Leading Change for Patient and Service Improvement

Leading Change for Patient and Service Improvement Module

about service quality: Service quality concept in the current literature

The developed countries have given a significant importance to the service sector of the country. With every passing day the segment of employment is growing and increasing very rapidly. This ultimately gives the members of the society a life with high quality and setting high standards for the members to a live a good life. Service sector contributes as a major portion of the country and without it other sectors cannot also develop. It also faces competition with global world as the world has become global all the way. The main point of this competition is to bring free circulation of the services and products. Getting confidence of the consumers is an essential part and while facing competition they need to provide the best services in order to sustain in the market. The quality of the services being provided is also to be measured and the service is then chosen to analyze and research the quality of the service. There are various methods to measure the service quality. Those methods are statistical methods, benchmarking, servperf and etc. However, to measure the service quality SERVQUAL method has been used in this research (Brown, Churchill, & Peter, 1993; Cronin & Taylor, 1992; Parasuraman, Zeithaml, & Berry, 1985). The basic reason to use this method is because it is most frequently used and is preferable among others (Buyukozkan, 2011).

The factor which distinguishes the similar products and services is the service quality. It differentiates it from other product and services. So, the companies need to focus on the quality of service they are providing in order to be different and competitive in the market. The service quality has gathered a lot of significance in today's era. However, the service quality of healthcare sector may vary as the health of human may be fluctuating. The health of the individuals is very important and that is why healthcare department is given so much importance. It is also expected that services provided by healthcare should be meeting the expectations of the patients. This sector is taken for implementation in Turkey as it is a growing country with increasing population. The major purpose of this study is to find out the factors which provide quality service by the healthcare sector and then those factors are considered to measure and evaluate the performance of the home healthcare staff (Buyukozkan, 2011).

It is difficult to measure the quality of the services as they are intangible, inseparable and heterogeneous. It cannot be measured easily because there is no proper concrete way to describe its quality. The evaluation is done by the analysis of the evaluator of the linguistic variable so it should be performed in an environment o uncertainty and fuzziness. The fuzzy set theory (Zadeh, 1965) is used in the measurement of performance to prevail over the issue. This theory helps in going through the uncertainty and indistinct perspective of the concepts which are connected with subjective finding of the human being. These days' fields like management sciences have been using fuzzy set theory for decision making (Hsu, Chen, & Tzeng, 2007; Huang, Chu, & Chiang, 2008; Kahraman, Buyukozkan, & Ates, 2007; Liu & Lai, 2009) but it is also mentioned that this is used in a limited way in the grounds of the service quality (Bilsel, Buyukozkan, & Ruan, 2006; Tsaur, Chang, & Yen, 2002; Tseng, 2009a, 2009b).

The measurement for the service quality is essential and for this identification and criteria for prioritizing is used and this combines as a systematic process. This also leads to decision making and becomes more useful. Moreover, there are different theories which are used in the process of service quality measurement including AHP (analytic hierarchy process), a MCDM (multiple criteria decision making) a theory projected by Saaty in 1980.

Service concept

The meaning of service concept is a basic portion of the tactical gain hunting processes of service design, service innovation and service development (Goldstein, Johnston, Duffy, & Rao, 2002; Stuart & Tax, 2004). Due to its difference from material objects, it is very tricky to classify service. There are many types of services; ranging from that given in a beauty parlour to that given by an insurance firm. Another reason for the difficulty in classifying service is that there are a wide range of activities being performed. In spite of these difficulties, some researchers are still able to define service (Devebakan, 2005).

Unlike goods, services are in-tangible products that are there to satisfy the customer needs. In terms of economics, the term service can be explained as an economic activity which provides time, place, shape and comforts at a psychological level. Accordingly, Edvardsson and Olsson (1996) have classified service concept as what needs to be done to satisfy the client and how to perform those tasks. Goestch and Davis (1998) on the other hand describe service as any activity performed for someone else, while Collier agrees on the fact that service could be a performance or an event that is created and utilized at the same time (as cited in Uyguc (1998). However the statement takes a different path when he describes it as a work which links the customer with the service provider (Tar-m, 2000). It is observed by Goldstein (et al., 2002) as a combination of material and non-material objects put together to develop a service package. Liu, Bishu and Najjar (2005) concur that service is whatever the customer requires. There are so many definitions available that can help managers in grasping what service concept is (Buyukozkan, 2011).

