GHANA HEALTH SERVICE
CUSTOMER CARE MYSTERY SHOPPING REPORT
22ND MARCH, 2010
The Study was carried out by Dr Cynthia Bannerman - GHS Mrs Susana Larbi Wumbee -GHS Miss Anna Plange - GHS Mr Yaw Brobbey - GHS Miss Nana Yaa Konadu - Ecobank Ms Marina Osei National Service Personnel Winifred Asare National Service Personnel Comfort Boye National Service Personnel Alberta Sarpong National Service Personnel
Chapter 1 Introduction and Background 1 .0 INTRODUCTION The Ghana Health Service has been concerned with the recent public outcry of negative staff attitude in its health facilities and has instituted a customer care program and other strategies to help improve client services. Mystery shopping was conducted in twelve
purposively selected government hospitals and polyclinics in the Greater Accra Region. The study will provide baseline information on customer care practices in these facilities which will be used to review customer care training program and also to improve customer care practices within health facilities as well as building on positive performances observed Mystery shopping is the art of obtaining information on customer service, It is designed to capture the experience of customers and staff, and measure their satisfaction level and performance. It helps to gain insights into their experience at various points of interaction in a particular service environment (Wilson and Guttman 1998).
1.1 BACKGROUND In recent times the word “customer care practice” has attracted much attention in the service industry. The word “customer” has therefore been adopted for clients to give credence and focus on their needs with the view of satisfying them. Customer
satisfaction has now become the priority of every service institution (Goodsell 1998). The reason can be due to obvious competition among institutions offering the same
service. The customer in this perspective has a choice and would patronize the institution that satisfies his or her needs. It is not surprising that customer satisfaction has become the core goal in organizations. This is because satisfying a customer enhances an organization’s reputation and reduces loss of revenue because it is likely for the customer to return and even bring along new ones. Exhibiting poor staff attitude can discourage clients from coming back again. Poor staff attitude has created a bad public perception of health care workers in Ghana. The evidence reflects in comments by the public following health staff rampant strike actions, discussions on radio and television programs (Mmaa Nkomo) and reports of service providers to their regulatory bodies by clients. Health service providers
explain that their work schedule is too much to allot them enough time to relate well with their clients. Others have also cited long working hours and low incentives as some of the reasons that hinder them to engage to come out with their best. These may be
genuine concerns but in spite of these the public reaction clearly indicates that their confidence in health staff is eroding fast. The Ghana Health Service is committed to the delivery of client focused, quality health services. In the provision of services the clients’ needs and expectations must be met. It is therefore important that health staff promote good relationship with clients, their support persons, communities and even fellow health workers. Such an approach will not only promote good customer relations but enhance the corporate image of the GHS. It is based on these developments that the customer care program was launched. A training manual, posters and video tapes for customer care training of all health care providers within the Ghana Health Service outfit has been developed by a task team at
the headquarters with support from Ecobank. The training manual was pretested at Tema General Hospital. However it is necessary to have some baseline study before training is rolled out to the other health facilities. The information will be used to improve the training program and customer care practices. It will allow for evaluation at the end of the training in order to assess how the training has impacted customer care practices at the health facilities.
One aspect of organizational performance that receives less attention in the actual process of service delivery is customer care. The quality of customer service provided by frontline staff to citizens should be important to administrators because “courtesy and friendliness become important not as ends in themselves, but because customers delight in courteous and friendly treatment and uses them to assess quality of service” (Fountain 2001).
Poisant (2002) suggests that “to analyze customer, or citizen experiences, an organization must put itself in citizens’ shoes and ask questions about how they are greeted, the appearance of frontline staff, and the aesthetics of the office place”. Such an approach is usually achieved by “Mystery Shopping”. Mystery shopper, or secret shopper, is an independent contractor who visits your establishment unannounced, interacting as a customer to provide objective quantitative and qualitative feedback about the experience (Grove and Fisk 1992). A mystery shopper makes inquiries and observations and notes specific details about the reception, environment and the level of customer service provided. How much time elapsed before the mystery shopper was greeted, and what was the tone of the greeting? Was the secret shopper treated courteously throughout the visit? Were the service providers knowledgeable about their work, and did they provide effective assistance? Was the location clean, organized, and ready to welcome customers? www.Beyondhello.com/services The literature on mystery shopping indicates that
organizations use it as customer surveys or a feedback technique that focus on the process of service delivery rather than on the outcome of a service encounter. To undertake mystery shopping it is important to identify the standards most important to customers and most critical to the success of your organization. This is used to produce a standard set of questions with marks allotted to each question. At the end of the mystery shopping assignment, the shopper completes all information on the questions.
