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Emerald Article: Applying the ISO 9001 process approach and service blueprint to hospital management systems Hsiang Ru Chen, Bor-Wen Cheng
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To cite this document: Hsiang Ru Chen, Bor-Wen Cheng, (2012),"Applying the ISO 9001 process approach and service blueprint to hospital management systems", The TQM Journal, Vol. 24 Iss: 5 pp. 418 - 432 Permanent link to this document: http://dx.doi.org/10.1108/17542731211261575 Downloaded on: 16-08-2012 References: This document contains references to 42 other documents To copy this document: permissions@emeraldinsight.com
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Received 24 March 2010 Revised 11 August 2011 Accepted 10 October 2011
Applying the ISO 9001 process approach and service blueprint to hospital management systems
Hsiang Ru Chen
National Yunlin University of Science & Technology, Yunlin, Taiwan, and
Bor-Wen Cheng
Graduate Institute of Healthcare Industrial Management, National Yunlin University of Science & Technology, Yunlin, Taiwan
Abstract
Purpose The purpose of this paper is to integrate the ISO 9001:2008 and blueprints by using a process approach, to have systematic regulation in hospital quality management. Design/methodology/approach This study promotes a process approach when developing, implementing, and improving the effectiveness of hospital service quality to enhance patients satisfaction by meeting their requirements. This study completes the hospitals blueprints with the process approach by using case study research methods such as in-depth interviews with relevant personnel, on-site observations, and experts advice. Findings The results of hospital blueprints described in this study comprise five-plane lines to have systematic regulations. The ISO 9001:2008 process approach and service blueprint are not merely a technological application for medical healthcare services, but rather a fully patient-driven, technologically integrated, and diligently implemented programme. Practical limitations Because of organisational financial confidentiality, this study does not consider the financial performance of the case hospital, and the results of blueprints may be revised afterward. Originality/value This paper promotes the adoption of a process approach when developing, implementing, and improving the effectiveness of a hospital outpatient service management system, to enhance outpatients satisfaction by meeting their requirements. Keywords Taiwan, Hospitals, Outpatients, Customer satisfaction, ISO 9000 series, Blueprint, Hospital management, ISO 9001:2008, Customer orientation, Process approach Paper type Case study
The TQM Journal Vol. 24 No. 5, 2012 pp. 418-432 r Emerald Group Publishing Limited 1754-2731 DOI 10.1108/17542731211261575
1. Introduction The implementation of National Health Insurance in Taiwan makes it clear that when patients consult a doctor, discrepancies will no longer exist because of the earnings that affect medical treatment rights. Even though the implementation of National Health Insurance increased options for the populace to select hospitals and doctors, it has been unable to guarantee a superior quality of medical treatment service. Customers should be the foundation of an organisation and customer relations are an essential factor of an organisations functions. Twenty-first century medical service should be based on an understanding of patients demands and provide the structure, process, and medical results to satisfy the patient. Service promotion is essential, especially in the field of medical care. Hospitals should be expected to treat their patients under the concept humanity always comes first. When a patient in the medical treatment process experiences negative feelings
while in a hospital, he or she could have a negative impression, and the hospital might then lose that patients loyalty. Hospital management should be discussed under the prerequisite of creating value for patients. Clinical service is the first communication interface between a hospital and its patients. Any medical treatment service can affect the patients judgement of the hospital based on the perception of its medical processes and results. Sigala (2005) argued that customer relationship management is a strategic necessity for attracting and increasing guests patronage. The blueprint method provides a way to make improvements by visualising the service process. After a service blueprint is created, it is easy to determine the sequence and interaction of these processes (ISO 9001:2008). Based on the above descriptions, in-depth interviews of this case hospitals outpatients and relevant personnel may be integrated into the ISO 9001:2008 quality management system and blueprint for planning. The hospital blueprint described in this study comprises five-plane lines so as to have systematic regulations. This paper promotes the adoption of a process approach when developing, implementing, and improving the effectiveness of a hospital service quality management system to enhance patients satisfaction by meeting their requirements. 2. Literature review This section is composed of three parts. This study will first explore ISO 9001:2008 to understand how it performs in an organisation; the second part reviews the patient orientation; finally, a methodology of the blueprint is surveyed. 2.1 ISO 9001:2008 quality management system requirements The International Organisation for Standardization (ISO) is the worlds largest developer and publisher of International Standards and is a non-governmental organisation. Its Central Secretariat in Geneva, Switzerland, coordinates the system. The adoption of a quality management system should be a strategic decision of an organisation. This International Standard can be used by internal and external parties, including certification bodies, to assess the organisations ability to meet customer, regulatory, and the organisations own requirements (ISO, 2009). Outline clauses of ISO 9001:2008 are demonstrated in Figure 1. An organisations quality management system design and its implementation should be influenced by the organisational environment, size and structure, product or service, quality objectives, the abilities of employees, the changes in that environment, and the risks associated with that environment. ISO 9000 (2005) also provides eight quality management principles, which are: customer focus, leadership, involvement of people, process approach, system approach to management, continual improvement, factual approach to decision making, and mutually beneficial supplier relationships to help the top management to lead the organisation toward improved performance. ISO 9001:2008 promotes the adoption of a process approach when developing, implementing, and improving the effectiveness of a quality management system in order to enhance customer satisfaction by meeting customer requirements. The quality management system can be divided into three processes, including customer-oriented processes (COPs), support processes (SPs), and management processes (MPs). These are shown in Figure 2.