The service of good healthcare is necessary to the society because of two main reasons; reprieve from diseases and enhanced health for humans (Bowers & Kiefe, 2002). Nevertheless, the healthcare system has been undergoing some extreme difficulties since the 90s. Express progress towards a method of controlled healthcare and incorporated delivery systems has seen healthcare suppliers to acknowledge a contest. One can only survive in this cut-throat environment when the healthcare supplied is beyond the client's expectations (Lee, Delene, Bunda & Kim, 2000). In order to provide economical healthcare to the customers, the hospitals need to study the major factors of service quality (Li, 1997).

One change that is very much visible in Turkey is that customers are becoming more and more involved with the whole process. They are demanding for precise services which they require. They then study the services available which means healthcare suppliers needs to keep a track of how they are being assessed by the customer. Consequently, hospitals along with caring for the customers and keeping apparently competent service need to look at healthcare as well. Behind all this, the service quality is now an important factor for healthcare suppliers (Dagger, Sweeney, & Johnson, 2007).

Healthcare has been observed in a number of ways in the regions of conventional healthcare research. Quality was explained by Donadedian, 1988 as the capability to reach the wanted goals by fair means only, here the wanted goals means an attainable position of health. However in the same way it is observed as the similar way to attain better and good outcomes of health (Dagger & Sweeney, 2006; Marshall, Ron, & Rebecca, 1996; O'Connor, Shewchuk, & Carney, 1994). If we look at it from a completely different perspective it can be observed as a way to increase patronage, long-term profitability and competitive advantage (Brown & Swartz, 1989; Headley & Miller, 1993).

Healthcare is a very different service industry than other services. The main difference is that the patient does not have the choice to choose a doctor among those who offer low prices or who have better and upgraded technology. Things are different in healthcare industry. Here the doctor is undoubtedly chosen by the patient himself but those choices are based on the opinions of the doctor's existing patients or from the doctor's health organization or from friends and acquaintances. The services provided to service recipients' is very important as it is the sole base of enhancing the quality of healthcare industry (Lee et al., 2000).

Healthcare institute, if they want to flourish, should evaluate the quality of their service as well as grasp on the service delivery charter. Proper strategies and tactics should be implemented in the healthcare however a suitable and legitimate measure should be present in order to evaluate the strategies and tactics that are implemented. The most popular service quality measure that is being applied is the SERVQUAL. Many studies have been measure against this standard in the past such as Babakus and Mangold (1992), Bakar, Akgun, and Al Assaf (2008), Bowers and Kiefe (2002), Dean (1999), Devebakan (2005), Devebakan and Aksarayl? (2003), Lee and Yom (2007), Lee et al. (2000), Li (1997), Ramsaran-Fowdar (2008).

A number of conceptual frameworks have been developed for assessing the offered care qualities hence drawing attention to the literature of healthcare. Li (1997) assessed the performance of the quality in terms of clinical quality and also included patient satisfaction, response to patient requests and patient complaints. Lee et al. (2000) described the main medical services, Haywood-Farmer & Stuart, 1988 explained the fundamental features of medical service which included benefits, appropriateness, effectiveness to the patient and professional skills, Brown and Swartz, 1989 evaluated knowledge, level of training and expertise of the personnel which were discovered as another aspect to responsiveness, sympathy, dependence, assurance and tangibles in assessing the quality of the healthcare service. A four feature structure was presented by Choi, Hanjoon, Chankon, and Sunhee (2005) which included the staff concerned, the physician concerned, tangibles and ease of process of care and this structure exposed the characteristics of administrative, environmental, technical and functional quality (Buyukozkan, 2011).

A similar kind of scale was presented by Dageer et al. (2007) which completely assessed the quality of the healthcare service and quality. This scale included environment quality, technical quality, interpersonal quality and administrative quality. Communication, relationship and manner were the three core themes which were found in order to constitute customers. Beneath the perceptions of the customers about technical quality, there lie two core themes; outcome and expertise. Two main core themes surrounding customer's perceptions of environment quality are atmosphere and tangibles. 3 things determined the administrative quality; operation, timeliness and support (Dagger et al., 2007). A significant overlap was obvious during the comparison of healthcare dimension with many of them being evident in the literature (Buyukozkan, 2011).