Mystery shopping is not all about ﬁnding faults in performance and decor, so they can be corrected, however capable and experienced the ‘shoppers’ it is also for what’s being done right! That’s because it’s easier to build on positive performance (e.g. smiling during conversations and personal interviews (Rouleu 2007). It can be used anytime and at anyplace and considered as a performance evaluation tool over time. It can therefore be re-used as appropriate to ensure positive customer care experience by clients. http//www.Manufacturedhousing.org
Mystery shopping can be seen as a participant-observer evaluation method that can be used to measure the quality of customer service provided by frontline staff (Grove and Fisk 1992). Mystery shoppers can be thought of as participant evaluators who make multiple, covert observations that focus on the service-delivery aspect of programmatic effectiveness (Patton, 1990).
There are three schools of thoughts on who should be mystery shoppers. One aspect says professional shoppers should be used because they are almost always capable, experienced and motivated people. Others prefer to employ freelance personnel as shoppers who are employed to work for realty fee. This is best done by staff who’ll take the time to train and practice with a novice shopper. There’s also the “do it yourself ” approach to mystery shopping this is less expensive, less detailed, far less effective, but easier to schedule (Leeds, 1995)
Mystery shopping uses a trained observer posing as a client or customer to contact agency offering service. The technique focuses on “activities and procedures that do or do not occur rather than gathering opinions about the service experience” (Wilson 2001) In addition to this fundamental training, the nature of mystery shopping requires shoppers who are “objective, smart, and able to think on their feet” (Leeds 1995). The validity of the mystery shopper technique hinges on the employee believing that the observer is in fact a real customer, not an “undercover” evaluator. To both protect the anonymity of the shopper and to increase positive interactions, mystery shoppers may follow a script, or scenario, to solicit responses from the employee or service providers. Immediately after the interaction, the shopper or evaluator rates the quality of customer service received based on an established set of criteria.
Although mystery shopping is a valuable tool for assessing the quality of customer service, its inﬂuence can be short-lived. Without an ongoing commitment from management to reinforce service standards, “the novelty of being shopped can wear off,
leaving personnel complacent about their service and lacking motivation to take steps to improve it further” (Wilson, 2001). The technique of mystery shopping perhaps works best when coupled with other measurement devices, such as general customer service surveys, and followed up with a concentrated training component for management and staff alike.
The importance of quality customer service in the health sector cannot be overstated. Because any given citizen only periodically comes into contact with health personnel, those few experiences are greatly inﬂuential on that citizen’s perception on the quality of
care. For this reason, any Mystery Shopping program serves as a valuable measurement tool for continuously assessing employee-customer interactions. If the program is replicated, participants are encouraged to take responsibility for seeking ways to use the data produced by the shoppers to routinely address areas needing improvement.
CHAPTER 3 METHODOLOGY 3.0 THE PROBLEM Customer care as a service discipline has not received much attention in health care delivery in the country until recently when efforts have been made in health service delivery to offer client focused services to clients. The problem of poor customer care has to do with the professionally and technically oriented nature of the training of health workers with little or no emphasis on customer care in the nation’s training institutions. Thus the average health care worker is not exposed much to the principles of customer care during training or even given adequate in–service training on customer care during employment. This means that the average health care worker, though adequately equipped with what (technical skills) it takes to deliver the service, they lack the customer care skills of service delivery. This factor among many others is what has contributed to poor staff attitude and bad customer care practices.