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Management responsibility
Management commitment Customer focus Quality policy Planning Responsibility, authority and communication Management review
Product realization
Planning of product realization Customer-related processes Design and development Purchasing Production and service provision Control of monitoring and measuring devices
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Resource management
Provision of resources Human resources Infrastructure Work environment
Service realization Customer-oriented processes (COPs) Monitoring and measurement of treatment process
Continual improvement
Payment operations
Treatment process verification Control of monitoring and measuring equipment Request for treatment Treatment process Identification of patients requirements Determination of requirements
Patients requirements
Support processes (SPs) Resource management Purchasing process (e.g. Eisai/drug procurement) Competence, training and awareness Measurement, analysis and improvement
Management processes (MPs) Performance monitoring and measurement Control of non-conforming Management review Internal audit Analysis of data
Order confirmation
2.2 Patient orientation Cheng and Song (2004) advocated the revelation of medical information is an important index for patient needs and indicated that 73 per cent of respondents took medical quality information as reference when coming to visit a hospital. Crall and Morris (1988) and Newsome and Wright (1999) determined six major factors that affect patients perception of medical treatment. These include medical
personnel specialty, the relationship between patient and hospital, convenience, experience of payment, capability of staff, and ease of use of equipment. Arnetz and Arnetz (1996) proposed eight quality indices, and these are currently intrinsic aspects of the total quality management programme at modern hospitals. The eight factors are information illness, information routines, physical environment, security, accessibility, diagnosis, care, and work environment. Other research shows that fervour, employee commitment, and control initiatives are critical and have become major focuses of hospitals (Chen, 2004; Van den Heuvel et al., 2005; Wilkins, 2004). Exterior verification is also an important method for elevating a hospitals quality. The Joint Commission International ( JCI) is a non-profit organisation that seeks to improve the safety of patient care through the provision of accreditation and certification services to help organisations implement practical and sustainable solutions through educational and advisory services. In recent years, more and more hospitals have applied this accreditation to provide good medical quality and drive positive changes that get noticed by clinical staff, patients, and management ( JCI, 2009). 2.3 Blueprint An activity is taken by well constructed the using resources management, and managed in order to enable the transformation of inputs into outputs, can be considered as a process (ISO 9000, 2005). A service blueprint is a tool for conceptualising a service design and delivery system; a design that correctly describes the service system and a process to view the service output. As a brief view, a blueprint is a picture of a service system, such as a flow chart, process diagrams, failure modes, and effects analysis that consist of input-process-output loops, control methods, and all the documents that the blueprints are required to establish (Berkley, 1996; Harteloh, 2003). Blueprints also describe (what do they describe?) objectively, analyse service processes, and make them visible. The visual aspect also can be divided in front-office and back-office components. The front office is the visual part that is in contact with customers, and these visual front-office parts include equipment, facilities, people, and services. The back office organises inner designs and operational support, including management, hardware and software, personnel, and so on. The customers cannot observe the back-office operation or its line of visibility and differences (Shostack, 1982, 1985, 1987; Kingman-Brundage et al., 1995; Zeithaml and Bitner, 2000; Lovelock and nroos, 1984). Yip, 1996; Gro A service blueprint is composed of its purpose, content, and its delivery process. It requires consideration of the relationships among people and issues as well as service quality, process, and value, especially during the client-guided service design process. In order to allow service providers to understand more about the service procedure, some scholars divide the service design blueprint into four levels with five main activity scales (Kingman-Brundage et al., 1995), which makes people-oriented service certain. The latest-related research has added the penetrating line (Flie and Kleinaltenkamp, 2004), which comprises the five-plane line blueprint design as follows: (1) (2) line of interaction: based on the customer perspective, separate service providers, and customer activities; line of visibility: lies between staffs service supply and logistics support service preparation;
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(3) (4)
line of internal interaction: lies in the interactions between logistics support, client services, and technicians; the line of penetration: the action required by clients decisions to apply for the ordering production (or service supply) strategy organisations inner value chain relates to value-added activities; and the line of implementation: the logistics staffs technical service and management checks.
