Customer Satisfaction in Healthcare

This paper outlines the current scenario in the healthcare industry in India, particularly it’s deficiencies relating to quality of care. It raises the question whether modern quality improvement methods are applicable in modern healthcare. It outlines the first steps taken at the Gopikrishna Piramal Memorial Hospital, Bombay in improving the quality of services rendered to its customers and summarizes lessons learned of a year’s experience on the hospital’s “Quality journey.”

Background
The Gopikrishna Piramal Memorial Hospital is a charitable hospital treating about 25,000 patients a year. More than 60% of the patients get free treatment. It provides ambulatory care ie. day surgical and medical facilities. Its two main wings are:

1. The medical wing with comprehensive medical facilities like pediatrics, pathology, radiology, dentistry, cardiology, ophthalmology, ENT, physiotherapy, orthotics, psychiatry, child guidance, etc.
2. The sports medicine wing which provides facilities both for the elite athlete and the lay person who wants to become fitter. This wing provides surgery, orthopedics, human performance laboratory and nutrition.

The Juran Quality Improvement program started in January 1993. There is a 12 member quality council which meets weekly.

New age medicine-dazzling technology
Medicines today deserves to boast about the power of its technologies, the depth of its bioscientific roots, the grandeur of its facilities and the audacity of its reach into the human body. Cancer specialists can help cause remissions with children suffering from leukemia which was not possible a decade ago. Biotechnology, genetic research, the use of computers that can peer inside the body have revolutionized medicine today.

The customer expects excellence
The patient who goes for help to a doctor expects that the medical care given to him is of the highest quality. Errors by the healthcare service are indeed very costly in terms either mortality or morbidity because of failure in the medical system.

“We want to believe in health care-in the trusted doctor, the chrome-clad hospital, the gentle touch. We need something to rely trust and we expect excellence.” Say Berwick, Godfrey and Roessner in their landmark book curing Heath Care

“The profession of medicine wants, in its turn to be trusted, and it too, prizes excellence. Quality is implicitly guaranteed by social contract between medicine and those it serves.”

The fabric of trust has worn thin
“These are times of exceptional discomfort, both in medicine and those who rely on it. The fabric of trust has worn thin. What has become of patient's confidence and a physicians pride? We are not celebrating the quality of health care today as much as we are questioning it.”

Today, perhaps, it is the worst of times in health care. Almost no one is happy with the health care system. It costs too much, it excludes' too many: it fails too often: it knows too little about its own effectiveness. There is increasing greed and fraud in sectors of the health industry.

Failure to understand customer needs
According to professor Herzlinger of the Harvard Business School the reason why many health care ventures fail or health care organizations perform badly is because of a failure of management: ie, “a misspecification for the need.” In other words they fail to understand the needs of people who the organization is serving.

Needed: A transformation for survival
What needs to be done? As Professor Juran points out “Darwin's concept of survival of the fittest has universally applied. Institutions that responded to customer needs survived. Those that did not respond became extinct-replaced by competitors that provided society with better service and lower prices. Such competition for survival is now beginning to take place in the health industry.”

Health care systems have long raced daunting economic, social, and technological pressures for change:

1. Health costs that are inflating rapidly
2. Health care consumers who voice growing discontent with the orientation, effectiveness and convenience of the system

Health care has a somewhat Jekyll and Hyde role, enabling medical miracles for many sick people yet requiring massive expenditures for interventions of questionable efficiency. A transformation seems inevitable.

Application of modern quality methods
Can the tools of modern quality improvement with which other industries have achieved a breakthrough in performance, help in health care as well? Health care organizations do not believe that improving quality is for them necessary for survival. Moreover, it is a central belief of health care - that quality is made by doctors alone: that health care depends first and last on physicians doing their work properly. Seeing health care as a production process by any name violates the image of the profession.

