Service failure can occur on multiple dimensions. A core service failure occurs when a customer is not able to use the product or service they have purchased. A service encounter failure occurs when customer interaction with employees of a firm leave the customer feeling negative about the firm. Inadequate responses to other types of service failures entail their own category of service failure.
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Service failures could be grouped into four categories: service delivery system failures, gap between needs and requests, unprompted/unsolicited employee actions, and problematic customers (Bitner, Booms, and Tetreault, 1990). In a similar fashion, Lewis and Spyrakopoulos (2001) classified service failures into five categories, namely organization procedures, mistakes, employee behaviour, functional/technical failures, and actions/omissions of the organization that are against the sense of fair trade.
The following objectives have been defined for this study:
¿½ To identify causes of usual service failure in health care
¿½ To understand specific complaints and categorize them into generic classes
¿½ To identify usual strategies health care adopt to cope with such failures
¿½ To measure the outcome of these service recovery strategies and evaluate the impact of the chosen strategy on consumer perception and future behaviour
SERVICE CATEGORIES IN HEALTHCARE
Services offered can be broadly classified into core services and supplementary services.
Core Services
Core service in hospitals includes the treatment provided by the Doctors to the patients and diagnostic services. It is very difficult to measure the success rate of core services as it mainly depends on the criticality of the patient and his conditions. Core service failure might lead even to the death of the patients. In case of death of the patient or any major failures in the core service provided, since there are no recovery mechanisms possible, legal redress is available to ensure sufficient financial compensation for the loss.
Supplementary Services
Supplementary service in hospitals includes Nursing Services, Operations & Administration, Food & Beverage, House Keeping Services, Facility & Maintenance, Dietary Services, and Billing and Insurance Services. These supplementary services act as differentiators and helps define the level of service which has to be provided to the customers based on their willingness to pay. Hospitals earn their premiums only through the supplementary services which are provided in addition to the core medical service.
Till a few decades ago, patients did not have too many choices. But now with the mushrooming number of multi-specialty hospitals, patients have a wide choice of hospitals to choose from. In such a scenario, it becomes critical for hospitals to ensure that there is zero supplementary service failure.
CATEGORIES OF SERVICE FAILURE IN HEALTHCARE
The study has found generic resemblance across the two service sector segments as far as causes for dissatisfactions are concerned. This study finds that, most of the service failures were common in both the sectors and can be categorized in three main headings those are:
1. Hygiene and Physical Evidence- poor cleanliness, untidy staff, not appealing (looks), poor ambience, stingy, water and facilities arrangement not proper, congestion, arrangement in waiting room not proper, uncomfortable temperature.
2. Operations- slow service, specialist unavailability, ambiguity of rate, ambiguity in process/ waiting time, machine or equipment unavailability, wrongly charged, work not done proper, lost order, missing of your personal items, reservation missing.
3. Employee related ¿½ untidy staff, staff not prompt, staff not attentive, lacking in efforts, does not understand your needs, staff does not have knowledge about their jobs, unfriendly and unhelpful staff The operations related failures were considered the most significant in relation to customer complain behaviour. Then in the rank comes employee related, followed by hygiene and physical evidence category.
CORE SERVICE FAILURE
Medical Services – Doctor to Patient
1. Explaining patient about his condition
One of the major failures that occur in Indian Hospitals is failure of doctor explaining the condition of the health to the patient. In some cases it is the doctor who is responsible for this failure as he does not spend required time with the patient. In few cases the patients are not interested to know about the condition.
2. Hospital acquired infections (MRSA)
Another major failure in a hospital is the occurrence of hospital acquired infections. This serves as a critical failure because many hospitals even have a specific KPI for such occurrences. For example MRSA occurs when a doctor who goes on rounds to visit patients does not clean his hands when he moves form one patient to another. This failure should be prevented at any cost as it delays the curing cycle of the patient and also complicates the treatment process.
3. Borderline cases
Borderline cases are cases in which there will be an involvement of two departments in the treatment of the patient. For example in the case of an infected Pregnant women the hospital should know which department is responsible for her, either Gynaecological or Medical department. But this does not happen properly in some cases and leads to core service failure.
4. Mass causalities
Even though this is not a regular occurrence, but when there is a mass casualty hospitals in India are not equipped to deal with it. This leads to loss fo life for many people. Hospitals should be equipped and staffs should be trained to deal in such situations.