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(5)
3. Method 3.1 Concept This concept model is based on outpatients that come to visit a hospital. In order to redesign the service functions using the process approach to create a blueprint of the quality management system, this study captures the needs from in-depth interviews with relevant personnel who participate in the service system. 3.2 Case research method The case study hospital was established in 1966. It is located in southern Taiwan and is one of the area hospitals granted by the Department of Health in 2002. In the past, the hospitals primary clientele were demobilised soldiers and veterans who sought medical treatment and care in over 500 wards from several departments, including internal medicine, surgery, nephrology, urology, psychiatry, dentistry, ophthalmology, ENT, orthopaedics, nursing, and medical affairs. In 2008, some departments obtained the certificate of ISO9001:2008, the quality management systems certificate, including the following departments: outpatient services, department of X-ray, department of nursing, department of pharmacy, medical records office, registration office, social work office, medical management office, and the secretariat office. The hospital has 32 doctors, 162 nurses, 66 technicians, 46 general technicians such as mechanics, manual workers, and drivers, and 63 administration staff members including social workers, salesmen, and general staff. Top management includes the department directors of internal medicine, surgery, anatomy, reinstate, urology, gynaecology, family medicine, psychiatry, ophthalmology, dentistry, etc. According to the case hospital organisational chart, the hospital superintendent appoints a vice superintendent as management representative to ensure that quality systems are established, implemented, and maintained. The objectives of the case hospital are to construct and provide a community health service network for the physical and mental well-being of the regions population. A case study of this area hospital was undertaken. In-depth interviews of relevant patients and hospital employees were conducted. These were done based on the quality manual, procedures, work instructions, Institute of Medicine (IOM), and the healthcare quality bid which was revised in 2001, as well as on-site observations and experts advice. 3.3 The proposed approach In this study, the proposed approach is presented in Figure 3. (1) Step 1: task assignment:
. .
Process: blueprint the hospital services by using the process approach. Product: set up the management review committee.
Hospital blueprint
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IOM bids ISO requirements
Hospital accreditation
In-depth interviews
Document review
Management review
Process: an in-depth interview method was chosen for this study. It is an open-ended, discovery-oriented method for describing both programme processes and performances from the perspective of the superintendents, management representatives, committee members, patients, and others. Product: records of in-depth interviews.
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Process: classify the in-depth interview results into several customer-oriented classifications. Product: summarise the in-depth interview data. Process: review and evaluate again by the management review committee members to determine if appropriate to meet patiet requirements. Product: determination of management review committee. Process: integrate customer-oriented items into the front-office and back-office dimensions of the blueprint service. Product: confirm and publish the blueprint of the organisation.
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The case hospital in this study is currently applying for ISO 9001:2008; some results shown in this paper may be revised afterward. A complete patient-service blueprint is demonstrated in this study but may only be suitable for this case hospital because of different circumstances (e.g. resources, hospitals purpose, location, traffic, etc.) among other hospitals. Because of financial confidentiality, this study does not consider the financial performance of the case hospital.
4. Results The research uses a process approach to set up a hospital service blueprint under the ISO 9001:2008 requirements to satisfy patient requirements. The service blueprint has the following five steps: (1) Step 1: task assignment
.
