Study on safety and Quality of health care system in India

Submitted in the partial fulfilment of the requirements for the

award of the degree in

MASTER OF BUSINESS ADMINISTRATION

By Shama Zakir Khan
(215012301290)

Under the guidance of

Dr Kasthuri

FACULTY OF MANAGEMENT STUDIES

Dr M.G.R.
Educational and
Research Institute
(Deemed to be a university)

Maduravoyal, Chennai-600 095

(An ISO 9001-2008 certified Institution)

University with Special Autonomy Status

November / 2022

i
 DECLARATION

I Shama Zakir Khan hereby declare that the Project Report entitled
Study on Quality and Safety of Healthcare System in India is
done by me under the guidance of Dr Kasthuri is submitted in
partial fulfilment of the requirements for the award of the degree in
MASTER OF BUSINESS ADMINISTRATION.

DATE: 15th November 2022

PLACE: Salem, Tamil Nadu, India SIGNATURE OF THE CANDIDATE

ii
 ACKNOWLEDGEMENT

To acknowledge here, all those who have been a helping hand in completing
this project shall be an endeavour in itself

I am highly thankful to our Chancellor Thiru A.C.SHANMUGAM, B.A., B.L., our

President Er. A.C.S. ARUN KUMAR, B.E.

I express my sincere thanks to our Secretary Thiru A. RAVIKUMAR and our Vice
Chancellor Dr S.GEETHALAKSHMI I would like to take the opportunity to express
my profound gratitude to Dr S.NIRMALA SUGIRTHA RAJINI, Dean of Online
Programmes and also express my special thanks to Dr G BRINDHA, Professor &
Head Faculty of Management Studies.

I thank Dr Kasthuri for guiding me to execute my summer project.

I owe my wholehearted thanks and appreciation to the entire staff of the

company for their cooperation and assistance during the project.

SHAMA ZAKIR KHAN

Name of the Student

iii
 TABLE OF CONTENTS

ABSTRACT............................................................................................. vi-vii

CHAPTER 1 –

​ 1.1 - INTRODUCTION .................................................................................... 01

1.2- INDUSTRY PROFILE ............................................................................. 02-07

1.3- OBJECTIVES OF THE STUDY .............................................................. 08

1.4- IMPORTANCE OF THE STUDY ..............................................................09

1.5- SCOPE OF THE STUDY ...................................................................... 10-11

1.6- LIMITATIONS OF THE STUDY .............................................................. 12

CHAPTER 2 – LITERATURE REVIEW ....................................................... 13-27

CHAPTER 3 – RESEARCH METHODOLOGY ........................................... 28-29

3.1- RESEARCH DESIGN

Research Hypothesis & Methodology

Data Analysis
Sample Size
Data Collection Approach

iv
CHAPTER 4 – DATA ANALYSIS AND INTERPRETATION ..................... 30

CHAPTER 5

5.1 - FINDINGS

5.2 SUGGESTIONS

5.3 CONCLUSION

REFERENCES ............................................................................................. 50-52

APPENDIX – QUESTIONNAIRE ................................................................. 53-55

v
 ABSTRACT

This project endeavours to form a key vision to empower India's stroll in

public clinic way to convey a larger amount of patient fulfilment Quality. The
study aims to determine if there are any critical differences in the level and
sort of healthcare administrations In India's public and private hospitals as
recognized by patients. And To identify the safety and quality dimensions
which play an important role in patient satisfaction. This is quantitative,
descriptive and explanatory, and to some extent exploratory project. It
follows the survey strategy approach and consists of the survey instrument.
This study is conducted in two major hospitals in India. The questionnaire
was randomly distributed to the five most busiest and crowded clinics in
Indian hospitals. The total size of the sample is 125. The data analysis is
obtained by using different statistical techniques like percentage analysis,
bar charts, etc.

Research Questions:

1. How long do the patients have to wait in the Out Patients Department?
2. Where are the patients coming from?
3. How many critical patients are being admitted to public hospitals or
private hospitals in India for further treatment?
4. What sorts of preparation for formal quality systems are available for health
professionals?
5. What evidence is there about the best techniques for preparing
clinicians for quality change? The study covers two hospitals in India:

(a) KEM Hospital Mumbai, India

(b) Lokmanya Tilak Municipal General Hospital, Mumbai, India

vi
Samples Taken: 125

The following are the bird’s view of the details included in the chapters of the study

Chapter 1 deals with a brief introduction to the project followed by

the industry profile, importance, limitations and scope of the study

Chapter 2 deals with the review of literature relevant to the topic and the company
profile

Chapter 3 renders the methodology of the research, which includes

objectives, research design, data collection, sampling, analytical tools
adopted in the study and the limitations of the study.

Chapter-4 deals with the analysis of the data collected with the help of various
statistical tools and summarizes the entire process of the current research through
a briefing about the various findings and suggestions.

Finally, it gives the conclusion drawn by the researcher on the study.

vii
 CHAPTER 1

​– INTRODUCTION

The role of the Indian government in the accountability of hospitals for quality
of care involves shaping the community of those interested in quality,
developing methods and infrastructure, standardizing information, providing
information and technical assistance, and patient care.

Several state governments in India have begun standardizing and providing

quality information and this role is also assigned to the government in several
reform proposals. Enforcing standards, including licensure and certification, is
the most widely understood governmental role; states license whereas the
government certifies compliance with Medicare conditions of participation
either directly or through accreditation by the Joint Commission. These
standards are evolving rapidly. Only recently has the government taken on
the role of providing technical assistance for quality improvement.

We analyze the causal impact of competition on quality at hospitals both in

India and Other countries. To address the variables of market structure we
analyze the hospital sector in India where entry and exit are controlled by the
central government. We find that higher competition is positively correlated
with management quality, measured using a new survey tool. Adding a rival
hospital increases the quality of hospitals from the patient’s perspective
through research and increases survival rates from emergency diseases.

1
– INDUSTRY PROFILE

INDIAN HEALTHCARE INDUSTRY:

Healthcare has become one of India’s largest sectors, both in terms of revenue
and employment. Healthcare comprises hospitals, medical devices, clinical trials,
outsourcing, telemedicine, medical tourism, health insurance and medical
equipment. The Indian healthcare sector is growing at a brisk pace due to its
strengthening coverage, services and increasing expenditure by public as well
private players. India’s healthcare delivery system is categorised into two major
components public and private. The government, i.e. public healthcare system,
comprises limited secondary and tertiary care institutions in key cities and focuses
on providing basic healthcare facilities in the form of primary healthcare centres
(PHCs) in rural areas. The private sector provides the majority of secondary,
tertiary, and quaternary care institutions with a major concentration in metros and
tier-I and tier-II cities.
India's competitive advantage lies in its large pool of well-trained medical
professionals. India is also cost-competitive compared to its peers in Asia
and Western countries.

Indian Healthcare industry is a wide and intensive form of services which are
related to the well-being of human beings. Health care is the social sector
and it is provided at the State level with the help of the Central Government.
The healthcare industry covers hospitals, health insurance, medical software,
health equipment and pharmacy in it.