The concept of service quality

The concept of quality has many dimensions, so it has variant meanings for different people. It can be simply said an abstract which is very difficult to describe and materialize. The products' value can never be declared until they reach in the consumers' hands. Consumers normally buy out something and they evaluate it on the basis of their experience with that particular product. If the consumer makes the purchase of the same product or brand again, this would be because of his good experience with that, and the he will tell others also about the level of quality of that product. In this regard, we can say that the product's image is established in the process of usage by the consumer market and resultant word of mouth kind of marketing and referral. Due to all of these factors, the service quality is considered vague and very difficult to explain (Parasuraman et al., 1985). In this era of technological development, the concept of quality has become much more subjective and that's why it is very difficult to explain and be analyzed in short words (Buyukozkan, 2011).

There is a very general indication of service quality and that can be judged by the attitude of the consumers, based upon his different experiences and product's performance (Bolton & James, 1991; Parasuraman, Zeithaml, & Berry, 1988). It can also be analyzed in the future anticipations of a product's performance. The baseline for this analysis is consumers' trust in the level of performance in turn of his wants and requirements (Buyukozkan, 2011).

Hence, the service quality can be described as the gap between what a consumer expects and perceived performance of the service. In the case customers' hopes exceed the performance level, so the quality will be less than the satisfaction level and this will ultimately cause dissatisfaction (Buyukozkan, 2011).

As per the work of Parasuraman et al. (1985), if we study the previous literature on quality and services, we come to three basic concepts:

The quality of service is difficult for the customer than that of products. The comparison between the consumers' expectations and actual level of services determine the quality of services and these comparison and performances are not service outcomes. The service quality dimensions include the process involved in the delivery of that service (Buyukozkan, 2011).

Gummesson (1992), in a research on the commonalities and specialties between the industries and services, has concluded that there are at least 2 biased opinions exist. The manufacturers are of the view that the service quality can be maintained the same way as the products' quality is ensured. Conversely, the service industries experts are of the view that services are much more difficult to evaluate as compared to goods as it is intangible unlike products which are measurable (Buyukozkan, 2011).

It is very true that measuring quality of services is very difficult to imagine and measure unlike manufacturing but this does not mean that the quality check on services is out of reach as since 1970s many researchers have been studying the same subject. Despite the availability of various service quality measurement tools, Parasuraman et al. (1985, 1988) gives SERVQUAL preference over others.

We can get a broad way by SERVQUAL to measure and manage the quality in services. In many studies and published researches, SERVQUAL has been declared and used for many quality analysis exercises. Many experts have utilized the leverage provided by SERVQUAL in service quality measurement in various sectors (Brady, Cronin, & Brand, 2002; Caro & Garc?'a, 2008; Coulthard, 2004; Cronin & Taylor, 1992; Brown et al., 1993; DeMoranville & Bienstock, 2003; Lin, 2010; Parasuraman, Zeithaml, & Malhotra, 2002, 2005; Narayan, Rajendran, Sai, & Gopalan, 2009; Santouridis, Trivellas, & Reklitis, 2009; Saravanan & Rao, 2007; Sun & Lin, 2009; Tsai & Tang, 2008; Tseng, 2009a, 2009b; Tsitskari, Tsiotras, & Tsiotras, 2006).

The industries where the SERVQUAL tools have been much successful include; retail, medical services, restaurants, travelling and tourist services, auto services, business education services, higher education services, B 2 B. services, accountant's services, architect's services refreshment services, medical centers, airline services, cookery services, financial services, boutiques services, shoe selling services and many governmental services. As the quality has greater relationship with the profitability, cost of doing business, consumer happiness, retention and good feedback, so it has become among the most studied and researched upon topic these days (Buttle, 1996).

The fundamental of SERVQUAL survey is that the customers' evaluation is supreme in quality assessment. This assessment is done by finding the gap between what customer expects from the service provider and what is their perceived level of performance of some particular service provider (Buyukozkan, 2011).

Parasuraman et al. (1985) had presented ten qualities in his earlier researches, which can describe the quality of services: dependability, receptiveness, capability, right to use, politeness, communication, reliability, safety, sympathetic / perceptive the customer and tangibles. However, by 1988, he summed up all of them in five areas (Buyukozkan, 2011).

