvement, improving customer satisfaction, focusing on suppliers and partners,
monitoring and evaluating service quality are all necessary (Rad, 2005). The quality
awards criteria encourage staff to participate in quality improvement strategies and our
survey provides insight into relationships between quality awards, which suggest that
instruments can be used for self assessment. By combining MBNQA, EFQM and KBEM
quality award dimensions into a framework for guiding policy and practice, healthcare
staff are taking significant steps toward implementing quality practices. Comparing
quality award criteria and their constructs represent the influence of service quality
management in health care institution. The results of our work are similar to the
conclusions of Baldrige criteria and its relationships (Pannirselvam and Ferguson, 2001).
Our results show that doctors, nurses, technicians and patients attach different levels of
importance to hospital service sub-factors. However, there are number of practical
difficulties such as time and resources. Our evidence, therefore, supports quality and
process management issues that can make the quality management option unworkable.
An important contention is the development of a quality award based on a model
that interprets the relationship between service quality and the award factors. The
importance of leadership, resource measurement, people management, process
management and customer satisfaction constructs are clear in our model, which
evaluates service quality and provides a useful tool for use in healthcare organizations.
Our data suggests that doctors need to be alert throughout but we found that medical
practitioners do not want flexibility in their work schedule. Owing to patients’ critical
conditions, emergency situations etc., doctors need to be fully occupied during normal
and beyond working hours. Table I and II indicate that doctors perceive hospitals
should be endowed with physical resources. But because of under-qualified staff,
physical resources are not fully utilized. Similarly, owing to a lack of training and
awareness, staff may not use sophisticated equipment. Table III indicates that senior
doctors perceive themselves, by virtue of their experience and seniority, as hospital
leaders. However, hospital administrators may not allow them to take unilateral
decisions in crucial matters.
Table IV shows that senior doctors also perceive that hospitals have good
infrastructures, physical resource, state-of-art the facilities and work environment etc.,
IJHCQA conducive to sound medical treatment. Functional quality, which includes doctors’
20,5 attitude, behavior, service mindedness, appearance, accessibility, internal relations and
patient contacts, however, may be lacking. Table V shows that paramedical staff
perceive they have the requisite professional skills, but they are not able to improve
because of inadequate training. Table VI explains that if mundane health care
institution processes are streamlined then standards will be enhanced. But
376 paramedical staff perceive that managers lack ability to maintain standards and
promote effective functioning. As a result, management processes suffer.
Table VII explains the kind of treatment, modes and costs from the patients’ view.
In our investigation, patients perceive that treatment costs differ according to the
hospital, which influences customer satisfaction. Table VIII shows patients see that
doctors are motivated by means of experience. At the same time, patients do not have
knowledge (since most patients are from rural backgrounds) about doctors’
professional expertise. Table IX summarises the instrument’s dimensions that are
responsible for quality measurement. The statistical parameters indicate that there is
sufficient evidence that award dimensions improve service quality; notably the
importance of satisfying patients’ needs and wants. The importance attached to
constructs seems to vary between patients, staff and institutions. In fact, healthcare
systems based on such dimensions encourage staff to perform well. Medical
practitioners (74 per cent) and the paramedical staff (61 per cent) are more interested in
concentrating on “process management”, which is essential for efficiency. Department
heads, on the other hand, attached least (39 per cent) importance to “measuring
resources”, which is a dominant factor in quality recognition awards.

Limitations
Our study is subject to constraints; for example, doctor, patient and paramedical staff
sample sizes were smaller owing to the questions’ sensitive nature, lack of time and
resources. We intended to capture insights into the dimensions based on the providers
and users’ assessments of health care institutions but the female patients’
unwillingness to complete the questionnaires made data collection difficult.
Nevertheless, in future it would help readers to know what size sample is needed
with sufficient power to distinguish differences between groups. This study was
conducted in private hospitals in Tamilnadu, a state in India, where hospitals are
important geographically, demographically and politically owing to its urban, rural
environment. The study is confined to private health care institutions and government
run institutions are largely unmeasured. Our results, therefore, can be generalized to
private health care institutions only. Since the study was conducted in one
geographical region, it cannot be assumed that the results are relevant more broadly.
However, our study lays the foundation to investigate the same themes in other Indian
states. It is recommended, therefore, that our study is repeated in different countries
and contexts. The results will be useful for developing a measurement model based on
quality awards.

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Further reading
Raja, P.N.M., Deshmukh, S.G. and Wadhwa, S. (2004), “Comparing service quality an exploratory
study on technical education and health care services”, Proceedings of the First
International Conference on Service Systems and Service Management, Beijing, PR China,
Vol. II.

Corresponding author
M. Palani Natha Raja can be contacted at: pnatharaja@rediffmail.com

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