The rampant corporate problem that destroys an organization’s reputation, morale and services is poor staff attitude which often generates customer complaints. The
challenge is therefore to build a culture that uses customer concerns as an opportunity for even greater service and loyalty, also creating team pride and an identity that relishes excellent service. The health service encompasses different sectors, the
output of each area is crucial to maintain a good reputation. Poor work ethic is an affront to an enthusiastic competent health service whose frontline staff approach their work with a genuine desire to serve clients to ensure customer satisfaction. Mystery shopping is a strategy that is undertaken to know whether services meets customer needs. The results help to plan and evaluate effective customer care programs, improve facility performance and tailor customer service training for employees.
3.2 OBJECTIVES • • Assess customer care practices in selected health facilities Collect data to improve on GHS Customer Care Program for health care providers • Provide a baseline to evaluate the effect of customer care training program on customer care practices in the selected region
3.3 METHODOLOGY Twelve health care facilities was purposively selected for the Mystery shopping. They are Ridge hospital, Adabraka polyclinic, La polyclinic, Kaneshie polyclinic, Maamobi polyclinic, Tema hospital, Ashiama Health Center, Dansoman Health Center, Korle-Bu polyclinic, Usher Fort Clinic, Amasaman hospital and Madina Health Center. The scope of the mystery shopping was limited to the Out Patient Departments of these facilities. The focus on the outpatient is because that is where majority of patients are seen.
A mystery shopper initiated an interaction with a service provider in obscurity at the O.P.D. The anonymity of the mystery shopper was essential to get the right information that depicts the reality on the ground. The encounter was to know how clients are treated when they come into contact with service providers, in other words the details of what actually occurs at the key moment of customer - health provider interaction. The interaction afforded the opportunity to also examine the appearance of the facility. A total of four National service persons were trained to undertake the mystery
shopping. One day training session was organized for them to know how to carry out mystery shopping. Each trained mystery shopper visited six health facilities that was not familiar to her as a sick person and went through the process on OPD consultation. This strategy was to make the mystery shopping effective.
3.4 DATA COLLECTION Purposive sampling was used for data collection. Each health facility was visited twice a day that is morning and afternoon by different mystery shoppers. This approach was to have a blend of what happens during the morning and afternoon at the Out Patient Department. The mystery shoppers used a questionnaire that reflects the benchmarks of the customer care. They reported back with detailed and objective information that helped to determine how their experience measured up to the customer care service standard. 3.5 ETHICAL CONSIDERATION Names of individual staff were not collected and findings not linked to individuals.
Data collected was available only to the research team. The immediate benefits will be to improve customer care practices to patients/clients. It will also help improve content and evaluate the customer care training program for staff and will contribute in the long term to improve the image of GHS health facilities. The risks involved were negligible with no harm to individuals or the facilities. The findings were not to be used to penalize any member of staff or health facility.
CHAPTER 4 FINDINGS The findings of the Mystery shopping are presented under the following headings according to the questionnaire used by the Mystery Shoppers. 4.1 External and Internal Appearance of the Hospitals The external appearance of the hospital compounds was generally clean; dustbins were covered and placed at vantage points. However, in one or two of some of the dustbins were not covered especially the small bins therefore those places were littered in other places the dustbins were inadequate. Most of the facilities have clearly visible directional signs to the entrance The following were observed with some sign posts • • • . There was sale of food at the entrance of a few facilities and in some instances peddlers were selling toiletries. Fading Covered by tree branches or telephone pole Overshadowed by advert of the sponsoring company
With the internal appearance most of the floors, windows, counters and furniture were clean. In only a few facilities were some furniture and windows found to be dusty. The facilities have internal directional signs showing clients to service areas which are labeled. A few of these signs had their writing peeling off
4.2 Registration and Waiting Areas Patients were seen in the mornings and afternoons but in one facility after 1.20pm the nurse asked patients to go to a nearby private hospital as the only prescriber on duty was tired since he has been working from morning There were two cards in use the old card and the new GHS folders. The fee schedule for the various facilities and type of cards issued are shown in table 1.