Diagnostic and Nursing Services
1. Contaminated samples and sample collection (Diagnostic and Nursing services)
Sample collection from the patients is one of the major areas where both the diagnostic and nursing services fail in a hospital. This may be due to lack of proper training or due to overwork. This creates a negative opinion about the hospital in the minds of the patient and they might prefer not to come back.
2. Lack of proper supervision and not giving a dose (Nursing services)
This mostly happens when there is a shift change and there is no proper transition taking place among the staffs, due to which the patient ends p suffering. This in some cases may even be fatal. One of the reason for this to happen is there is no proper supervision of the nurses and also no coordination
Key Performance Indicators
1. ER waiting times
This KPI measures the average amount of time each patient has to wait in an ER. ER wait times are one of the most important indicators of your hospital’s performance and patient satisfaction. Wait times are calculated over a specific time period to account for any anomalies in the data.
Example: 90 min wait / past 30 days
2. Average length of stay
This KPI measures how long, on average, patients stay in the hospital. This metric can vary widely based on what type of facility you are operating (long term care vs. short term) and what type of medical conditions are involved.
Example: 4 days is the average length of stay
3. Number of hospital acquired infections
This KPI tracks the amount of hospital acquired infections (HAI) per 1000 patients. This is a challenging metric to track simply because there are so many factors involved in determining where and how someone is infected. A high HAI needs to be addressed quickly, since this is a public safety concern.
Example: C. Difficile 3.2 / 1000
4. Inpatient mortality rate
This KPI measures the percentage of patients who pass away while under your care. This metric should be calculated with an understanding of the underlying medical conditions involved in each case. If the mortality rate for a certain condition suddenly goes up, one can start getting to the root of the problem.
Example: Congestive heart failure 2.6 / 100
SERVICE RECOVERY FOR CORE SERVICE FAILURE
It is a fact that ¿½More than the actual complaint, the way the complaints are handled causes much more customer dissatisfaction¿½. Since there is an emotional stress associated with core service failure in hospitals, recovery mechanism should be designed carefully. Fairness in terms of handling the service failure and empathy are very critical for service recovery in hospitals.
Procedural fairness is a key aspect of service recovery. An example for procedural fairness is to empathize and accept the event of service failure. This is the first step even when the fault was on the patient¿½s side. Usually in all other service sectors, investigation as to who is responsible for the service failure-the patient or the doctor and identifying the cause for the failure is the next step which follows the acknowledgement. In case of healthcare, since the situation is critical and every minute is important, investigation should be the last step. Necessary steps like corrective surgeries, etc. should be taken up at the earliest.
Acknowledge and act is the two immediate steps which need to be done to ensure positive service recovery. In case, the hospital or the doctors are aware of the fact that the service failure, then they should apologize to the patients and their relatives for the physical and mental agony that they are undergoing and ensure that things get well at the earliest. A clear explanation has to be given to the patients who are undergoing the ailment.
Hospitals need to ensure that there is responsibility, accountability and appropriate care from all doctors and nurses and Para-medical staff. In case of healthcare, there are also legal procedures which are available for the patients to get genuine monetary compensation for the amount of physical hardships undergone. The hospitals do have a legal team which guides them in case of legal procedures.
Service Failure Prevention
Service failure is inevitable in healthcare. Though there is no fool proof prevention strategies, prevention to a certain extent can be done by ensuring the following:
1. Poka Yoke:
This means mistake proofing. Doctors can adopt poke yoka before any surgeries. For example: in case the surgery has to be done on the right knee, the doctor can mark the knee even before getting the patient to the operation theatre and verify it twice with the nurses and supporting staff.
2. Centralised Database:
In India, the problem is most of the time; there is no sufficient medical history/record for a particular patient as the patients do not most of the time patronize the same hospital. This is primarily due to the fact that the doctors have clinics which are conveniently located to the patient which do not have much of these facilities. In case the patients patronize these multi-specialty hospitals, patients forget to carry their Registration number and end up paying Rs.100/- to Rs. 250/- every time they enter the hospital and create new ID numbers. This makes it difficult to consolidate the information. There is a lack of information which is being provided to the Doctor and Doctor is forced to take a call at that point of time.
