I typed this out earlier.
Wohoo! I arrived Labuan yesterday. Yes, Labuan… heaven for chocoholics and alcoholics. Lol. duty free baby!!!! Can you believe it? Jack Daniels for RM55!!!!, it used to be RM60 but now it’s down by RM5…holy canoly!!!! Lol, I bought 2 JDs (obviously both is not for me, 1 for my brother and 1 for moi!) In KK, JDs cost about twice that amount (RM100++)…now that is one thing that we can say “whoaaaaaaah!” to.
The chocolates and the alcohols here are dirt cheap compared to Sabah. The ferry ride was quite boring except moments when the ferry was rocking side to side due to the strong wind and waves. That was a freaky moment but I had to stay cool because my nephew was in the car. Labuan is quite a nice island, the city is quite ‘polluted’ by trash. It isn’t that bad but it is noticeable though…but further from the city you can a lot of the sea and remarkably the further you are from the city, the cleaner it gets…or so to speak. There are quite a number of expats here in Labuan and some of the house that I’ve seen here are beyond my wildest imagination…another thing that we can say “whoaaaaaaah” to. I saw this mansion and it’s so huge that I thought it was some hall or something. Victoria Mansions (It’s like an estate or housing area with mansions – very exclusive, probably for the crème de la crème of Labuan)
We are staying in Manikar Beach Resort which used to be a really nice 5 star hotel. It’s up and running now but the facilities aren’t the way they were before. The pool is quite nice though. I loved the fact that the pool is an infinity pool and overlooking the beaches. It’s very nice – you could run to the sea, have a quick dip, wash self and then run over to the pool to have a swim. The idea of it all is very exciting.
We will be going back to Kota Kinabalu tomorrow with the 1 o’clock ferry ride but I think it will be a little bit delayed though. I have nothing more to write so this is it for now.
Monday, February 11, 2008
Cheap booze, chocolates and ciggies
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Measuring service quality at a university health clinic
The Authors
Elizabeth A. Anderson, Assistant Professor of Operations Management, Department of Decision and Information Sciences, College of Business, Administration, University of Houston, Houston, Texas, USA.
Acknowledgements
The author gratefully acknowledges the efforts of Linda Vincent, Molly Lochmeyer, and David Bowden, who performed data entry and assisted in data analysis, and B. Gayle Prager, Associate Director of the University of Houston Health Center, who provided background information as well as helpful comments and suggestions.
Abstract
Describes research undertaken to assess the quality of service provided by a public university health clinic. The SERVQUAL instrument was administered to patients of the University of Houston Health Center in order to evaluate customer perceptions of service quality. The results of this study are currently being incorporated into the clinic’s strategic planning process, specifically with respect to future resource allocation towards quality improvement projects.
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Article Type: Case study
Keyword(s): Clinics; Customer satisfaction; Health care; Improvement; Service quality; Strategic planning; University of Houston Health Center; USA.
International Journal of Health Care Quality Assurance
Volume 8 Number 2 1995 pp. 32-37
Copyright © MCB UP Ltd ISSN 0952-6862
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Introduction
The issue of health-care quality management has drawn considerable attention from both academics and practitioners over the past few years. In the wake of pressure to move towards a managed care environment, health-care providers are being forced to drive down costs, while at the same time maintain acceptable levels of quality. These pressures are especially acute for public university health clinics, which must survive with decreased state funding and limited student service fees. Thus, health clinic administrators must contain costs, yet at the same time not sacrifice quality. Consequently, the ability to define, measure, and monitor quality is critical to the survival of university health clinics, as well as other public health-care institutions.
This article describes research undertaken to assess the quality of service provided by a public university health clinic. Measurement of customer perceptions of service quality is necessary to evaluate the impact of quality improvement activities initiated through the clinic’s strategic planning process. By measuring quality in this manner, management can better direct financial resources to improve clinic operations in those areas which impact on customer perceptions of service quality the most. Such evaluation of service quality is essential in today’s competitive, cost-conscious health-care market.