Is medicine delivered by a doctor or a medical team?
This is an important issue. Today more than ever before medicine is a team process. The doctor operating in a theatre requires that his back-up is functioning at a high level because the patient’s survival depends on it. He or she must depend on the anesthetist, the nurse, the theatre cleaner, the drug company that supplies oxygen, gases or medicines. If the link in the chain is suspect then disasters during the last couple of years in many hospitals in the city (like the J J Hospital deaths of children due to poor quality of drugs, and the Bombay Hospital deaths due to contaminated parenteral medicines). In fact, increasing morbidity and mortality due to poor quality in medical care are almost a daily occurrence in newspaper articles.

In the hospital of the 1990’s can any one person be held totally accountable for the care we create together? Or is that an ideal of a romantic past, which no longer serves patients well in the complex present.

Focus of accountability vis locus of control
However, accountability for quality of care is still with the doctor. In the past, patients rarely sued the doctors. They were like “gods” to the patients. Lately, aggrieved patients themselves are beginning to wield the scalpel and beginning to sue doctors under the powerful legislation of 1986 (Consumer Protection Act). An increasing number of doctors are finding themselves in the dock, battling charges of negligence.

We will pay a high price

The involvement of insurance companies is increasing. Premiums are being hiked up. Doctors are ushering in the concept of defensive medicine. Series of expensive tests are called for before a diagnosis is made. This will slowly, but surely drive up the cost of health care as the high cost of insurance, increased litigation and expensive diagnostic tests will be passed onto the patient. In a poor country like ours the price we will have to pay for expensive health care will be very high.

We need knowledge. We need instruments for adaptation' and change. What we do is too important to let our pride keep us from lessons that have been taught and learned outside medicine how quality can be planned, controlled and improved.

Questions and more questions
There are however immediate questions and concerns.

• Healthcare is not the same as other industries.
• Medicine is not a standard uniform product.
• Every patient is different.
• Health care is not an assembly line.
• Doctors do not see themselves as team players.
• How can we measure quality in health care?
• Isn’t medicine an art?
• A doctor's decision may be subjective.
• Isn’t the real problem not quality but cost?
• Won't higher quality mean higher cost?

Problem - The variation in clinical practice
Firstly, there is variation in clinical practice. Take for instance, the different prescriptions given to a patient for a burning pain in the stomach. He may be prescribed an antacid for hyperacidity or a H2 antagonist to stop excess acid secreted by the stomach or he may be asked to undergo a barium meal investigation or even a diagnostic endoscopy. Finally, some surgeons may advice surgery! The patient asks a question? Is the doctor’s decision based on scientific fact or is his decision just arbitrary? Recent scientific evidence is bearing a message no one is happy to hear namely, that almost anywhere one looks in health care, variability in patterns of clinical practice is rampant.

This is not subtle, marginal variation, either, it is a “slam dunk” variation commonly twofold and threefold differences in rates of test ordering, surgery, drug use and hospitalization. Health care expenditure is not only inflating, it is being spent largely in some colossal game of dice, the care patients receive apparently depends in large measure on who happens to be treating them!

Starting JQI at Piramal Hospital
Because we were convinced that there must be a way out, we started a Juran Quality Programme at the Gopikrishna Piramal Memorial Hospital in January 93. The hospital is part of the Piramal Enterprises Group of Companies where JQI efforts were started at the same time. Being a small hospital it was perhaps easier to start pilot projects and form a quality council. In this paper we will share with you some of our early results.

Quality in the modern sense is defined as meeting the needs of the customer. We looked at quality as providing the features and services needed for our customers and making sure that these services were free from failures or defects.

Who are our customers?
The best ideas for improvement were obtained from customers who depended on our hospital’s products and services. The first step was to define our customer. We have multiple customers. Starting with a patient, say a child who comes to our pediatric department, the parent, family, community are our customers as are other physicians, non physician staff members, regulators and insurance payers. We began to understand the concept of internal and external customers who depend on other health care workers or processes and external customers or patients. Listening to the voice of the customer meant directly assessing the degree to which our services are meeting the needs of those who rely on them.