Reliability: what service provider promises, it delivers.

Assurance: the abilities and courteous attitude of service providing staff and their competence to send some trustworthy message and imbibe confidence.

Tangibles: what looks visible like the location, building, people and equipment and material used for service deliver.

Empathy: extreme care for the customers.

Responsiveness: the readiness of service providers to help the customers and present timely services.

The focal point i.e. three main dimensions; reliability, receptiveness and tangibles stayed in the dimensions of quality but the remaining seven merged into the remaining two dimensions of empathy and assurance. Now, the RATER model can be described as the best suitable for assessment of services quality in terms of expectations and performances in a qualitative manner by any service oriented organization. This model can be very helpful for any organization in bridging the gap between the expected services and perceived quality (Buyukozkan, 2011).

Assessing the system in which the writer works and reviewing relevant literature

People who lived in their homes instead of living in any health care center comprised of people that were recuperating, aged or senior are generally helped by healthcare employees. There are a number of designations available in this field, anyone can serve others as nurse, healthcare specialist, natural therapist, therapist of any particular field, work as social supporter and also work as shelter home like orphan or old age houses workers. They give all treatment in instruction of professional medical workers. These sorts of services includes in house help like in dressing, eating, awakening, etc. Or it also help in giving medical help like helping in providing food with veins, direct medications, giving exercise for bones relaxation, or supporting and guiding in dealing with artificial body parts, braces used on teeth, removing bandages etc. According to the percentages 89% of healthcare workers are ladies from which 24.4% are linked to black or African-American background, 20.0% are Latino or Hispanic while 4.4% are Asian (BLS 2008a). There are no specific hours or time limit for healthcare workers they are available at any moment (NIOSH 1999; BLS 2008b).

From a number of industries Healthcare industry is a rapid raiding industry in United States. As Bureau of Labor Statistics (BLS) shows that 896,800 employees were hired for healthcare services during 2007 and this will amplify by 55% in future specifically between 2006-2016 (BLS 2008b). The requirement of healthcare industry is rapidly increasing in this country; the reason behind this cause is that population is increasing; more services are provided in home by number of hospitals; less number of hospitals; it is demanded that patient treatment will be done at home; mostly for the purpose of saving cost of medical treatment and other expenses like stays or lunch costs (NIOSH, 2010).

For healthcare workers the rate of turnover is very high and it's even further more for healthcare house employees. It is reported by Stonerock (1997) that the turnover is at about 75% between healthcare employees in few parts of country and it is also found that labor prefer other such jobs more enthusiastically rather than health care jobs. That's why most of healthcare centers worry about holding the workforce and are working for its recovery and are also trying to provide more healthy, disagreeable, and supportive work climate so that it help in holding the workforce more easily (NIOSH, 2010).

Home setting also creates some difficulties for healthcare employees that vary from one to other. This is because the environment is out of control for all and that's why there is more chance of facing new and unknown problems like animals, filled firearms or other devices, disturbance in home, building or nearly surroundings. People come for the sake of visit are also one of the parts of disturbance and add more problems in working of employee (NIOSH, 2010).

The chances of mistakes does get amplified when workers are working on snow, pathways, ice covered floor, paths for pedestrian, driveways and ways of getting patient to home (BLS 1997).

There is a significant chance of getting injured, or it may cause an event that can create death of patient while driving to home, so healthcare employees take a careful view of all the things going on (NIOSH, 2010).

As it is mention in BLS that 27,400 injuries occurred to health care employees while taking patients to their home in 2007 that cause 4.3 rate of occurrence per 1,000 full time employees (BLS 2008c). Injury by twisting or straining of ligament of joints is most common in healthcare employees (BLS 2008d). While injuries can be cured through regular healthcare, home healthcare and dietary plans are also very important in order to sustain the recovery process. This is especially true for children and youths as they are the one most vulnerable to injuries and lack the will or the commitment to follow through with a healthcare plan. In the following few pages we will discuss the healthcare and dietary concerns for children and youths.

Who is at risk for nutrition-related Health Problems?