We administered the SERVQUAL instrument, developed by Parasuraman et al.[1], at the University of Houston Health Center during the Spring 1993 semester to assess the quality of service provided by the clinic. The results are currently being incorporated into the clinic’s strategic planning process, specifically with respect to future budgeting for quality improvement projects. Measurement of service quality has enabled management to assess the benefits of increased investment in quality improvement activities. As such, the most important outcome of this research is the linking of student perceptions of service quality to resource allocation decisions. Specifically, the results of this study indicate areas in which the University of Houston Health Center must allocate more funds to improve performance, as well as areas in which additional investment is unnecessary, and perhaps even counter-productive.
The University of Houston Health Center
The University of Houston Health Center provides services to university students, faculty, and staff. However, its mission emphasizes low-cost services to students. Included in its services are general health examinations, vaccinations, emergency care, pharmaceuticals, and gynaecological, dermatological, orthopaedic, and psychiatric consultations. During the fiscal year 1991-1992, the clinic provided 31,358 patient visits, 38,244 prescriptions, 12,238 lab visits, and 25,180 telephone consultations. The health centre is managed by a medical director and an associate director. Together, they administer daily operations and ensure that the clinic meets its mission and all regulatory obligations. The general medical clinic is run by 5.60 physician FTEs (full-time equivalents). Five other physicians provide medical support on a part-time basis to the gynaecological, dermatological, orthopaedic, and psychiatric specialty clinics. The general medical and specialty clinics are supported by 11.75 nurse FTEs, 3.40 pharmacist FTEs, 2.00 technician FTEs, and 5.00 ancillary staff FTEs.
The health centre receives revenues from several sources. Patients are required to pay a nominal charge each time service is rendered. A student insurance plan is offered at registration in order to reduce student health-care financial obligations. Additional funds are designated by the university and are charged as a health centre service fee to each student’s tuition and fee bill. Other revenues are received through gifts and, indirectly, through pharmaceutical and supply discounts. For the 1992-93 fiscal year, the health centre was budgeted for revenues of $1,601,788.
As an auxiliary enterprise, the clinic supports the overall mission of the university but does not receive state funds as do the university’s academic units. Thus, the health centre is essentially self-supporting. As such, its survival is dependent on student-generated revenues, which in turn are dependent on patient satisfaction. The University of Houston is a large urban university with a diverse population of students, most of whom commute to campus. Thus, the health centre does not have a captive customer base as do comparable clinics at primarily residential universities. There are many medical facilities in the city of Houston which compete on the basis of low price, and are therefore especially attractive to college students. In order to remain competitive relative to such alternative health care facilities in the city, the University of Houston Health Center must provide high-quality service at low cost. As such, patient satisfaction is critical to its survival.
Service quality measurement
Service quality has most often been defined in terms of customer perceptions. Hence, most of the operational definitions or conceptual frameworks that have been suggested for service quality are based on marketing concepts[2,3 ]. Researchers have divided service quality into two components: technical quality and functional quality[3, 4,5,6, 7]. Technical quality refers to the quality of the service “product”, whereas functional quality refers to the manner in which the service “product” is delivered. In the health-care environment, technical quality can be defined by factors such as average length of stay, readmission rates, infection rates[ 8,9,10, 11] and outcome measures[ 7,12]. On the other hand, functional quality can be defined by factors such as doctors’ and nurses’ attitudes towards patients, cleanliness of facilities, and the quality of hospital food[7,13].
Customer evaluations of service quality are based on perceptions of the quality of service received relative to prior expectations. This service gap, defined as the difference between expectations and perceptions, is the basis of most recent service quality research[ 1,3,4, 6,14]. The SERVQUAL instrument[1] was designed to measure the gap between expectations and perceptions. The instrument is a 22-item Likert-scale survey which compares customer expectations and perceptions based on five dimensions of service quality: tangibles, reliability, responsiveness, assurance, and empathy. The SERVQUAL instrument has become the industry standard in evaluating customer perceptions of service quality, and has been applied in several recent case studies with promising results[10,15 ,16,17, 18,19].