The major inputs of health care industries are as listed below:

1. Hospitals
2. Medical insurance
3. Medical software
4. Health Equipment

2
 Different types of health care services are available in India

● Hospitals
● Pathology Clinics
● Blood Banks
● Meditation Centres
● Emergency services like Ambulances, etc.
● Online Medical Services
● Telemedicine
● Naturopathy
● Yoga Centres
● Fitness Centres
● Laughter Clubs
● Health Spas

In the Constitution of India, health is a state subject. Central govt’s

intervention to assist the state govt is needed in the areas of control and
eradication of major communicable & non-communicable diseases, policy
formulation, international health, medical & para-medical education along
with regulatory measures, drug control and prevention of food adulteration,
besides activities concerning the containment of population growth including
safe motherhood, child survival and immunization Program.

Another major component of the central sector health programme is purely

Central schemes through which financial assistance is given to institutions
engaged in various health-related activities. These institutions are
responsible for contributing to the field of control of communicable &
non-communicable diseases, medical education, training, research and
parent -care. In our project, our focus has been the hospital sector which is
the major component of the healthcare industry.

3
Factors Attracting Corporates in the Healthcare Sector

Recognition as an Industry: In the mid-’80s, the healthcare sector was

recognized as an industry. Hence it became possible to get long-term
funding from Financial Institutions. The government also reduced the import
duty on medical equipment and technology,

Socio-Economic Changes: The rise in literacy rate, higher levels of

income and increasing awareness through deep penetration of media
channels, contributed to greater attention being paid to health.

Brand Development: Many family-run business houses, have set up

charity hospitals. By lending their name to the hospital, they develop a good
image in the markets which further improves the brand image of products
from their other businesses.

Opening Of The Insurance Sector: 60% of the total health expenditure

comes from the self-paid category as against the government's contribution
of 25-30%. The opening up of the insurance sector to private players is
expected to give a shot in the arms of the healthcare industry. Medical
equipment, Medical Software and Hospitals will see the biggest boom.

THE SERVICE MARKETING TRIANGLE:

4
 ⮚ Company: Here, the hospital is the company that dreams up an idea

of service offering (treatment), which will satisfy the customer’s

(patient’s) expectations (of getting cured).

⮚ Customer: The patient who seeks to get cured is the customer of

the hospital as he is the one who avails of the service and pays for it.

⮚ Provider: The doctor, the inseparable part of the hospital is the

provider, as he is the one who comes in direct contact with the

patient. The reputation of the hospital is directly in the hands of the
doctor. A satisfied patient is a very important source of
word-of-mouth promotion for the organization.

UNIQUE CHARACTERISTICS:

The service industry has the following characteristics.

5
1) Intangibility:- Intangibility means that a customer would have to visualize the
service offering. Since the offering cannot be seen or felt there would be no
stock and hence one would not be able to keep track of the sales etc. This
characteristic also makes it different to measure the benefits and utilities of the
product. An individual would only be able to experience the same.

In the product service continuum, hospitals fall in the bracket of highly intangible
where the service has credence qualities.
i) The services of a doctor i.e. the consultation provided by the doctor, his
diagnosis etc cannot be touched felt or seen. One can only visualise the
same.
ii) They can also not measure the benefits. These can only be experienced
by the customer.
There is no ownership over the doctor or the services provided by him.
The remedial measures to overcome intangibility are
a) The marketer should visualize the product/service for the patient. In the
case of hospitals, any visual of the hospital displaying the well-maintained
interiors, and the hi-tech equipment used for treatment would help to
tangibles of the product.

b) Association: - The association of a hospital with any well-known

personality would help as a good image-building exercise. It would also
give the customer a certain level of confidence regarding the services
provided in the hospital.

For (eg 1)- Hospitals like the Tata Memorial Hospital or the Hinduja Hospital are
associated with Corporate Houses. They are owned by these corporate families.
Hence a customer is sure about the services provided in these hospitals.
(eg 2)The Dinanath Mangeshkar Hospital. Since it is owned by Lata Mangeshkar
the customer is sure to receive quality services.

6
b) Physical Representation:-

Intangibility could also be overcome in the case of a hospital through physical

Representation in the form of:-

1) Color- The Red Cross signifies the Hospital.

2) Uniforms- The white uniforms of the Doctors And Nurses in enemy hospitals.
3) Symbols – The Red Cross is the common logo with which people identify
hospitals. Also logos of hospitals like Wockhardt.
4) Buildings – In the case of hospitals the external appearance of the building or
the maintenance i.e. how well maintained it is

d)Documentation –There are several hospitals which have received ISO 9000
certificates. (Eg) Apollo Hospital.

2) Perishability
A service cannot be stored. So if the service is not consumed immediately then it
loses its value.
For Eg – If a doctor does not reach his dispensary on time or has his clinic locked
for that particular day. He loses all his patients for that day.

A situation may also arise when the doctor may be unable to attend to some of his
patients due to a huge rush. In such a case again the doctor could lose out on all
his patients. The same would be the situation faced by the hospitals. In such a
case the hospital too may lose all its patients for that day.

_____________________________

7
 OBJECTIVES OF THE STUDY

● To determine whether there are any critical differences in the level and
sort of healthcare administrations In India's public and private
hospitals as recognized by patients.
● To identify the safety and quality dimensions which play an important
role in patient satisfaction
● To test the dimensionality of the healthcare system in India between
public and private hospital.
● In a few studies it was presumed that the exchange capacity of
Service Quality scale to distinctive administration setting required to be
tried. Inquire about on health care industry has demonstrated that the
five nonexclusive sizes of Service Quality were not further affirmed
showing the need for further research directed at examples from
diverse parts of the planet. The project additionally endeavours to form
a key vision to empower India's stroll in public clinic way to convey
larger amounts of patient fulfilment Quality

8
– IMPORTANCE OF THE STUDY

It is noted that every year, hundreds of thousands of patients around the

world suffer injuries and even die due to unsafe and poor-quality healthcare
and the case in our country is no different. It is universally accepted that
quality health services globally must be effective, safe, and people-centric.
Also, to realize the benefits of quality health care, health services must be
timely, equitable, integrated, and efficient. Patient safety is considered
fundamental to delivering quality essential health services. To that end,
Patient Safety is defined as a healthcare discipline that is continuing to
emerge with the evolving complexity of healthcare systems. It is aimed to
prevent and reduce risks, errors, and harm that could occur to patients
during the provision of health care.
A study of differences between public and private sector medical care will
provide a clear picture of the status of complete medical service in India
thereby enabling us to come up with all the possible ways to overcome the
drawbacks of each sector and progressively work on it for a healthier and
safer India.

As the ultimate role of healthcare is to develop a happier and healthier

civilisation the aim of studying quality and safety and its various dimensions
is to satisfy patients and fulfil all their valid needs of living life in a dignified
and safe manner. This study focuses on this aspect and aims to To identify
the safety and quality dimensions which play an important role in patient
satisfaction.

9
– SCOPE OF THE STUDY
The role of the Indian government in the accountability of hospitals for
quality of care involves shaping the community of those interested in
quality, developing methods and infrastructure, standardizing information,
providing information and technical assistance, and patient care.

