What determines choice of hospital

The patient is not only interested in what he or she receives as an outcome of the process, but in the process of delivery of healthcare itself. FILE PHOTO | NMG  AJID TWAHIR

Summary

• Core to healthcare is the performance of the clinician, including that of physicians, nurses, nutritionists, physiotherapists and all other professionals involved in patient care.
• Clinician performance can be technical or interpersonal.
• Technical quality assessment is easier to measure as it is fairly standardised and varies from patient to patient in a predictable and usually predetermined manner.
• It is measured based on existing knowledge and against best practice of the time.

Delivered healthcare can be measured and identified customer needs can be met and exceeded. There must be a process of identifying and evaluating the customer needs–their expectations and their experiences.

The patient is not only interested in what he or she receives as an outcome of the process, but in the process of delivery of healthcare itself, that is, how the healthcare is delivered is also important to the patient. From the patients’ perspective, this may be what they consider as the entirety of the service they have received. This quality dimension is called functional quality.

The functional quality dimension cannot be evaluated as objectively as the technical dimension. The functional dimension is perceived in a very subjective way. This perceived service is the result of a patient’s view of a bundle of service dimensions, some of which are technical and others functional in nature.

When this perceived service is compared with the expected service, one then gets the perceived service quality. In the context of healthcare, perception of quality is thus a function of both process and outcome.

Core to healthcare is the performance of the clinician, including that of physicians, nurses, nutritionists, physiotherapists and all other professionals involved in patient care. Clinician performance can be technical or interpersonal.

Technical quality assessment is easier to measure as it is fairly standardised and varies from patient to patient in a predictable and usually predetermined manner. It is measured based on existing knowledge and against best practice of the time.

Quality of care is deemed to have been achieved to the highest level if knowledge and practice as it is known then has been applied even if the outcome is adverse.

As an example, if the patient with a heart attack was given treatment as per best practice, highest level of quality is deemed to have been achieved even if the patient dies.

Quality is the driver of customer satisfaction. Therefore customer satisfaction is improved by improving quality. Thus improving quality influences future behavioural intention of the customer. The intention is either to return or refer others favourably to the institution.

Poor quality has a large negative impact and likelihood of non-return (69.5 per cent) as well as to inform others (one customers informs nine others) about adverse experience. If this is so, then quality is a driver for future patronage either directly or through influencing of others. But which aspect of quality – technical or functional?

Inasmuch as technical quality is mandatory and a pre-requisite to sustainability of an institution, information on it is usually not available to patients or patients are not able to interpret it accurately.

Information on functional quality is the only one that informs the patient on the quality of the hospital. Patients’ intention to re-visit a hospital or to inform others favourably of their experience at a hospital is determined by their satisfaction level.

In turn, their satisfaction is determined by the perceived value of care received which in turn is determined by quality of medical care received as perceived by the patient. There is a significant and positive correlation between satisfaction and intention to revisit the hospital or to inform others favourably about the hospital.

Understanding patient satisfaction is important in gaining better insight and influencing healthcare delivery which has an effect on patients’ willingness to adhere to treatment plan and intention to return.

Patient satisfaction, in turn, is a complex phenomenon involving clinical outcome, empathy of the clinician, physical ambience, financial and geographical access and efficacy among other attributes many of which may vary from region to region depending on local and cultural context. This therefore implies that knowing the needs of the patients is imperative and that the organisation may then put structures, systems and processes in to place to meet and potentially exceed these expectations of the patient.

From a patient’s perspective, technical quality, once present, it does not contribute further to patient satisfaction. Absence of positive treatment outcome is a cause of dissatisfaction but its presence (positive treatment outcomes) does not guarantee satisfaction. Thus patient satisfaction, of necessity must include the other components of quality namely functional quality.

The interpersonal interaction must be tailored to enhance delivery of technical quality and must be within cultural contexts and in an acceptable format that includes privacy, confidentiality, informed choice, concern, empathy, honesty, tact and sensitivity.

The interpersonal relationship between clinician and patient may hamper or enhance technical quality. Thus clinician performance must be both technically as well as service delivery based. This is a fact that eludes many clinicians.

A doctoral research undertaken by the writer showed that not all determinants of perception of quality are of equal importance. There is clearly a hierarchical dimension when patients are choosing a hospital or recommending a hospital to others. In order of descending importance these are Interpersonal, Environment of care and hospitality, Administrative processes and Access.

Of all the aspects of Interpersonal dimension, the customer-provider interaction is the most critical, of which assurance and empathy are the most important determinants of patients’ choice of a hospital.

Within these, in order of importance are Doctors’ who listen, doctors’ who are courteous and who spend enough time with patients, nurses who are courteous and are efficient, doctors’ and nurses that are professional.