Process: a task assignment is designated by the hospital superintendent to blueprint the hospital services by using the process approach to ensure that the task is appropriate to the objectives of the hospital. The superintendent is the head of the hospital, the vice superintendent is in charge of the management representative, outpatient services, department of X-ray, department of nursing, department of pharmacy, medical records office, registration office, social work office, medical management office, secretariat office, etc., and every director is in charge of top management members to establish, implement, improve, and maintain the quality management system. Product: the management review committee is assigned to develop the tasks. Process: in order to satisfy patients needs, having a professional relationship with the patients can help the hospital staff understand the requirements of
patients. The relevant personnel interviewed in this study included the management representative, medical administrative director, pharmacy, surgery, psychiatry, nursing department representative, and consultants. There were nine management participants in total as well as five patients that were interviewed. The selection criteria are shown in Table I. One of the consultants is an assistant professor, and her major is in hospital management; another consultant is from a different hospital and serves as a supervisor. In-depth interviews were held in May 2009, and the results will be used for constructing a service blueprint systems draft.
.
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Product: semi-structured, in-depth interviews were conducted with an open framework for focused, two-way communication. This was done so that interviewees were free to answer in a flexible way. Interviews were tape recorded and later transcribed. Patients and management interviewed were asked different questions, as listed in Table II and Table III.
From the semi-structured and in-depth interviews with relevant personnel, eight major customer-oriented classifications were collated and arranged as follows.
Selection criteria Was a patient of the hospital Was a volunteer at the hospital Over three years At least high school degree or Above
Member 1 2 3 4 5
Age 54 52 58 55 48
Questions 1. 2. 3. 4. 5. Are you a healthcare worker, staff or consultant of the hospital? What kind of work or services you are responsible for? How effective are hospital services in your opinion? In your opinion, what improvements are needed in hospital services or processes? Any other comments or suggestions?
Participants 9 Table II. Questions for management review committee members in case hospital
Questions 1. 2. 3. 4. 5. 6. Are you a patient or a visiting family member? Why have you come to this hospital before? Do you know what additional services are provided by this hospital? Are you satisfied with the hospital services? In your opinion, which hospital services or processes need improvement? Any other comments or suggestions?
Participants 5
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The first classification is efficiency (results of in-depth interviews; CMS, 2006; IOM, 2001; Gershon et al., 2000): (1) (2) (3) (4) personal health records; flexible mechanisms to suit customers demands; sufficiency of medical resources for providing focused, useful, and adequate healthcare resources based on the characteristics of patients; and suitable healthcare interface to facilitate patient use.
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The second classification is safety (results of in-depth interviews; CMS, 2006; IOM, 2001; Gershon et al., 2000): (1) (2) (3) (4) (5) (6) (7) undertakes risk analysis to prevent abnormal events; reduces risk of infection in healthcare; improves emergency medical aid and security; trains patient to use emergency equipment; encourages patients to participate in medical care; two-way communication to maintain medical safety; and multiple methods to confirm patient identity.
The third classification is patient centeredness (results of in-depth interviews; CMS, 2006; Grime and Poll, 2004; Mitchell, 2001; IOM, 2001; Gershon et al., 2000): (1) (2) (3) (4) (5) focuses on patient rights; health promotion activities which are beneficial to public health; medical staff with good responsive attitudes; humanely designed and easily understood by users; and non-malfeasance.
The fourth classification is timeliness (results of in-depth interviews; Mohan et al., 1999; Jen et al., 2007; Charlotte and Paul, 2006; IOM, 2001; Gershon et al., 2000): (1) provides information and communication services with advanced information technology; (2) (3) (4) quick responses; carries out service provisions under controlled conditions; and service process synchronisation.
The fifth classification is efficacy (results of in-depth interviews; Charles et al., 2006; IOM, 2001; Gershon et al., 2000; Pearl, 1999; ISO 9001:2008): (1) (2) (3) (4) measurement of the medical treatment; continuous improvement in techniques and services; adopts advanced medical equipment; and excellent medical care, human resources, and infrastructure.
The sixth classification is equity (results of in-depth interviews; IOM, 2001; Mooney and Jan, 1997; Lindholm and Rosen, 1998; Lindbladh et al., 1998; ISO 9001:2008): (1) (2) (3) (4) equitable medical treatment; the medical service should break the myth of outstanding doctors and reduce the time of waiting for these doctors; eliminates complaints about treatment inequity; and mutual fidelity and trust.
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The seventh classification is administrative management (results of in-depth interviews; Li and Benton, 2003; Jen et al., 2007; ISO 9001: 2008): (1) (2) (3) (4) (5) determines, provides, and maintains the infrastructure needed to achieve conformity with patient requirements; stronger support and MPs; consistent with the requirements of QMS; monitors information related to patient perceptions; and continually improves the effectiveness of QMS.