The government's role in shaping an atmosphere of trust or distrust is critical

but underestimated. The research and development of methods and
infrastructure is widely acknowledged and many health systems' reform
proposals emphasize it. Several state governments in India have begun
standardizing and providing quality information and this role is also assigned
to the government in several reform proposals. Enforcing standards,
including licensure and certification, is the most widely understood
governmental role; states license whereas the government certifies
compliance with Medicare conditions of participation either directly or through
accreditation by the Joint Commission. These standards are evolving rapidly.
Only recently has the government taken on the role of providing technical
assistance for quality improvement. We analyze the causal impact of
competition on quality at hospitals both in India and Other countries (from the
patient’s perspective). To address the variables of market structure we
analyze the hospital sector in India where entry and exit are controlled by the
central government. Because closing hospitals in areas where the governing
party is expecting a tight election race is rare due to the fear of electoral
defeat, we can use political marginality as an instrumental variable for the
number of hospitals in India.
RESEARCH METHODOLOGY
This research is considered quantitative, descriptive and explanatory, and to
some extent exploratory. It follows the survey strategy approach and
consists of the survey instrument. This study is conducted in two major
hospitals in India. The questionnaire was randomly distributed to the five
most busiest and crowded clinics in Indian hospitals. The total size of the
sample is 125. The data analysis is obtained by using different statistical
techniques like percentage analysis, bar charts, etc.

10
 CHAPTER DESIGN:

The following are the bird’s view of the details included in the chapters of the study

Chapter 1 deals with a brief introduction of the project followed by

the industry profile, importance, limitations and scope of the study

Chapter 2 deals with the review of literature relevant to the topic and company
profile
Chapter 3 renders the methodology of the research, which includes
objectives, research design, data collection, sampling, analytical tools
adopted in the study and the limitations of the study.

Chapter-4 deals with the analysis of the data collected with the help of
various statistical tools and summarizes the entire process of the current
research through a briefing about the various findings and suggestions.
Finally, it gives the conclusion drawn by the researcher on the study

LITERATURE REVIEW:
Consumers’ rights cannot easily be applied in a healthcare context (Carr- Hill,
1992). Greeneich (1993) and Sitzia and Wood (1997) argue, on the other hand,
that the concept of ‘consumer’ dignifies the professional healthcare patient
relationship in a way that the concept of ‘patient’ does not. ‘Consumer’ and
‘customer’ satisfaction are concepts commonly used in economic research. Patient
satisfaction is the concept most often used in research within the healthcare
sciences. Using the concepts ‘consumer’ or ‘customer’ does not automatically give
power to the person in need of healthcare. As is shown in the Norwegian Patients’
Rights Act of 1999 (Ministry of Health and Care Services, 1999), the patient is no
longer looked upon as powerless and passive. Both healthcare authorities and
healthcare personnel expect the patients to be actively involved in their own
healthcare. Boudreaux, Ary and Mandry (2000) view the patient provider
interaction as a dynamic one, during which both the patient and the provider are
constantly giving, receiving, and evaluating information 62about one another.

11
 1.6 - LIMITATION OF THE STUDY:

The research area had never been conducted before in other countries,
and the absence of previous experience especially has created some
difficulties and challenges during research. This study was subjected to
certain limitations which should be pointed out:

● A major limitation of this study is that it was conducted with

outpatients only. It is indeed an important point if inpatients were
included in the study.
● The data was collected from only four public hospitals in India. A
large sample size comprised of outpatients from other hospitals
should be examined to validate the findings of this study.
● Our study is conducted on only one sector which is outpatients and
lacks management participation, having the hospitals` management
perception of service quality would give a good understanding of the
patient's overall satisfaction.
● Our sample is not representative of the general population
concerning service quality because business people and people with
high-income levels tend not to use public hospitals.
● The current study chooses to use the perception measurement of
public hospitals' quality as a predictor of the service quality concept.
It would be interesting to study whether the only use of perception is
more acceptable than the expectation-perception approach

12
 CHAPTER 2- LITERATURE REVIEW

A patient has traditionally been associated with powerlessness against

the medical establishment (Sitzia & Wood, 1997). In the 1980s, the
concept of ‘consumer’ began to appear in quality literature as part of a
general shift towards consumerism evident in aspects of public service.
The consumerist approach to healthcare was evident through
governmental acts and regulations in different countries (Carr-Hill, 1992;
Greeneich, 1993; Sitzia & Wood, 1997; Ministry of Health and Care
Services, 1999; The Norwegian Directorate of Health, 2005). ‘Consumer’
originates in the private rather than the public sector, and is strongly
connected to the commercial world. There has been strong criticism of
the use of the concept in the healthcare field (Carr-Hill, 1992; Sitzia &
Wood, 1997).

Consumers’ rights cannot easily be applied in a healthcare context

(Carr-Hill, 1992). Greenwich (1993) and Sitzia and Wood (1997) argue,
on the other hand, that the concept of ‘consumer’ dignifies the
professional healthcare-patient relationship in a way that the concept of
‘patient’ does not. ‘Consumer’ and ‘customer’ satisfaction are concepts
commonly used in economic research. Patient satisfaction is the concept
most often used in research within the healthcare sciences. Using the
concepts ‘consumer’ or ‘customer’ does not automatically give power to
the person in need of healthcare. As is shown in the Norwegian Patients’
Rights Act of 1999 (Ministry of Health and Care Services, 1999), the
patient is no longer looked upon as powerless and passive. Both
healthcare authorities and healthcare personnel expect the patients to be
actively involved in their healthcare.

13
Recently hospital wards have been implementing ‘patient-centred’ care
(Olsson, Hansson, Ekman, & Karlsson, 2009). The development of
patient-centred nursing and healthcare changes the focus from the
illness in a person to the person with an illness (Pelzang, 2010). The
term is described as the unique way to care for the individual patient and
is also recognized as a measure of the quality of healthcare and used in
quality research (Robinson, Callister, Berry, & Dearing, 2008). More
recently the concept of ‘person-centred’ care has been introduced in the
delivery of nursing and healthcare (McCormack & McCance, 2006).
Implementing a person-centred approach to nursing and healthcare may
provide a more therapeutic relationship between healthcare personnel,
patients and their families underpinned by the values of seeing patients
as equal partners in planning, developing and assessing healthcare
(McCormack, Dewing, & McCance, 2011).

The term "patient" has historically evoked the picture of a person in some
form of pain who suffers in (patient) silence. Etymologically as it moved
from its Latin roots to the old French and Middle English in the late
1800s, it carried the same meaning of accepting or tolerating delays,
problems or suffering without becoming annoyed or anxious. Synonyms
associated with the word patient are "forbearing, uncomplaining, tolerant,
long-suffering and resigned.

This historical understanding of the term “patient” seems paradoxically at

odds with today’s efficient, technologically savvy, experience-elevated
consumer. It also begs the question, to what extent have organizations
that deliver on health unintentionally eroded or misconstrued the
experience by seeing an individual as a condition and not a person – a
patient instead of a consumer? Could it be that in seeing someone as a
patient we have created an unconscious treatment bias loop that
nurtures a “victim” mindset and a passive approach to health?

14
The debate over using consumer vs. patient has mostly resided within academia
for the last 20-plus years, with concerns tied to the patient relationship becoming
commoditized – treating individuals as objects or goods, thereby reducing the
compassion and care extended to those who are sick or experiencing a health
event. It’s time to change the term – and our thinking – to a consumer mindset.
Today’s consumer is squarely in control and demand to have their elevated
expectations met or exceeded. Consumers outside of healthcare largely have a
better experience than “patients” in the healthcare system today due to the shift
and focus articulated by Gilmore and Pine toward the experience economy. Yet
healthcare still produces woefully lacking experiences and remains behind other
industries.