Furthermore, as total quality management (TQM) is a critical element in strategic planning[20,21 ,22,23], the measurement of service quality is essential in determining what quality attributes contribute the most to customer satisfaction, and ultimately to revenues. Additionally, such measurement is necessary to evaluate costs associated with service provision. For example, if the results of a customer satisfaction survey reveal that a high-cost centre is perceived by customers to be of poor quality, then management can focus on restructuring this centre. Such decision making would concentrate on whether to allocate quality improvement dollars to improve the performance of the centre, or to cut the centre from the firm’s operations if management deems it too costly relative to other units.
Administration of the SERVQUAL at the clinic
During the spring 1993 semester we administered the modified SERVQUAL instrument[10] to University of Houston Health Center patients. The questionnaire contained 15 pairs of statements representing the five dimensions of service quality: tangibles, reliability, responsiveness, assurance, and empathy[ 1]. The first set of 15 statements measured patients’ expectations of service quality regarding university health clinics in general, while the second set of 15 statements measured patients’ perceptions specific to the University of Houston Health Center’s quality of service provided. The questions were presented in a five-point Likert scale with “Strongly disagree = 1” and “Strongly agree = 5”. The only deviation from the Babakus and Mangold[10] modified SERVQUAL instrument was the change of the term “Hospital” to “University Health Center”. Additionally, respondents were asked to weight the importance of each SERVQUAL dimension by allocating a total of 100 points across the five dimensions.
The survey was administered during a one-week period in March and a one-week period in April 1993. The section pertaining to patients’ expectations of service quality was given to the patient on registration of request for service and was returned prior to examination or treatment. The section relating to perceptions of service quality provided was given to the patient after the service was delivered. In total, 431 completed surveys were returned. The questionnaire was completely anonymous, without the inclusion of any identifying information.
Results
Figure 1 shows mean expectations and perceptions aggregated according to the five SERVQUAL dimensions: tangibles, reliability, responsiveness, assurance, and empathy. Figure 2 displays this information for each questionnaire item. As shown in Figure 1, perceptions fell short of expectations for every category, indicating negative service gaps (i.e. perceptions minus expectations). In analysing the distance (gap) between expectations and perceptions, empathy and tangibles exhibit the smallest gaps while assurance has the largest gap. The gaps for reliability and responsiveness are very close in size, following assurance. Thus, clinic performance with respect to empathy and tangibles is more closely in line with patient expectations than that of assurance, reliability, and responsiveness.
At first glance, it may appear that the health centre is performing well with respect to tangibles and empathy since these attributes exhibited the smallest gaps. However, tangibles and empathy had the lowest levels of patient expectations. Thus, a small gap does not necessarily mean that the health centre is performing at a high level in a particular category. Rather, a small gap indicates a relatively close matching of patient expectations and perceptions. A small gap could result from lower levels of performance in a given category coupled with lower levels of patient expectations. In the current study, patients apparently have lower expectations with respect to tangibles and empathy. Since the health centre is virtually meeting these lower expectations, the resulting service gaps for these attributes are smaller.
A meaningful input to managerial decision making is the comparison of these service gaps with the relative importance of each dimension as determined by the weights allocated by respondents to each category (see Figure 3). According to these mean weights, tangibles is the least important attribute, followed by empathy, while reliability is the most important. As shown in Figure 1, tangibles and empathy have the least negative gaps; however, they are the least important dimensions. Since the health centre is fairly close to meeting patient expectations of tangibles and empathy, additional resources allocated to these areas may be unnecessary. On the other hand, reliability is the most important attribute to students, but exhibits a larger service gap. This is a clear opportunity for improvement in health centre operations.
In addition to looking at the service gaps across the five quality attributes, it is useful to examine particular questionnaire items. As shown in Figure 2, the only positive gap (perceptions exceeded expectations) is for item 2, “The health centre’s facilities are visually appealing”. This gap is 0.0766. Two other gaps are negative but very close to zero: statement 3, “The health centre’s employees appear neat” (-0.0048), and statement 14, “The health centre’s employees give patients personal attention” (-0.0186). These statements fall under the attributes tangibles and empathy. As discussed previously, these areas are not as important as the others. Thus, it may be a worthwhile strategic consideration to divert quality improvement dollars to the more critical areas, as indicated by large negative gaps for important categories.