3. Tests:
These days in multi-specialty hospitals, it has become customary for the doctors to prescribe all the tests for the patient to ensure proper diagnosis. Though this is a mistake proofing strategy followed by the doctors, it adds to the burden of the ailing patients as the hospitals charge humongous amount of money for each test that is carried out. This is still a controversial topic in the medical and healthcare field even today.
4. Supporting Staff:
The training and scheduling of supporting staff is an important part of service failure prevention. It is observed that most of the failure happens when the nurses come in shifts and there is no proper communication between the nurses handling the same patient during day time and night time which results in service failure. Nurses should be trained to communicate properly and sufficient number of staffs should be posted to avoid errors due to haste. There should also be an upper limit on the number of patients and the number of hours that the staff and doctors work; this will help in avoiding fatigue errors.
SUPPLEMENTARY SERVICE FAILURE
Supplementary services act as differentiators and helps define the level of service which has to be provided to the customers based on their willingness to pay. Hospitals earn their premiums only through the supplementary services which are provided in addition to the core medical service. Supplementary service failure may be hygiene related, operations or employee related.
Measurement of Failures in Supplementary Services (Apollo Hospital)
The management of the hospital has a separate department to collect feedback from both in-patients as well as out-patients about the service they receive during their stay.
Self-administered questionnaires and feedback forms were distributed to both inpatients and out patients in the survey to collect the required dataset. The questionnaires distributed in the survey were returned and analysed. The feedback form has separate divisions for each department and will collect the issues encountered by the patients. They are supposed to rate each department on a scale of 10.
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Every day the feedback is collected at 11 AM and this data is consolidated and Daily point average score (DPA) is calculated. DPA signifies the number of complaints in the department. Higher the DPA more the number of complaints in the department and appropriate actions need to be taken to improve the overall quality of the hospital. This DPA score is calculated and that department whose value exceeds critical value is notified about the complaints and immediate measures are taken. The following flowchart represents the mechanism that hospital employs in collecting data.
Figure: Data collection and Reporting Process
Daily Point Average (DPA) is calculated using the formula:
Even though DPA is collected every day, the number of issues did not follow any downward trend. The trends are listed in appendix. Therefore we decided to consolidate all complaints together and perform analysis on this data to find out departments which need attention.
Data Sourcing
Apollo collects feedback from most of their inpatients regarding their stay at Apollo. They collect an overall satisfaction score on a scale of 1-10 along with any complaints specific to each department. Feedback of about 1210 inpatients for a timeframe of 14 months (March¿½11 ¿½ April¿½12) was obtained. This data is used in the analysis.
Data Analysis
Binary logistic Regression is performed on the data with overall satisfaction score as dependent variable.
REGRESSION: MODEL 1
B S.E. Wald Df Sig. Exp(B)
Step 4a Food(1) -.634 .242 6.839 1 .009 .530
Housekeeping(1) -.705 .223 9.977 1 .002 .494
Facility(1) -.644 .282 5.199 1 .023 .525
Constant 3.510 .450 60.850 1 .000 33.450
a. Variable(s) entered on step 3: Facility.
The overall model is significant and the significant variables obtained indicate that the probability of a good rating decreases significantly with any complaint in Food, Housekeeping and Facility departments.
There is a general perception that patients in Executive or Platinum rooms might be getting a better service than the patients in General Ward or Twin sharing rooms. So, in the model, we included the room type in which the patient stayed to check this.
REGRESSION: MODEL 2
B S.E. Wald df Sig. Exp(B)
Step 8a Housekeeping(1) -.480 .217 4.884 1 .027 .619
Daycare(1) -1.091 .556 3.843 1 .050 .336
ER(1) -20.456 1.004E4 .000 1 .998 .000
Executive(1) -2.359 .482 23.981 1 .000 .095
Gen(1) -1.165 .266 19.244 1 .000 .312
PVT(1) -1.411 .225 39.203 1 .000 .244
Twin(1) -1.258 .268 21.993 1 .000 .284
Constant 28.941 1.004E4 .000 1 .998 3.706E12
a. Variable(s) entered on step 7: Daycare.
According to the above model, it can be said that there is no difference in the services offered.
FREQUENCY OF COMPLAINTS:
The next step was to find out the most frequent complaints and therefore we tried to use wordle that gives pictorial representation of a complaint that was made maximum number of times. All the complaints are consolidated and are given as input to the wordle editor. The output from wordle is given below.