According to the 2019 Consumerization of Healthcare Study by Econsultancy and

Adobe, the healthcare industry – both insurance companies and medical providers
– ranked second-lowest in terms of being fast to respond and offering choices for
communications. In addition, 75% of consumers stated they wanted the same
experience in healthcare that they get from other industries.
Some of the basic expectations that are lacking in health care include price
transparency, price consistency, the ability to understand the product coverage
and benefits, bill payments and help with getting simple tasks completed.
Consumers are looking for highly personalized, simple and connected experiences
that place them squarely in charge and make them feel empowered. They want to
be heard, understood and accompanied by friends, family and healthcare experts
as they traverse their health journey – all while receiving the highest levels of
quality care.

(WILSON FORBES)

15
16
 .

QUALITY IN HEALTH CARE

The World Health Organization (WHO) (2009) and The International Council
of Nurses (ICN) (2006) state that the overall goal is the highest possible
health for all people, and providing high-quality care is one approach to
reaching this goal. The Norwegian national action plan on Health and social
care (Ministry of Health and Care Services, 2011) emphasises the
importance of high-quality care through patient-centred care and the
importance of building systems for patients to take part in evaluating the
quality of care regularly.
“Quality of care” is a concept that can be given different meanings,
depending on different cultures, whether it is on an individual level or a social
level, which aspect we are looking at; process, structure or outcome, whether
it is the patients, the relatives, the healthcare personnel, the administrators or
the politicians who define the term and the time at which it is defined
(Donabedian, 1966, 1980; Wilde, 1994; Pettersen, Veenstra, Guldvog, &
Kolstad, 2004)
.
17
 It is considered by researchers to be a multidimensional concept (Crow, et al.,
2002). Florence Nightingale was the first to organise and structure nursing care in
the middle of the 19th century. Her notes have to be understood in the context of
her time, but much is relevant today in hospitals around the world. She described
in her book, Notes on Nursing (1859/2010), her views of good nursing. Nursing
aimed to place the individual in the best condition for nature to act. She was
concerned about the quality of care given to each patient.

During the Crimean War, she was a proficient bedside nurse with great
concern for the soldiers, an,d she also took systematic notes of the care and
the patient’s reaction to the care to improve nursing (Nightingale, 1859/2010).
She did not explicitly use the concept of ‘quality’, but quality care is what she
implicitly aims at with her notes on nursing. She saw, however, the quality of
care from the nurses’ perspective.

Florence Nightingale introduced the importance of quality nursing care back

in the 1850s, when she started using her knowledge of statists to evaluate
the quality of nursing practices and patient outcomes (Burston, Chaboyer &
Gillespie, 2013). Patient lives are impacted by the quality of nursing care
delivered to them. Quality is defined by the Institute of Medicine (IOM) as
“continually reducing the burden of illness, injury, and disability, and
improving health and functioning by pursuing six major aims – safety,
effectiveness, patient-centeredness, timeliness, efficacy, and equity (2001).

Donabedian (1966) is one of the leading researchers in quality of care

research and has found that aspects of structure, outcome and process are
indicators of the quality of medical care. ‘Structure’ was described as the
fixed part of the practice-setting and consisted, like today, of providers,
resources and tools. ‘Process’ was the relationship between care activities
and their consequences of them on the health and welfare of the patient.
‘Outcomes’ were interpreted as changes in the patient’s condition.

18
Donabedian (1966) wanted to turn the assessment process from evaluation
to understanding, i.e. from “What is wrong here?” to “What goes on here?”
He claimed that the quality of care is as good as the patients say their
satisfaction with the care received, and stated that patient satisfaction is not
simply a measure of quality, but the goal of health care delivery (Donabedian,
1980). In other words, patient satisfaction is both an outcome and a
contributor to other objectives and outcomes, according to Donabedian
(1980, 2003). This is supported by Zastowny, Stratmann, Adams and Fox
(1995). Donabedian was among the first to make a link between quality of
medical care and patient satisfaction (1966), and to view quality of care from
the patient’s perspective (1980). Based on a literature review, he found that
quality of care from a patient’s perspective is a combination of the quality of
three aspects: technical ward, interpersonal ward and organisational ward
environment (Donabedian, 1980).
Wilde, Starrin, Larsson and Larsson (1993) using a grounded theory
approach developed a theoretical model of quality of care from a patient
perspective. Through this approach, they turned the perspective of quality of
care from that of the healthcare workers to the patients’. Patients’ perceptions
of what constitutes quality of care are formed by their systems of norms,
expectations and experiences, and by their encounters with an existing care
structure. The theoretical model outlined two basic conditions that quality of
care builds on, i.e. ‘the resource structure of the care organisations’ and ‘the
patients’ preferences’. The resource structures are person-related qualities
that refer to the caregivers, and physical and administrative environmental
qualities that in turn refer to infrastructural components of the care
environment, such as organisational rules and technical equipment. The
patients’ preferences consist of a rational aspect that refers to the patient’s
strive for order, predictability and calculability in life, and a human aspect that
refers to the patient’s expectations that her/his unique situation is taken into
account. The patients’ perception of quality of care based on this theoretical
model may be considered from four dimensions: the medical-technical
competence of the caregivers, the identity oriented approach of the
caregivers, the physical-technical conditions of the care organisation, and the
socio-cultural atmosphere of the care organisation

19
PATIENT SATISFACTION

Patient satisfaction, which has its roots in the consumer movement of the 1960s,
has both practical and political relevance in the current healthcare system. It is
commonly used to guide research into patients’ experiences of healthcare (Gut,
Gothen, & Freil, 2004; Danielsen, Garratt, Bjertnes, & Pettersen, 2007). A
commonly accepted conceptual definition has not been established (Merkouris,
Ifantopoulos, Lanara, & Lemonidou, 1999). There are, however, different ways of
looking at the concept of satisfaction. The discrepancy theory, the fulfilment theory,
the equity theory (Lawler, 1971), and the value-expectancy model (Linder- Pelz,
1982), are alternative approaches to the concept of satisfaction. A tentative model
developed by Larsson, Wilde and Starrin (1996), and further developed by
Larsson and Wilde-Larsson (2010) that views patient satisfaction as an emotion,
presents an alternative approach to the concept.

Lawler (1971) categorized satisfaction studies according to their implicit

theoretical perspective due to the way in which satisfaction was measured.
He identified discrepancy theory, equity theory and fulfilment theory (Lawler,
1971). The three theories are similar, in that they define satisfaction as being
concerned with differences between what one wants and what one perceives
receiving. There is no agreement about what the concepts of ‘want’ or ‘desire
encompass (Linder-Pelz, 1982; Williams, 1994). In addition, equity theory
states that satisfaction is the perceived balance of inputs and outputs, and
one evaluates one’s own balance against the balances of others (Lawler,
1971), which introduces the role that social comparison processes might
have in healthcare evaluations (Linder-Pelz, 1982; Williams, 1994).