The eighth classification is service innovation design (results of in-depth interviews; Li and Benton, 2003; Jen et al., 2007; Raju and Lonial, 2002; ISO 9001: 2008): (1) (2) (3) (4) (5) provides multilingual services; identifies and traces the service by suitable means throughout service realisation; determines action to eliminate the causes of potential non-conformities to prevent their occurrences; provides a barrier-free environment; and communicates with patient in relation to service, feedback, and complaints. Process: in this step, this study followed the method that Flie and Kleinaltenkamp (2004) proposed to embed in-depth interview data into front-office and back-office categories, and the contents of the five-plane lines will be reviewed and confirmed in the next step. Product: summary of in-depth interview data.
The in-depth interview data are divided into front-office and back-office dimensions, and the COPs, SPs, and MPs are engaged in the organisations to increase network value. In the front office, there exists a line of interaction to differentiate service providers and customer activities, and these are the major COPs. When outpatients come to visit the hospital and register, verifying and validating patient identification is essential. During the process of waiting or sequential medical treatment, the rights of patients are promoted and protected by the entire process. There are eight classifications concerning patients which are located under the interaction line and shown in Figure 4.
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Out-patient registration
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Identity verify and validate
Line of interaction Efficiency Safety Patient centeredness Timeliness Treat patient with Efficacy sympathy Equity Administrative management Service innovation design Line of visibility Patients classification Internal communication Medical matters management Educating and training
Line of interna linteraction Out-patient registration information system Transdepartment quality meeting
Patient oriented
Management
Execute
Audit
Continuous improvement
Software
Hardware
Technique
Culture
Human resources
Behind the line of visibility in Figure 4, there are some back-office functions implemented in the internal organisation, which belong to SPs and MPs. Resource support and quality of training are fundamental to hospital execution. Patient classification and medical records can help the patient division to customise and provide medical care services. Internal communication is vital and includes vertical and horizontal communications by trans-departmental meetings within an organisation.
During these trans-departmental meetings, the focus is on the details of QMS. The medical management office first portrays the organisational framework, then sets up the infrastructure and technology (i.e. hardware and software) to facilitate patient care. Human resource development should be regarded and emphasised as a strategy. An organisation manager needs to take the staff seriously and make sure they understand why they are asked to be responsible. Development and improvement should be continued based on complaints and external requirements, such as a third-party audit of the JCI or ISO 9001:2008. Sequentially developing and learning the needs of patients will provide the capability to create feedback loops. Moreover, it allows the customers voice and concerns to be clearly felt throughout the hospital. (4) Step 4: review and evaluate
.
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Process: after the summary of the in-depth interview data is completed, it will be taken to a management review committee for review and evaluation to determine if it is appropriate to meet patients needs and other requirements. The input to the management review shall include information on: results of in-depth interviews; process performance and service conformity; status of preventive and corrective actions; follow-up actions from previous management reviews; changes that could affect the quality management system; and third-party requests. Product: a draft of the service blueprint is established in this step. Process: the confirmation of the service blueprint from the management review committee shall include any decisions and actions related to: improvement of the effectiveness of the quality management system and its processes; improvement of services related to patient requirements; resource needs and allocations; and the purpose of the hospital foundation. Product: a service blueprint based on the ISO 9001:2008 patient-oriented process approach is shown in Figure 4.
5. Conclusion and suggestions 5.1 Conclusion This study primarily concentrates on the development of patient-oriented services; furthermore, a healthcare service strategy is built from the ISO 9001:2008 requirements and blueprint perspective by using the process approach. The contribution of this study is to illustrate the visualisation and organisation with a practical case in a hospital and to describe process activities. The advantage of the process approach of the ISO 9001:2008 quality management system is that it has an ongoing control that provides a linkage between individual processes within the healthcare service system and blueprints.