Table 1 Fee Schedule Type of facility
Hospitals (folders) Polyclinics (Cards)
GHc4 (2), GHc 5.50 (1) GHc2 (2) GHc3 (1) GHc 3.50 (1) GHc 5 (1) GHc4 (1)
GHc4 (1) GHc5 (2)
Polyclinics +HC (Folders)
GHc5 (2) GHc5.05 (1)
The fees were not standardized across board and even in 2 of the facilities the charges were different for the morning and afternoon visits. “The amount charged on registration is GH⊄ 5.00 in the afternoon and GH⊄ 4.00 in the morning, receipts were issued”. Yet in another facility the morning fee was GHc5.50 and afternoon fee was GHc5
Receipts were issued in all facilities. It was surprising to find that some of the receipts did not tally with the amount paid. Unfortunately mystery shoppers did not check immediately what had been written on the receipt, it was when they had reached home that this was noticed “I was issued a receipt but on the receipt, GHC 5.05 was written
instead of ¢5.50p”.This happened in 2 different facilities and the circumstances at that time did not indicate human recording error. The mystery shopper who used her NHIS card did not pay any registration fee and was not treated differently from fee paying patients Another practice that was observed was the lamination of identity cards at the records department. The lamination fees charged were GH⊄ 0.30p, GH⊄ 0.50p and GH⊄ 1, No receipts were issued. These fees were optional or compulsory depending on the facility. Record staff in a facility were buying second hand clothing and did not even acknowledge the presence of patients.
OPD waiting room/ screening area
In most of the facilities, morning devotion precedes the day’s activities during that time every activity come to a halt. After that a nurse gives health education talks and shows the patients where they can locate the washrooms, lab, X ray etc. There were bulletin boards in several facilities where posters on health education were displayed however there were no health education leaflets for patients/clients to read whilst waiting or to take home. Some posters were scattered on the walls and some of them look very old and worn out.
Facilities also had television sets in their waiting rooms. The televisions were either switched off or showing films. Suggestion boxes were also present at the OPD but had no papers and pens. Most facilities have their O.P.D crowded with poor ventilation. The place can be very hot. They were delays at the OPD; Some OPD staff did not call patients according to the queue as they favored some patients over others. This made waiting clients to be agitated. There was an incident where the mystery shopper was not present when the nurse called out her name, when she came back and informed the nurse, instead of her being called with the next batch of patients she had to wait till the third. A batch consists of 1020 patients. In another facility where a man had reported at 7.00am with his sick child and had not been attended to by 10.00am, when he complained was told to go away, this resulted in a scene at the OPD. Yet in one facility when the mystery shopper informed the nurse she was not around when her name was called out, she was immediately asked to see the prescriber. Some facilities charged Gh¢ 2.00 at the OPD for testing diabetes without issuing receipt. Some of the facilities have laboratory attached to the OPD but most of them do not work in the afternoon. In one of the facilities a staff directed one patient to go a laboratory outside the hospital for his tests.
Patients also had to pay an amount of GH¢0.50p at some facilities before they could the washrooms.
Some incidents that occurred at the screening area are described below. “When one of us got to the screening room, she was expecting the nurse to ask her to sit before she does so. Instead, she shouted at her and rudely asked whether she was afraid of her”. “As the nurse at the screening area was taking my blood pressure, she was busily chatting with someone which the afternoon patient later got to know to be the doctor on duty. The doctor had moved from the consulting room and was sitting at the OPD waiting area watching television and at the same time busily engaging the nurse at the screening area in a conversation. My appearance did not even discontinue their conversation. When the nurse told him there is a patient, he said “I am tired, I wish we have closed. Take the lead to the consulting room; I will be with you soon”.
4.4 Consulting Room During consultation some of the prescribers probed further after patient gave symptoms of their illnesses and took their time to explain the patients’ condition to them whilst some didn’t. Others seldom asked patients questions. One prescriber had time to draw the abdomen using it to explain something for the patient. Most prescribers were
friendly but others were not polite and complained about work load. In some facilities because of shortage of health staff, there were delays in accessing services at the consulting room.