20
Linder-Pelz (1982) has developed a value-expectancy model of satisfaction.
The model was based on the attitude theory and the job satisfaction
research carried out by Fishbein and Azjen (1975). Linder-Pelz (1982)
defines patient satisfaction as: ‘positive evaluations of distinct dimensions of
the health care’. The care evaluated might be a single visit, a particular
healthcare setting or healthcare in general. Very little of patient satisfaction
has been explained in concepts such as ‘values’ and ‘expectations’
(Williams, 1994). The nature of expectation is complex and a theoretical
description is lacking (Schmidt, 2003). Expectations might change during a
hospitalisation because of what is experienced.
Just as Williams (1994) and Schmidt (2003), Wilde (1994) found it more
relevant to relate a patient’s experience of actual healthcare to his or her
preferences, rather than to expectations. Preferences show the subjective
meaning of a care episode to a person. This means that measuring
patients’ expectations does not tell us much about the patients’ perception
of quality of care or patient satisfaction. It tells us something about how the
patients believe it will be.It is open to discussion whether patient satisfaction
is an attitude, a perception, an opinion of healthcare, or an attitude towards
life in general, and not especially towards the healthcare in a hospital
(Merkouris, et al., 2004). It is also unclear whether patient satisfaction and
dissatisfaction are opposite ends of the same continuum, or two different
phenomena that require two different definitions (Biering, Becker, Calvin, &
Grobe, 2006

PATIENT CARE IN PUBLIC HOSPITALS:

Issues in regard to public and private health infrastructure are different and
both of them need attention but in different ways. Rural public infrastructure
must remain in the mainstay for wider access to health care for all without
imposing an undue burden on them. Side by side the existing set of
hospitals at district and sub-district levels must also be supported
adequately. This demands better routines, more accountable staff and
attention to promote quality.

21
More autonomy for large hospitals and district health authorities will enable
them to plan and implement decentralized and flexible and locally controlled
services .Further most preventive Some feasible steps in revitalizing
existing infrastructure are examined below drawn from successful
experiences and therefore feasible elsewhere.

FEASIBLE STEPS FOR BETTER PERFORMANCE:

Supervised administrative routines such as orderly drug procurement,

adequate O&M budgets and supplies and credible procedures for redressal
of complaintsThe immediate task would be to look at deepening the range
of work done at all levels of existing centres and in particular strengthen the
referral links and fuller and flexible utilization of PHC/CHCs.

The persistent underfunding of recurring costs had led to the collapse of.
Only genuine devolution or simpler tasks and resources to panchayats,
where there will be a third of women members- can be the answer as seen
in Kerala or M.P. where panchayats are made into fully competent local
governments with assigned resources and control over institutions in health
care.

PHCs were meant to be local epidemiological information centers which

could develop simple community. The bulk of non-corporate private entities
such as nursing homes are run by doctors and entrepreneurs. Medical
education has become more expensive and with rapid technological
advances in medicine, specialization has more attractive rewards. There
has been talk of public private partnerships, but this has yet to take
concrete shape by imposing public duties on private professionals. With the
overall swing to the Right after the 1980s, it is broadly accepted that private
provision of care should take care of the needs of all but the poor.

22
FUTURE OF STATE-PROVIDED HEALTH CARE
The Indian commitment to health development has been guided by two
principles with three consequences. The first was State responsibility for
health care and the second (after independence) was free medical care for
all. The ambitious and far-reaching NPP - 2000 goals and strategies have
been formulated in the hope that the gaps and the inadequate would be
removed by purposeful action.

Indigenous health systems must be promoted to become credible delivery

mechanisms in which people have faith and away fond of the vast number of
less-than-qualified doctors in rural areas. Public programs in rural and poor
urban areas engaging indigenous practitioners and community volunteers
can prevent seasonal and communicable diseases using low-cost traditional
knowledge based on the balance between food, exercise medicine and
moderate living.

KEY ACHIEVEMENTS IN HEALTH

Our overall achievement in regard to longevity and other key health indicators
are impressive but in many respects uneven across States. In the past five
decades, life expectancy has increased from 50 years to over 64 in 2000.
IMR has come down from 1476 to 7. Crude birth rates have dropped to 26.1
and death rates to 8.7.

At this stage, a process understanding of longevity and child health may be

useful for understanding progress in future. Longevity, always a key national
goal, is not merely the reduction of deaths as a result of better medical and
rehabilitative care in old age rather it also includes reasonable quality of life in
the extended years marked by self-confidence and absence of undue
dependency. So the quality of life requires many external bio-medical
interventions.

23
Other achievements include a reduction of mortality among infants through
immunization and nutrition interventions and a reduction of mortality among
young and middle-aged adults, including adolescents getting informed
about sexual reproduction and safe motherhood. At the same time, some
segments will remain always more vulnerable - such as women due to
patriarchy and traditions of infra-family denial), the aged (whose survival but
not always development will increase with immunization) and the disabled
(constituting a tenth of the population).

Reduction in child mortality involves as much attention to protecting children

from infection as to ensuring nutrition and calls for a holistic view of mother
and child health services. The cluster of services consisting of antenatal
services, delivery care and post-mortem attention and low birth weight,
childhood diarrhoea and ARI management are linked priorities.

There have been facility gaps, supply gaps and staffing gaps, which can be
filled up only by allocating about 20% more funds. The initial key mistake
arose from the needless bifurcation of health and family welfare and
nutrition functions at all levels. There has not been enough convergence in
"escorting" children through immunization coverage and nutrition education
of mothers.PHCs and CHCs are funded by States several of whom are
unable to match the Central assistance offered and hence these centres
remain inadequate and operate on minimum efficiency. On the other hand,
over two-thirds of the cost of three-fourths of sub-centres is fully met by the
Center due to their key role m family welfare services.

HEALTH STATUS ISSUES

The difference between rural and urban indicators of health status and the
wide interstate disparity in health status are well known. For the children
growing up in rural areas, the disparities naturally tend to get even worse
when compounded by the widely practised discrimination against women,
starting with the foeticide of daughters.

24
 Not only are the gaps between the better performing and other States wide
but in some cases have been increasing during the nineties. Large
differences also exist between districts within the same better-performing
State urban areas appear to have better health outcomes than rural areas
although the figures may not fully reflect the situation in urban and
peri-urban slums with large migration with conditions comparable to rural
pockets

HEALTH FINANCING ISSUES

Public expenditure levels

Health spending in India at 6% of GDP is among the highest levels

estimated for developing countries. In per capita terms it is higher than in
China Indonesia and most African countries but lower than in Thailand. It is
only through such a community-based approach that revitalization of
indigenous medicines can be done and people trained in self-care and
accept responsibility for their health.

The PHC approach was intended to test the extent to which

non-doctor-based healthcare was feasible through effective down-staging
of the delivery of simpler aspects of care. This may indeed be more
acceptable to the medical profession than the draft NHP proposal to restart
licentiates in medicine as in the thirties. Such a licentiate system cannot
now be recalled against the profession's opposition nor would people
accept two-level services.

PATIENT CARE IN PRIVATE HOSPITALS:

25
Quality of care in private hospitals has seen a paradigm shift from a
traditional focus on structural approaches to a broader multidimensional
concept which includes the monitoring of clinical indicators and medical
errors. Strong political commitment and institutional capacities have been
important factors in making the transition. What is still lacking, however, is a
culture of rigorous programme evaluation, public involvement, and patient
empowerment.