Adolescents and children, at danger for diet related health issues, require particular health care. This populace can be explained as children having elevated risk for a constant physical, developmental/evolutionary, behavioral, or emotional circumstance, needing health and related services of a sort or amounting ahead of that needed by children usually. Around 7-18% of children from infancy to 18 years of age within the U.S. have a constant physical, behavioral, evolutionary or emotional situation causing cessation in activities, and needing extra care. The cause of the developmental unfitness and exceptional health care requirements is multifaceted. Children with exceptional health care requirements may have evolutionary/developmental hindrance, physical injuries or constant medical circumstances that are linked with following factors: Genetic disorders, congenital pathologies, precocity, congenital metabolism related pathologies, neurologic defects, injury/accident, neural tube deformities, parental substance abuse, environmental poisons.

What is the significance of nutrition-related problems in children with special health care needs?

It is predicted that nearly 40-50% of children and youth with exceptional health care needs have diet related risk issues that call for the attention of a professional on diet, nutritionist, or health care expert. Diet risk issues can be physical, may involve chemical, psychological or environmental concerns in nature. Physical deformities like cleft palates or cystic fibrosis may cease a person's capability to eat or digest/absorb food. Interactions of the drug and nutrient may change digestion, consumption or the bioavailability of nutrients in the food.

Psychological circumstances play part in a person's capability to admit and deal with a disorder or treatment procedure. For instance, depression may change a person's dietary habits and motivation to tag along a particular nutrition plan. Environmental issues like family and social encouragement, financial assistance and reinforcements for coping up with certain dietary schedules can also surface. Such issues may put an adolescent or a child with extra health care requirements at danger for dietary troubles. Frequent dietary troubles for the child or adolescent with extra health care requirements may contain the following: Distorted energy and dietary requirements, deferred or underdeveloped linear growth, skin-and-bone, obesity, feeding delays or oral-motor dysfunction, defecation problems, drug-nutrient interactions, appetite disorders, odd dietary habits, dental and gum diseases

How Can Intervention Help

For an adolescent or child dietary services with exceptional health care requirements may need more specialized services to tackle multifaceted dietary issues and may call for an interdisciplinary team. The team approach permits for individuals from diverse disciplines to tackle the complex troubles that may influence diet and nutrition. The main members of the team should be the child and the caregiver(s) in the detection of troubles and maintaining priorities to be tackled in the treatment/management plan. All the way through the team approach a wide-ranging plan is build up to tackle all the issues that may influence growth, development and physical condition. The aim of the treatment/management plan is to give best diet to maintain growth, development and level of performance. Examples of the troubles that may influence nutrition and the particular team associates to tackle these requirements are highlighted below: Medical problems-general practitioners, nurses, Neuro-motor troubles-physical counselor, occupational therapists, speech pathologists, Behavior issues-psychologists, Dental and oral health problems-dentists, Financial problems and-social workers, Community resources-local health education and information center, Quality and quantity of nutrition, growth-dietitian/nutritionist

All children and adolescent with exceptional health care requirements should have a dependable plan across all the environments where they reside, learn, play and have employment. A first-rate plan for incorporating dietary goals and purposes outside the residence is to work with the academic system. In the local communities, most of the public schools offer a resource for children with exceptional health care requirements through the implementation of the Child and Adult Care Food Program which manages the National School Lunch and National School Breakfast Programs. Federal regulations allow modified school food, at no additional charge, for students with abnormalities/disabilities or constant medical troubles who need particular diets. Meals replacements and modified food wanted for a medical or exceptional dietary requirement are offered for individuals acknowledged by the academic system as having a disorder. Children in special academic programs must have a nutrition prescription from a medical doctor in order to get this advantage. The prescription must have the following info: a clear expression identifying the disorder, and how it affects the child's nutrition, plus identifying the chief vital activity affected by the disorder. The exact list of nutritional changes, adaptations or replacements needed for the diet. Children with extra health care requirements who need an unusual diet but are not receiving exceptional education services must have an order on paper from a recognized medical authority (e.g., general practitioner, doctor's assistant, nurse or other experts identified by the state). For children with constant conditions like diabetes or allergies who are not getting exceptional academic services, determinations about giving meal alterations are made on a case-by-case basis. To confirm that diet goals and purposes are tackled in the child's academic program, it is significant to have diet goals and purposes included in the Individualized Education Plan or 504 Accommodation for children with important nutritional and food concerns.