‘Being the 14th patient to see the doctor, it took 2hours, 30minutes before one of us finally met the doctor because the consulting room was supposed to have two doctors but one left to Accra. The one present was also busy seeing to “protocols” whilst we kept waiting. There were illegal chargers at the consulting rooms of some facilities. In some facilities the amount charged was as high as GH⊄5.00 without any receipt. ‘At the consulting room, one of us was asked to pay an amount of GH ⊄ 1.00 which I did not hesitate. Later, I asked two other patients who also went to see the same prescriber who said they also did likewise. I then asked another patient who went to a different consulting room and she replied no’. Again, I questioned the lady at the revenue service point if patients had to pay for consulting fee in the consulting room but she said ‘no’ and was ignorant about such a practice. I then went back to the consulting room when the prescriber had left and requested for a receipt from the ward assistant who was in house attire. To my surprise, she said “there is no receipt for the money you paid, the money collected is just a token for the prescriber. If you really want a receipt, then wait for the prescriber to come back.” The doctor was so nice to me that, I could not wait to question her about it. In one of the facilities, a prescriber agreed to see a patient who had jumped the queue for a fee which was bargained, agreed on, and the amount paid in front of the mystery shopper was then in the consulting room. In another situation where the mystery shopper was asked to pay GHc5 in the consulting room and she said she did not have money, she was allowed to go without paying
One mystery shopper had to buy and pay for some drug from the prescriber in the consulting room.
It was observed that the shifts were not properly managed, prescribers sometimes left even though their relievers had not come.
4.5 Staff Attitude The staff in majority of the facilities did not wear name tags, some staff also wore mufti to work. Some of the staff showed good behavior. They were described as Polite Friendly Welcoming Proactive Courteous Maintaining good eye contact
On the other hand some were also described as Cold Shouting at patients Irritated when asked questions Used impolite words Buying second hand clothing Rude Unresponsive to patients questions Disrespectful Doing their own things instead of seeing to patients instead of working
In most of the facilities “greeting was a problem, patients had to greet about three times without response”. Some staff were rude and impolite: When the ward assistance was mentioning the names of the first ten patients to see the doctor, some cards fell but she did not organize the cards in the right order. A lady patient got annoyed and tried to draw her attention to that but the ward assistant spoke rudely to her “should I stop mentioning the names”, she said it amidst chewing gum.
“We also encountered some negative attitude at the records and waiting area. Two young nurses in mufti attacked a patient, who thought they were laughing at her. This created a scene at the OPD.” A doctor showed no compassion when he was informed that a patient with Haemoglobin of 3gms had been brought to the facility in an ambulance. He was annoyed and asked why the patient was brought without prior phone call to the facility and for that matter the accompanying nurse should take the patient back and phone. This he said would teach her a lesson. But for the intervention of the consulting room nurse who begged the doctor and took it upon herself to go and look for a bed this patient might have been turned away. All this happened in the consulting room in the presence of the mystery
Complaints/Information desk There were complaint desks in most of the facilities but they were not manned In one facility security men manned the desk, apart from this facility that has complaint forms all the other facilities did not have complaint forms. They had registers A member of staff got irritated when asked for direction to the complaints desk
Notable incidents These are presented in a verbatim report of the Mystery Shoppers
1. The nurses were attending to their favorite who came in late at the expense of
the other patients when we were waiting at the OPD waiting area. For instance, the morning patient got to the clinic by 7:00a.m and later met this calm man with his sick daughter of about five years of age at the OPD waiting area. She did not meet them at the records, so it meant they had come earlier than she did. It was almost 10:00a.m and the child had not been called for screening. Some people we witness holding their cards and had just passed by were attended to all in the name of “protocol”. Occasionally we witnessed the “khaki nurse” go through the cards in the box and removes particular ones and called them to them to be screened. In fact, it became too much though few truly needed that immediate attention, the gentleman had to approach the “pediatric nurse” since his child was also very sick. She did not hear exactly what he told the nurse but she asked him to go away. The man got angry even though he did not insult the nurse; he wanted the other nurses to hear him out. It took the intervention of the senior nurse (in green belt) and a patient to calm the situation. The scene was appalling. 2. A nurse was able to convince a doctor to admit a patient referred from Pantang hospital and whose HB was 3.0. The doctor had wanted to punish the nurse who
accompanied the ambulance since he did not follow the lay down procedure to refer a patient to the hospital. 3. Delay in change over.