Quality care is by no means a new concept in private hospitals, where it has

long been assumed to be an implicit goal of the healthcare system. What is
new is the adoption of a systematic and scientific approach to its
measurement and management.1 Likewise, the recognition of ‘‘medical
errors’’ as a systemic problem requiring systemic solutions 2 is a recent and
positive development.

The government—as the regulator, major purchaser, and major public

provider—is pushing for change on behalf of private hospitals’
non-vociferous, law-abiding citizens.
Private hospitals inherited a clean style, largely tax based, and publicly
provided healthcare system at independence in 1965. Today, health care is
financed by a combination of state subsidies (25%), employer benefits (35%),
out-of-pocket payments (25%), compulsory medical savings for acute care
expenses (8%), risk sharing for catastrophic illnesses (2%), and private
health insurance (5%) (Ministry of Health, unpublished data, 2000). National
healthcare expenditure has remained fairly constant at 3% of GDP over the
last two decades.

26
Patients have complete freedom of choice of providers. Primary health care
is easily accessible through private medical practitioners (80%) and
government outpatient polyclinics (20%). There are 26 well-equipped
hospitals and speciality centres providing 11 798 beds (ratio of 3.7 beds per
1000 population). Eight public hospitals and five speciality centres (ranging
from 80 to 3110 beds) account for 80% of the beds while 13 private hospitals
(from 25 to 500 beds) account for the remainder. Three private hospital
chains are listed on the Stock Exchange in India.

Since 1985 every public sector hospital has been ‘‘restructured’’—the latter
term referring to the granting of autonomy in operational matters so as to
inject private sector efficiency and financial discipline, but with the
government retaining 100% ownership of the hospitals. Initially managed by a
monolithic government company, the restructured hospitals underwent further
reorganization in 2000, splitting into two competing clusters—the National
Healthcare Group and the Health Services—but ultimately reporting to the
MOH.

27
 CHAPTER 3- RESEARCH METHODOLOGY

This chapter concerns the methodology that will be used in the study. It includes
the research design, research hypothesis and methodology, sample size and
sampling design, data collection approach, data source and collection procedures
and data analysis techniques that will be used

3.1 - Research Design

Research methodology -

The study adopted a descriptive survey. Descriptive survey designs are

used in preliminary and exploratory studies ( luck and Robin 1992) to allow
researchers to gather summarize, present and interpret information
appropriately. A survey in the form of standardised questions in a
questionnaire was established to collect customer views and experiences. It
is quantitative, descriptive and explanatory, and to some extent exploratory
research.

It follows the survey strategy approach and consists of the survey

instrument.

Research Hypothesis- Both Public and Private healthcare sectors in India

face serious issues of safety, quality and staff burnout, and dissatisfaction

Target Population-

This study is conducted by distributing questionnaires to healthcare professionals

in the two hospitals including doctors, nurses and technicians.

Locale of Study
1. The study covers two hospitals in India:

1. KEM Hospital Mumbai, India

2. Lokmanya Tilak Municipal General Hospital, Mumbai, India

28
Data Analysis tools

(I) Percentage Analysis-

1. Health care spending statistics on the

(As per NABH data between 2017 to 2021)

2. Private expenditure as of percentage of total

expenditure on health (2004- CII Mckinsy REport, 2002)

(II) Bar Graphs - to represent the various dimensions in percentage form of

the respective number of respondents on the various questions asked on
different aspects of quality of healthcare and employee satisfaction

(III) Histograms - comparison public vs private healthcare system

Sample size

Samples Taken: 125

DATA COLLECTION APPROACH

1. Primary Sources
Questionnaire - on various aspects of healthcare

The questionnaire was randomly distributed to the five most busiest and crowded
clinics in Indian hospitals.

2. Secondary Sources

NABH DATA AND REPORTS(National Accreditation Board for Hospitals &

Healthcare Providers (NABH) is a constituent board of the Quality Council of India,
set up to establish and operate an accreditation programme for healthcare
organisations.)
29
CHAPTER 4 – DATA ANALYSIS & INTERPRETATION

30
31
ANALYSIS AND INTERPRETATION

​Are doctors and nurses familiar with the Duties and Responsibilities
assigned by Public hospitals in India?

Table 5.1

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 59 47
Agree 46 37
Disagree 10 8
Strongly disagree 2 2
Neither agree nor disagree 8 6
TOTAL 125 100.0

Graph 5.1

Inference:

From the above graph, it is observed that 84% of the respondents (47%
strongly agreed, 37% agreed) have accepted that they know about their
duties and responsibilities and 8% of respondents are not aware of their
duties and responsibilities

32
The Public Hospital provides proper Authority, Responsibility, and
Accountability to its health workers

Table 5.2
DIMENSIONS NO. OF PERCENTAGE
RESPONDENTS
Strongly agree 40 32
Agree 52 42
Disagree 15 12
Strongly disagree 10 8
Neither agree nor disagree 8 6
TOTAL 125 100

Graph 5.2

Inference:

From the above graph, it is observed that 74% of the respondents have
accepted that they are assigned the job with authority responsibilities and
accountability to perform well. Around 14% of the respondents have not
accepted the statement.
33
Identified new diseases and cases by the hospital management.

Table 5.3

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 30 24
Agree 50 40
Disagree 15 12
Strongly disagree 20 16
Neither agree nor disagree 10 8
TOTAL 125 100.0

Graph 5.3

Inference:
From the above graph, it is observed that 64% of respondents strongly have
accepted that they are identified new treatments and diseases, especially after
providing some healthcare training to them. Around 23% of respondents have
not accepted the statement

34
 Stress on public hospital employees (doctors and nurses) converts into a
positive manner.

Table 5.4

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

Strongly agree 30 24
Agree 50 40
Disagree 20 16
Strongly disagree 15 12
Neither agree nor disagree 10 8
TOTAL 125 100.0

Graph 5.4

Inference:
From the above graph it is observed that 64% of respondents have
accepted that they convert stress into positive manner and 20% of the
respondents have not accepted the same.

35
 Job rotation leads to individual improvement.

Introduction: Job rotation refers to health workers moving from one job to
another job and, in this it is to identify whether job rotation leads to individual
improvement and to public hospital benefit or not.

Table 5.5

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 35 28
Agree 40 32
Disagree 17 14
Strongly disagree 22 18
Neither agree nor disagree 11 10
TOTAL 125 100.0

Graph 5.5

Inference:
From the above graph, it is observed that 60% of the respondents have
accepted that their job is rotated and led to both individual improvements and
hospital benefits around 28% of respondents have not accepted the statement.

36
Doctors and physicians identifies patients diseases and treatments

Table 5.6

DIMENSIONS NO. OF RESPONDENTS PERCENTAGE

Strongly agree 30 24
Agree 50 40
Disagree 23 18
Strongly disagree 11 9
Neither agree nor disagree 11 9
TOTAL 125 100.0

Graph 5.6

Inference:
From the above graph, it is observed that 64% of the respondents have
accepted that the concerned in charge identifies their diseases and treatments.
Around 18% of respondents have not accepted the statement.

37
Public hospitals provide new treatments and researches apart from other
hospitals

Table 5.7

DIMENSIONS NO. OF RESPONDENTS PERCENTAGE

Strongly agree 33 26
Agree 50 40
Disagree 22 18
Strongly disagree 14 11
Neither agree nor disagree 6 5
TOTAL 125 100.0

Graph 5.7

Inference:
From the above graph, it is observed that 66% of the respondents have
accepted that public hospitals provide new treatments apart from other hospitals.
Around 16% of respondents have not accepted the statement.