The largest negative gaps were for statement 13, “The health centre employees get adequate support from their employers to do their jobs well” (-0.6868), and statement 1, “The health centre has up-to-date equipment” (-0.6427). Other larger gaps were for statement 4, “The health centre provides its services at the time it promises to do so”, statement 7, “health centre employees tell patients exactly when services will be performed”, and statement 10, “Patients feel safe in their interactions with health centre employees”. Table I and Table II show the means and standard deviations, respectively, of expectations, perceptions, and gaps for each questionnaire item. These results point out many opportunities for the evaluation of strategic allocation of quality improvement dollars. Specifically, management should consider reallocation of resources to some of the more critical areas, as identified by the larger service gaps.
Discussion and conclusions
The evaluation of service quality at the University of Houston Health Center through the measurement of patient satisfaction has significant implications for strategic planning. Specifically, recent resource allocation decisions should be re-evaluated in the light of the results of this research. Students do not seem to care as much about tangibles and empathy as they do about reliability, assurance, and responsiveness. One exception to tangibles is the large negative gap for “up-to-date equipment”. Currently, the health centre is in the process of installing new examination tables in an effort to change this negative perception. However, management is concerned that patients will tend to overlook this change since they sit on the table while waiting for the doctor and view the room rather than the examination table. Thus, other improvements to update medical equipment may be more visible to patients, and have a greater impact on perceived quality.
Other recent quality improvement efforts have focused on modernizing the physical appearance of the initial waiting area with new paint, new layout, and streamlining of the reception area. Since students do not appear to have high expectations for these types of tangible items, perhaps these quality improvement dollars should be allocated elsewhere, as this may not be the most prudent use of funds. Rather, quality improvement dollars should be directed towards responsiveness, reliability, and assurance. Specifically, waiting time is an important indicator of responsiveness. The clinic should redesign its operating processes to reduce student waiting time. For example, one of the most visible bottlenecks is the flow between the cashier and the pharmacy. Students must present a prescription to the pharmacist, pay the cashier down the hall, then return to the pharmacy to receive their prescriptions. Simplifying this process to avoid going back and forth from pharmacy to cashier is one potential area for improvement in responsiveness. Additionally, education of students regarding the use of appointments rather than relying solely on walk-in service would also help to reduce waiting time. Nevertheless, more personnel should be scheduled during peak hours to help buffer increases in demand. Finally, an effort should be made to educate students on the mission of the clinic and how that mission differs from the typical family doctor. If students are cognizant of the role the health clinic plays in the university, perhaps their expectations would be more in line with typical managed care environments, rather than what they have perhaps experienced from a family doctor.
In conclusion, we have found the measurement of service quality to be important in evaluating the effectiveness of the health centre’s strategic planning process with regard to quality improvement initiatives. The SERVQUAL questionnaire results demonstrate areas in which the health centre is close to meeting patient expectations, and areas in which it falls far short of expectations. As management goes through the budgeting process this year it should pay close attention to the allocation of quality improvement dollars. In this way the health centre can improve its level of quality in those areas which impact on patient perceptions of service quality the most. Through such measurement of quality, the effectiveness of TQM investments can be monitored over time, with resources being shifted to those areas which most heavily influence patient perceptions of service quality. In order to accomplish these goals, the University of Houston Health Center plans to administer the SERVQUAL on a yearly basis.
A special University of Occupational and Environmental Health in Japan
Toshiteru Okubo
The Authors
Toshiteru Okubo, University of Occupational and Environmental Health, Japan
Abstract
Shows how the Occupational and Environmental Health University in Japan, with its Institute of Ecological Sciences, delivers several unique national and international courses for Japanese and foreign students. Staff of the university also provide advice and assistance to other training centres and industry.
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Article Type: Case study
Keyword(s): Ecology; Environment; Occupational health/safety; Training.