Figure: Wordle Representing Frequency of Complaints
This is in line with the conclusion obtained from binary regression analysis performed earlier. Hence food, housekeeping and facility departments need to be trained properly in order to avoid the complaint. In Food department, it is very essential to reduce turnaround time in delivery to the patient rooms.
Supplementary Service Failure Recovery
The approaches companies can apply to handle service failures can be divided into three main strategies:
– Service failure prevention strategies to avoid failures from the beginning on
– Process monitoring strategies to forecast critical moments for the service delivery process
– Service failure recovery strategies to deal with customers appropriately after a service failure has occurred
Service Prevention Strategies
It is crucial to forecast the demand for supplementary services in the health care sector to get it efficiently managed. Variations happen both in the short and the long term and have to be assessed as precise as possible. Supplementary services in hospitals [like Nursing Services, Operations & Administration, Food & Beverage, Housekeeping Services, Facility & Maintenance, Billing and Insurance Services etc] are directly linked to the institution¿½s core services and can therefore be derived from this data using statistical predictions together with information technologies. Finally, health care suppliers have to track demand variations to identify potential sources of service failures along the health care supply chain and prepare themselves accordingly to avoid mistakes. For example, poor quality of nursing services due to a high workload can be prevented by effective shift planning (short term), employing more staff (long term) or simply preparing employees for demand variations with training.
Furthermore, front-line employees should be trained to continuously deliver a high service quality. This requires a clear frame of the customer expectations to meet and exceed them as well as identifying any potential sources of service failures together with appropriate reaction strategies. Some methods that can be used to train employees are structured scenario simulations, role plays, videotaping or installing quality teams. To prevent any service failures in health care¿½s supplementary services, performance standards should be set. This has the advantage to offer orientation for employees in their daily jobs as well as it is a starting point for evaluating the own operations.
Process Monitoring Strategies
Monitoring strategies are employed to measure the quality and performance during the service delivery process. The set-up of process performance standards makes it possible to recognize any mistakes that may lead to customer dissatisfaction and fix them directly. In supplementary services for example the time between cooking and delivering food can be tracked so that it is ensured that patients receive a warm meal at a reasonable time frame (e.g. between 12.30 and 1 pm). Another example is the time span between a patient ringing the emergency bill and a nurse arriving at the room.
At the same time, it is crucial to measure employee¿½s performance and to provide regular feedback based on a reliable measurement of customer satisfaction. As the interaction between employees and customers is critical for service quality, the staff must be motivated to constantly deliver high quality standards. This can be ensured through the provision of incentives in the form of reward and recognition (publish employee successes, promotions etc.) as well as applying disincentives for poor quality standards.
Service Failure Recovery Strategies
After a service failure took place, it is important that service employees apply appropriate service recovery strategies to solve the problem. Initially, customers should be encouraged to complain. Although this might be taken as granted at first sight, many customers don¿½t share their anger with the organization but tell their social network about the bad experience. This has three implications: firstly, the company doesn¿½t have the chance to learn from its own mistakes and might keep delivering service failures; moreover, the problem can¿½t be fixed and the customer can¿½t be convinced to use the service again and lastly, unsatisfied customers tell twice as many people about their frustration as delighted customers do. Therefore utilizing standardized evaluation forms or asking the customer during the billing process about the experience is an effective way to get to know the client¿½s satisfaction.
After a customer expressed his dissatisfaction, the problem must be acknowledged by the service employee followed by an apology and the promise of a quick and reliable recovery. For a disappointed customer it is in general more important to know that the problem will not occur again because the organization acknowledges the problem and apologizes for the same than getting the compensation.
Therefore a reliable and quick response towards the client must be ensured. This requires the empowerment of employees in lower hierarchies as they are usually the first point of contact. Furthermore the workforce should be trained to give the customer the chance to express his anger and to react empathetically and in a fair and respectful manner. The unsatisfied patient should then be offered a compensation that he believes is fair, considering all his costs. Furthermore it¿½s valuable for the client to receive a post-complaint feedback from the institution. Dealing correctly with failures in supplementary services offers a big chance for health care organizations because it allows them to improve their own processes. This requires constantly reporting complaints, analyzing underlying problems and to learn from former service failures.
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