38
Chief Doctors in the Public hospitals guides to their juniors as and when
required.

Table 5.8

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 35 28
Agree 50 40
Disagree 14 11
Strongly disagree 14 11
Neither agree nor disagree 12 10
TOTAL 125 100.0

Graph 5.8

Inference:
From the above graph, it is observed that 68% of the respondents have
accepted that they are asked to take decisions and their Seniors guides them as
and when required. Around 21% of respondents have not accepted the
statement.

39
 Management of the hospital addresses grievances immediately.

Table 5.9

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 30 24
Agree 45 36
Disagree 12 10
Strongly disagree 20 16
Neither agree nor disagree 18 14
TOTAL 125 100.0

Graph 5.9

Inference:

From the above graph, it is observed that 60% of the respondents have accepted
that Management of the hospital addresses grievances immediately. Around 20%
of respondents have not accepted the statement

40
Public hospitals utilize employee services effectively and efficiently.

Table 5.10

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 30 24
Agree 40 32
Disagree 19 15
Strongly disagree 24 19
Neither agree nor disagree 12 10
TOTAL 125 100.0

Graph 5.10

Inference:
From the above graph, it is observed that 56% of the respondents have
accepted that the hospitals utilize their services effectively and efficiently. Around
29% of respondents have not accepted the statement.

41
​ Present job leads satisfaction for the health workers in the public hospital.

Table 5.11

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 37 30
Agree 53 42
Disagree 13 10
Strongly disagree 17 14
Neither agree nor disagree 5 4

TOTAL 125 100.0

Graph 5.11

Inference:
From the above graph, it is observed that 72% of the respondents have
accepted that they derive satisfaction in performing the job. Around 18% of
respondents have not accepted the statement.

42
​ Seniors and subordinates are very cooperative in the hospitals'

Table 5.12

DIMENSIONS NO. OF PERCENTAGE

RESPONDENTS
Strongly agree 40 32
Agree 52 42
Disagree 16 13
Strongly disagree 13 10
Neither agree nor disagree 4 3
TOTAL 125 100.0

Graph 5.12

Inference:

From the above graph, it is observed that 74% of the respondents have
accepted that their seniors and subordinates are very cooperative and they
work as a team. Around 13% of respondents have not accepted the
statement.

43
​Doctors, nurses and technicians are recognized and rewarded suitably
by the public hospital.

Table5.13

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 26 21
Agree 40 32
Disagree 22 18
Strongly disagree 22 18
Neither agree nor disagree 15 13
TOTAL 125 100.0

Graph 5.13

Inference:

From the above graph, it is observed that 53% of the respondents have
accepted that they have been recognized and rewarded suitably by the
hospital for their performance as per the government policy. Around 30% of
respondents have not accepted the statement.

44
​ The public hospital provides compensation based on qualification, and
experience.

Table 5.14

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS
Strongly agree 27 22
Agree 64 51
Disagree 17 14
Strongly disagree 13 10
Neither agree nor disagree 4 3
TOTAL 125 100.0

Graph 5.14

Inference:

From the above graph, it is observed that 73% of the respondents have accepted
that they know that the compensation commensurate with the qualification,
experience exposure and especially with their job performance during the period in
delivering results in time. Around 15% of respondents have not accepted the
statement.

45
​ The public hospital provides job security to the employees.

Table 5.15

DIMENSIONS NO.OF PERCENTAGE

RESPONDENTS

Strongly agree 40 32
Agree 55 44
Disagree 9 7
Strongly disagree 16 13
Neither agree nor disagree 4
5

TOTAL 125 100.0

Graph 5.15

Inference:

From the above graph, it is observed that 76% of the respondents strongly
have accepted that they feel a sense of job security and sense of social
belongings in the hospital. Around 17% of respondents have not accepted
the statement.

46
 CHAPTER 5

– 5.1 FINDINGS

● It is found that 84% of the respondents (47% strongly agreed,

37% agreed) have accepted that they know about their duties
and responsibilities
● It is found that 74% of the respondents have accepted that they are
assigned the job with authority responsibilities and accountability to
perform well
● It is found that 64% of respondents strongly have accepted that they
are identified for new treatments and procedures especially after
providing training to them
● It is found that 64% of respondents have accepted that they
convert healthcare job stress into positive manner
● It is found that 60% of the respondents have accepted that their job
is rotated and led to both individual improvements and hospital
benefits
● It is found that 64% of the respondents have accepted that the
concerned in charge identifies their present skills and potentials in
performing the hospital services and training is imparted to them
accordingly
● It is found that 68% of the respondents have accepted that they
are asked to take decisions in job and their senior staffs guides
them as and when required
● It is found that 60% of the respondents have accepted that their
immediate in charge or hospital management addresses their
grievances and gives them feedback on the same.
● It is found that 56% of the respondents have accepted that the
hospital utilizes its services effectively and efficiently.
● It is found that 72% of the respondents have accepted that they
derive satisfaction in performing the job

47
 ● It is found that 74% of the respondents have accepted that
their seniors and subordinates are very cooperative and
they work as a team
● It is found that 53% of the respondents have accepted that they have
been recognized and rewarded suitably by the hospital for their
performance as per the policy.
● It is found that 73% of the respondents have accepted that they
know that the compensation is commensurate with the qualification,
experience exposure and especially with their job performance
during the period in delivering results on time
● It is found that 76% of the respondents strongly have accepted that
they feel a sense of job security and sense of social belongings in the
public hospital

– 5.2 SUGGESTIONS
1) Identify the key performance areas of the health workers in public hospitals in
India and other countries conduct training programmes to develop their skills and
knowledge.

2) 30% of the respondents are dissatisfied due to a lack of recognition and

rewards. This is especially happened in India, not in other countries. Positive
recognition for work boosts the motivational level of doctors and nurses in
public hospitals.

3) Immediate resolution of the grievance is necessary otherwise it will effects

the productivity of the public hospital so immediate actions should be taken to
resolve the grievance of the employees.

4) 30% of the respondents are not identified for new treatments so extend
their work by providing proper training to junior health workers in hospitals in
other countries.

5) Provide opportunities for career personal growth through training,

challenging assignments and more
48
– 5.3 CONCLUSION

Despite differences in how healthcare is organised, financed, and resourced,

our cross-sectional data suggested that both types of hospitals studied face
problems of hospital quality, safety, and nurse burnout and dissatisfaction.
Although worker shortages have been moderated partly by the global
economic downturn, nurses’ reports of their intentions to leave their jobs in
hospitals could indicate future difficulties, especially with the substantial rates
seen in India. In other countries, staffing and the quality of the hospital work
environment (managerial support for nursing care, good doctor-nurse
relations, nurse participation in decision-making, and organisational priorities
on care quality) were significantly associated with patient satisfaction, quality
and safety of care, and nurse workforce outcomes.

More specifically, public hospitals with good work environments and nurse
staffing had improved outcomes for patients and nurses alike. Although we
cannot be sure of causality because the data were cross-sectional, the public
hospital work environment was associated with outcomes in each country.