Content Indicators: Research Implication - ** Practice Implication - ** Originality - ** Readability - ***
Environmental Management and Health
Volume 8 Number 5 1997 pp. 179-180
Copyright © MCB UP Ltd ISSN 0956-6163
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The University in general
The University of Occupational and Environmental Health, Japan was established in April 1978 by the Ministry of Labour. The unique purpose of the university is to train occupational health physicians and their co-workers from the undergraduate level. To achieve this aim, all undergraduate students are eligible for a special scholarship if they apply. The amount is sufficient to cover all tuition fees and, in addition, partial support for living expenses.
Those who receive this scholarship are obliged to work at the positions prescribed by the university for a minimum of nine years. If a person fails to clear this obligation, he or she must pay a certain amount back to the fund.
The university established the postgraduate occupational health training course in 1989, which is five years in duration and is designed to fit the required training for the specialist qualification programme by the Japan Society for Occupational Health. The Occupational Health Training Centre was established in April 1991 in the university as the responsible institute for the course. Currently this centre is the only one which offers systematic postgraduate training in occupational health in Japan.
Institute of Industrial Ecological Sciences
The Institute of Industrial Ecological Sciences was founded in the university in April 1986. As its educational activity, the institute is operating the three-month course in fundamental occupational health every year. In addition to offering the educational course by itself, the staff of the institute are assigned to the above-mentioned training centre adjunctively and participate in the postgraduate programme. They are also sent to nationwide training courses held by regional medical associations through the centre. Thus the institute is acting as a national resource centre for the training of occupational health specialists.
The institute is composed of 13 departments: Department of Systems Physiology, Mental Health, Clinical Epidemiology, Health Development, Environmental Epidemiology, Environmental Toxicology, Pneumology, Systems and Health, Environmental Oncology, Environmental Health Engineering, Ergonomics, Health Policy and Management and Occupational Health Economics.
The name of the institute originated from an idea that dynamics of industrial structure resembles that of the natural ecology. Cross-sectional interrelations among different industries as well as longitudinal relations of inter- and/or intra-industry are almost similar to those in natural ecology. If the mechanism of a change in such industrial structure can be clarified, one can foresee future changes in the industry. Needs of occupational health would change from time to time, and research and educational needs must reflect those changes. There is thus an attitude of anticipating changes, based on inter-disciplinary collaboration among the departments of different specialities.
The three-month course in fundamental occupational health
The three-month course in fundamental occupational health was established in 1984 to provide basic knowledge and techniques necessary for graduates of medical schools to work as occupational health physicians. This course is held each year from April to June, and its curriculum includes lectures in introduction, Special topics related to industrialization, Physiology for occupational health, Industrial safety and human factors engineering, Industrial toxicology, Industrial hygiene, Occupational toxicology, Health care management and administration, Mental health, Occupational epidemiology, and Administrative aspects of industrial safety and health, and offers laboratory studies in small groups.
The participants who complete the course will be exempted from the written national examination and after the oral examination may become qualified occupational health consultants. The course is also an approved course of the Occupational Health Physician Certification Programme of the Japan Medical Association. Completion of this course is one of the prerequisites to taking the examination of the specialist qualification programme of the Japan Society for Occupational Health. The course was recently designated by the Ministry of Labour as one of the essential training courses for applicants wishing to become occupational health physicians as prescribed by the law.
International course on occupational health
Since 1985, a Group Training Course in Occupational Medicine commissioned by Japan International Co-operation Agency (JICA) has been offered by the institute. This course is designed for medical doctors who are interested in occupational health, and are engaged in various activities in this field. The course provides basic concepts and a fundamental knowledge of disciplines in order that participants may obtain a broad and systematic view of occupational health. This course is held each year from September to December and 126 trainees from 35 countries had completed this course by 1996. JICA fully supports these trainees for round trip airfare and living expenditures during the course.
Comment
The Occupational and Environmental University in Japan is, as far as I know, the only university in the world so-named. It is a shining example of what is possible in an institution which stresses the importance of research and training in ecological sciences, with particular relationships to health issues.
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