4. Mystery shoppers felt prescribers were few during this period therefore patients
waited longer before seeing the prescriber.
DISSCUSSIONS The Mystery Client study has brought out a lot of information about customer care practices in the selected health facilities. There are positive performances that have to be reinforced and negative attitudes that should be worked on It is encouraging that facilities are keeping their external and internal environments clean and attractive, however more covered dustbins should be made available at the OPD and hospital grounds and patients educated to put their general wastes in these containers The Outpatient departments were found to be crowded, hot and poorly ventilated. Most of the facilities are old and have inadequate space for expansion. The introduction of national health insurance in the country has removed financial barriers and increased access to health care thus the high patient load at the OPD. The large numbers of patients in poorly ventilated areas may pose potential threat for spread of respiratory infections particularly in this epidemic of H1N1. Whilst very little can be done about the infrastructure, improving work processes and some reorganizations and introducing innovations may help to reduce to reduce the volume of patients at the OPD
. Some staff were friendly and polite while others were rude. Most had no name tags, this is difficult for them to be identified with any untoward incident. There were variations in the amounts charged at the records unit for registration at the same facility. Although collection of money is dissuaded in consulting rooms some prescribers were charging money to the tune of Gh¢5.00 before attending to a patient. Others sell drugs which should have been done at the pharmacy unit with National Health insurance especially for those who have registered. It was found out that some clients were referred to private health facilities which is questionable, it was not known whether the facility has any arrangement with the private hospital. This would have been important because patients usually pay more in the private health facilities. Information desks in majority of the facilities are not manned, in such an instance where and how do patients channel their concerns, there were no complaint forms.
RECOMMENDATIONS In facilities where available covered dustbins are not enough, it is recommended that additional bins should be provided to help maintain a clean environment. Also even though most facilities used in the study, have sign board directing people to the facility some are fading and should therefore be changed for easy identification of the facility by newcomer to the facility. Based on the findings of the study, it is recommended that name tags should be provided for all health workers for easy identification. This will help to deal with the
negative attitude of staff, since they would be easily identified for any untoward behaviour. The study found too much delay in the health delivering process an issue which should as a matter of urgency be addressed so that more people would be attended to and on time. Need to look at the flow of patients, the mystery shoppers spent about 2-5 hours. There should be reorganization of the service areas to make access to them faster to save some time, other strategies must also be considered. There should be a way of staff to run the shifts effectively to prevent situations where health professionals leave when the replacement is not ready, causing a lot of delays. They study found that most facilities visit have no staff manning the information desk, thus patients have nowhere to go to make enquires. It is also recommended that the Institutional Care Division of the Ghana Health Service should design complaint forms for use in all health facilities so that patients who have complain can write them and such complains when received should be acted on immediately. Also health brochures and leaflets should be made available at the OPD for patients to read as they wait for services. Instead of the patients watching films of all kinds GHS should develop DVD on health issues for the OPD’s. It is again
recommended that trained supervisors are assigned to consistently observe activities of the OPD and attend to customer care practices. Staff who demonstrate good customer care practice should be rewarded, those who exhibit contrary behaviors should be sanctioned. All health workers should be trained in customer care, since most health
staff have the technical knowledge required to effectively carry out their work but lack the customer care skills to be able to satisfy their patients completely. Finally and most importantly, mystery shopping should be done in all health facilities and be part of the Customer Care Training program. Trainers can use the results to review their training contents and include some of the positive and negative incidents as case studies during their training sessions.
CONCLUSION The mystery shopping carried out in twelve selected health facilities in the Greater Accra Region will form a baseline data to inform the content of the customer care training programme soon to be rolled out is all health facilities in the country and also to evaluate the customer care training programme. In most facilities where the study was carried out, both the external and internal appearance of the facility were clean. Some staff encountered in the course of the study were polite and friendly, others on the other hand were rude. Certain negative incidents were reported including collection of illegal fees to which no receipts were issued.
The study therefore recommends that customer care training should be organized for all categories of health workers to sharpen the customer care skills of all staff to be able to satisfy the clients completely.
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