Patients’ and nurses’ ratings of public hospitals were similar. Whether

patients rated their hospital as excellent or would recommend their hospital to
other patients was associated significantly with nurses’ ratings of their
hospital work environment and reports of nurse staffing. Data from nurses in
every country suggested a lack of confidence that hospital management
would solve identified problems in patient care. Management’s uncertainty of
nurses’ complaints reflecting objective clinical observations of care quality
might need to be tempered by our results, which show that nurses’
assessments concur with those made independently by patients. Our data
support the conclusion reached by the World Alliance for Patient Safety that
organisational behaviours are important in promoting patient safety and the
quality of public hospitals.

49
 REFERENCES

1. https://www.ibef.org/industry/insurance-sector-india
2. Barlow, G.L., (2002) 'Auditing Hospital Queuing'. Managerial Auditing
Journal, vol. 17, no.7, pp.397-403.
3. Bielen, F. & Demoulin, N. (2007) 'Waiting time Influence on The
Satisfaction- Loyalty Relationship in Services'. Managing Service
Quality, Vol.7, Issue, p.174- 193
4. Buttle, F. (1994) 'What's Wrong with SERVQUAL?'. Manchester
Business School, Manchester.
5. Buhaug, H. (2002) 'Long waiting List in Hospitals: Operational
research needs to be used more often and may provide answers'.
British Medical Journal, Vol. 324, pp.252-253.
6. Carman, J. M. (2000) 'Patient Perception of Service Quality:
Combining the Dimension'. Journal of Service Marketing, Vol. 14,
Issue 4, p.337-352.
7. Creswell, W. John, (2002) Research Design: Qualitative,
Quantitative, and Mixed Method Approaches. 2nd ed. Saga,
Thousand Oaks, California, USA.
8. Cronin, J.J. & Taylor, S.A. (1992) 'Measuring Service Quality: A
Reexamination and Extension'. Journal of Marketing, Vol. 56, p.55-68
9. Davis, M.M., Heineke, J. (1998) 'How disconfirmation, perception and
actual waiting times impact customer satisfaction.' International
Journal of Service Industry Management, vol. 9, Issue 1, pp. 64-73.
10. De Man, S.,Vandaele, D. & Gmmel, P. (2004) 'The waiting experience
and consume perception of service quality in outpatient clinics'.
Working paper of Faculty of Economics and Business Administration,
Ghent University.
11. Duckett, S.J. (2005) 'Private Care and Public Waiting'. Australian
Health Review, Vol. 29, Issue 1, p.87-93
12. Fabnoun, N. & Chaker, M. (2003) 'Comparing the Quality of Private
and Public Hospitals' Managing Service Quality, Vol. 13, Issue 4
13. Ford, R.C., Bach, S.A. & Fottler, M.D. (1997) 'Methods of measuring
patient satisfaction in healthcare organizations'
50
14. Gonroos , C (1984) 'A service quality model and its market
implications', European Journal of Marketing, vol.18, issue 4,
p.36-44
15. Hornik, j. (1984) 'Objective Time Measure: A Note on the
Perception of the Time in Consumer Behavior'. Journal of
Consumer Research, Vol. 11, p.615-618.
16. Jones, P. & Peppiatt, E. (1996) 'managing perceptions of Waiting
Times in Service queues'. International Journal of Service
Industry management, Vol. 7, Issue 5, pp.47-61.
17. Karassavidou, E., Glaveli, N. & Papadopoulou, C.T. (2009)
'Quality in NHS
18. Klassen, K.J. & Rohleder, T.R. (2004) 'Outpatint Appointment
Scheduling With Urgent Clients in a Dynamic, Multi-Period
Enviroment'. International Journal Of Service Industry
Management, Vol. 15, Issue 2, p.167-174
19. Kotler, P., Armstrong, G., Saunders, J. & Wong, V. (2005)
Principles of Marketing. 4th European ed. Prentice Hall, Harlow,
England.
20. Lochman, j. E (1983) "factors related to patients` satisfaction with
their medical care". Journal of Community Health, vol.9, Issue 2, pp.
91-108.
21. Leclerc, F., Schmitt, B.H. & Dube, L. (1995) 'Waiting Time and
Decision Making: Is Time Like Money?', Journal of Consumer
Research, Vol. 22, Iss. 1; pg. 110-115.
22. Lou, W., Liberatore, M.J., Nydick, R.L., Chung, Q.B. & Elliot, S.
(2004) ' Impact of process change on customer perception of
waiting time: a field study'. Omega journal, Vol. 32, Issue 1, p.77-83
23. Maister, D. (1985) The psychology of waiting lines. in J. Czepiel, M.
Solomon, C. Suprenant (Eds.) The Service Encounter, Lexington
Books, D.C. Heath and Co., Lexington, MA.
24. Marley, K.A., Collier, D.A & Goldstein, S.M (2004) 'The Role of
Clinical and Proces Quality in Achieving Patient Satisfaction in
Hositals', Decision Sciences: Vol. 35, Issue 3, p.349-369

51
25. Ministry of Health (2004) 'Kuwait Health'. Department of
Planning and Follow-up, Public Authority for Applied Education
and learning press, Vol. 71
26. Ministry of Health (2006) 'Health Kuwait'. Department of
Statistics &Medical Records, Health & Vital Statistics
Division, Vol. 43
27. Ministry of Planning (2007) 'Annul Statistical Abstract'.
Central Statistical Office, 44th ed.Kuwait
28. Mowen, J.C, Licata, J.W & McPhail, J. (2002) 'Waiting in The
Emergency Room: How to Improve Patient Satisfaction'. Journal
of Health Care Marketing, Vol. 16, Issue 3, p.26-32.
29. Mike, H. (1995) 'Improving out-Patient Clinic Waiting Times:
Methodological and Substantive Issues'. International Journal Of
Health Care Quality Assurance, Vol. 8, Issue 6, P.14
30. Mostafa, Mohamed M. (2005) ' An Empirical Study of Patient'
Expectation and Satisfaction in Egyptian Hospitals'.
International Journal of Health Care quality Assurance, Vol.
18, Issue 7, pp.512-532
31. Naumann, S. & Miles, J.A. (2001) 'Managing waiting for Patients'
Perceptions: The Role of Process Control'. Journal of
Management in Medicine, MCB University Process: Vol. 15,
Issue 5, p.376-386.
32. Oliver, R.L. (1980) 'satisfaction: A Behavioral Perspective on the
Customer'. McGraw Hill.
33. Parasuraman, A., Zeithaml, V.A. & Berry, L.L. (1988)
'SERVQUAL:

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 APPENDIX QUESTIONNAIRE

1. Are doctors and nurses familiar with their Duties and Responsibilities assigned by Public
hospitals in India?
Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

2. The Public Hospital provides proper Authority, Responsibility, and Accountability to its health
workers.

Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

3. Identified new diseases and cases by the hospital management.

Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

4. Stress on public hospital employees (doctors and nurses) converts into a positive manner

Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

53
 5. Job rotation leads to individual improvement.

Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

6. Doctors and physicians identify patients' diseases and treatments

Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

7. Public hospitals provide new treatments and research apart from other hospitals
Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

8. Chief Doctors in Public hospitals guide their juniors as and when required.
Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

54
9. Management of the hospital addresses grievances immediately.
Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

10. Public hospitals utilize employee services effectively and efficiently.

Strongly agree
Agree
Disagree
Strongly disagree
Neither agree nor disagree

55