Action Project by Project
Our first project was a questionnaire to our customers to get their view on our services. As we collated the data, we found that rather than technical competence of the doctor, patients were more concerned about problems like long waiting times for doctors, difficulty of getting doctor’s appointments on the phone, inadequate parking facilities, having to come back the next day for test results.

(Similar findings occurred in quality projects in US hospitals, an example of the Park Nicollet Hospital is presented) we began to tackle these projects one by one. Next we began to understand the concept of COPQ (cost of poor quality) and began a project to calculate stationary wastage. As we began to bring quality into the clinical areas our projects are concerned with the safety of patients in the sports medicine department and in the operating rooms. A recent project compared features of our services to our competitors. We have begun a strategic quality planning exercise. Some of our findings are summarized in the charts given here.

Lessons Learned
The lesson we have learned in the past year are surprisingly similar to lesson learned by other hospitals in the US who are also beginning their journey in Quality Improvement. Here are some of them.

1. Quality improvement tools can work in health care.
2. Cross functional teams are valuable in improving health care processes.
3. Data useful for quality improvement abound in health care.
4. Costs of poor quality are high-that is there is a “hospital of wastage” within our hospital.
5. Involving doctors is difficult but when they do get involved there are good results.
6. Training needs arise early.
7. Non clinical processes draw early attention.
8. Health care as in industry the fate of quality improvement is in the hands of leaders.

We are convinced that every employee of the hospital must take part in quality related projects and all new employees have this specified in their appointment letters.

Scientific thinking must occur at all levels of the organization in the continuous improvement of the processes thro.ugh which work is done.

The safety of patients must depend on the fidelity of the systems that deliver information, training, supplies and options to doctors. It must be true that technical care is prompt, appropriate, effective and respectful of patients can best occur in medical organizations whose processes are streamlined, carefully designed, continuously improved and responsive to needs of both patients and health care workers. There exists at our hospital the potential to increase vastly the quality of health care.

A forward looking healthcare, quality organization
What will it mean to be a vigorous forward-looking health care organization in the 1990’s and beyond? We are constantly looking for ways to become more respected, more competitive, more effective. We are convinced that quality is a core area of knowledge necessary for us to fulfill our vision of being the leader in sports medicine and health maintenance in our country.

We reorganize that more than ever before, even though we are a charitable, not for profit organization, we need good quality management to achieve these goals. As management guru peter Drucker points out, for “non profit organizations are still dedicated to “doing good” but good intentions are no substitute for organization and leadership for accountability, performance and results.” The quality goal of providing “unparalleled customer care” which is both high in quality and best value-for-money care for our customers is written in our strategic plan. We are newcomers to the concept of “Total Service Quality” but we have a clear idea of our destinations and goals for the future and have taken the first, vital step on the “Quality Journey!”

Customer-survey sports medicine

Rating Scale

References

1. Atchison Turning Health Care Leadership Around Jossey-Bass Publishers 1991
2. Berwick, Godfrey, Roessner. Curing Health Care. Lea and Febiger 1990.
3. Blair, Fottler Challenges to Health Care Management Jossey-Bass Publishers 1990.
4. Fagerhaugh and all Hazards in hospital care Jossey-Bass Publishers 1987.
5. Herzlinger Creating New Health Care Organizations Aspen Publishers 1992.
6. Kotler, Andreasaen Strategic Marketing for Non-Profit Organizations Prentice Hall 1991.
7. Mick Innovations on health care delivery Jossey-Bass Publishers 1990.
8. Sloan and all Cost, Quality and Access in Health Care Jossey Bass Publishers 1988.

Dr Swati Piramal is Medical Director, Gopikrishna Piramal Memorial Hospital, Bombay

Dr Shakuntala Lulla is Director, Qimpro Consultants, Bombay