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In the healthcare industry, the issue of human resources has played a key role in the patient-oriented service strategy, both on behaviours of employees within the organisation and on patients. The ISO 9001:2008 process approach and service blueprint are not merely a technological application for medical caring services, but rather a fully patient-driven, technologically integrated, and diligently implemented one. A service blueprint includes the front office and back office, and the in-depth interviews done in this study were summarised and categorised into lines of interaction, visibility, internal interactions, penetration, an implementation. This paper proposes a hybrid ISO 9001:2008 process approach and blueprint method that can help hospitals to improve resource reallocation and increase process efficiency to meet patient needs by involvement of people who participate in the system. 5.2 Suggestions What makes one hospital different from others? How does a hospital stand out from its competitors? In this study, positioning is the starting point of an organisation for its distinction. Instead of trying to be everything, the customer will know what this particular hospital is and the stand its organisation takes. Patients seldom tell an organisation of its differences from its competitors. To reduce complaints, responses, and requirements, the development of a system for learning patient needs within the ISO 9001:2008 service system has thus become a matter of importance. The implementation of the patient-orientation strategy in a hospital has proven to be in need of supplementation by patient experience. This involves hearing patients voices and emphasises contacts with them in order to understand their requirements. In addition, the removal of service obstacles and conflicts will generate an improved service for the patients.
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Newsome, P.R.H. and Wright, G.H. (1999), A review of patient satisfaction: 2. Dental patient satisfaction: an appraisal of recent literature, British Dental Journal, Vol. 186 No. 4, pp. 166-70. Pearl, W.S (1999), A hierarchical outcomes approach to test assessment, Annals of Emergency Medicine, Vol. 33 No. 1, pp. 77-84. Raju, P.S. and Lonial, S.C. (2002), The impact of service quality and marketing on financial performance in the hospital industry: an empirical examination, Journal of Retailing and Consumer Services, Vol. 9 No. 6, pp. 335-48. Shostack, L.G. (1982), How to Design a Service, European Journal of Marketing, Vol. 16 No. 1, pp. 49-63. Shostack, L.G. (1985), Planning the service encounter, in Czepiel, J.A., Solomon, M.R. and Surprenant, C.F. (Eds), The Service Encounter, Lexington Books, Lexington, MA, pp. 243-54. Shostack, L.G. (1987), Service positioning through structural change, Journal of Marketing, Vol. 51 No. 1, pp. 34-43. Sigala, M. (2005), Integrating customer relationship management in hotel operations: managerial and operational implications, International Journal of Hospitality Management, Vol. 243, pp. 391-413. Van den Heuvel, J., Koning, L., Bogers, A.J.J.C., Berg, M.A. and Van Deijen, M.E.M. (2005), An ISO quality management system in a hospital: bureaucracy or just benefits, International Journal of Health Care Quality Assurance, Vol. 18 No. 5, pp. 361-9. Wilkins, E. (2004), Healthcare employee commitment rises among strong leaders, Managed Healthcare Executive, Vol. 14 No. 6, pp. 44-5. Zeithaml, V.A. and Bitner, M.J. (2000), Services Marketing: Integrating Customer Focus across the Firm, 2nd ed., McGraw-Hill Book Company, New York, NY. Further reading Bala, M.V., Wood, L.L., Zarkin, G.A., Norton, E.C., Gafni, A. and OBrien, B.J. (1999), Are health states Timeless? The case of the standard gamble method, Journal of Clinical Epidemiology, Vol. 52 No. 11, pp. 1047-53. Gowen, C.R. III, Mcfadden, K.L., Hoobler, J.M. and Tallon, W.J. (2006), Exploring the efficacy of healthcare quality practices, employee commitment, and employee control, Journal of Operations Management, Vol. 24 No. 6, pp. 765-78. Mathers, S.A., Chesson, R.A., Proctor, J.M. and McKenzie, G.A. (2006), The use of patientcentered outcome measures in radiology: a systematic review, Academic Radiology, Vol. 13 No. 11, pp. 1394-404. Murad, A.A. (2007), Creating a GIS application for health services at Jeddah city, Computers in Biology and Medicine, Vol. 37 No. 6, pp. 879-89. Sheard, C. and Garrud, P. (2006), Evaluation of generic patient information: effects on health outcomes, knowledge and satisfaction, Patient Education and Counseling, Vol. 61 No. 1, pp. 43-7. Wen-Yuan, J., Chia-Chen, C., Ming-Chien, H., Yu-Chuan, L. and Chi, Y.P. (2007), Mobile information and communication in the hospital outpatient service, International Journal of Medical Informatics, Vol. 76 No. 8, pp. 565-74. Corresponding author Hsiang Ru Chen can be contacted at: g9421809@yuntech.edu.tw
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