service quality management setting in the case of black lion hospital by damtew tessema 2014
DESCRIPTION
it is an empirical study on the Service Quality Management Setting in the Case of Black Lion Hospital by Damtew Tessema in 2012/13TRANSCRIPT
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Service Quality Management in the case of Black Lion Hospital
by Damtew Tessema 2014
INTRODUCTION
1.1 Background of the Study
For several decades “quality” and “quality management systems” have been leading philosophy
in the business world. According to Biolos (2002), numerous consultants have built their careers
around these topics, and quality issues in business have been responsible for the development of
new organizations and even industries. Now a day, many firms are adopting the quality
management system. According to Wolkins (1995) and NSWHEALTH (1998), the science of
quality management system is imperative to exercise in service institutions like hospital and
clinics. The system encompasses “continuous quality improvement, total quality management,
setting service standards, participative management and other related activities” (NSWHEALTH,
1998: 277). Therefore, the service centers like the health institutions, both the private and public
ones are in need for service quality management (SQM). According to the British Colombia
Institute of Technology (2001), health care quality management will prepare managers and
health care professionals to plan, develop and implement successful continuous quality
improvement/management programs in their organizations and health care regions.
With applying SQM principles, many service firms in both developed and developing worlds are
working to maximize their service quality to their customers. Similarly, such philosophy has
introduced into Ethiopian health service industries. One of the service organizations which have
been trying to provide quality services by exercising quality management systems is Black Lion
Hospital (BLH). “The hospital is one of the oldest and largest hospitals in the country’’ (Global
Health Reflections, 2011:2). In view to achieve the best result in its service BLH has its own
quality management setting. Moreover, according to BLH (2010), the focuses of the BLH are (1)
quality of clinical care provision (2) the provision of explicit accountability for the quality of
health care with a systemic orientation; (3) managing the quality of health services with applying
the Principles of Balance Score Card (BSC), striving to supply adequate health materials and
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work to promote the capacity of supportive stuffs members and the health science professionals.
Based on the above background, the study will examine the service quality management settings
and its problems in BLH with focusing on the post-2000 years. The components of health service
quality management and service quality management setting component, the stakeholders, the
change and continuity of practices and the entrenchment of BSC principles` in SQM practice of
BLH will be discussed. The variables of SQM and its conditions will be analyzed based on
respondents’ responses. Finally, the study will put findings, conclusion and recommendations.
1.2 Statement of the Problem
Black lion hospital is the country`s largest hospital that provides medical treatment services and
academic education (for both undergraduate and post-graduate students). Currently, it has short
comes to provide timely medical treatment to patients come from different corner of the country.
As stated above, the hospital is both education and treatment center, in which wide varieties of
activities are carried out. As an academic institution, according to (TAAAC, 2011), BLH is
Ababa University`s largest and oldest teaching hospital among all in Ethiopia providing teaching
for about 300 medical students and 350 residents every year. “It offers diagnosis and treatment
for approximately 370,000-400,000 patients per year” (Ibid: 1). For the sake of providing the
stated services, it has 800 beds, 130 specialists and 50 non-teaching doctors (ibid). However, the
professional manpower and the material resources are limited which would further constrain the
quality services. In regard to the materials, according to Broom (2011), materials that are basic in
the developed world like in America are not available. In this multi-service institution, there is
the dynamism of activities and managerial activities. The policy of the federal government like
the Growth and Transformation Plan, the introduction of Balance Score Card system and other
related newly adopted government programs exacerbates the dynamism of activities and service
quality management settings. The dynamism and program rearrangements are more rampant in
the post-2000. Further, it is no doubt in saying that, there are significant changes in the variables
of SQM. The changes are also visible within a year or less. This shows that continuous study and
assessment of the area is essential, although there are previous researches that conducted in 2012
and before. The previous researches related to this study are not enough to illustrate all the
impact of policy and program change on the SQM. The 2012/13 conditions of SQM in BLH is
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also the issue which has not yet studied. However, this does not mean that this study is limited to
the 2012/13 phenomenon.
Therefore, this research is aimed at filling these above stated research gaps. There is also a need
to conduct study on the change and continuity of SQM systems from the year 2000 to present. In
addition, the research has its own contribution to put directions in dealing with the prevailing
problems related to quality services.
1.3 Core Argument
The existence of an ever increasing number of patients enrolled to BLH is the reality any years.
The supply of materials that are essential to provide adequate and quality service is limited and
thus the supply and demand are not synchronized. The professional man power is also found to
be limited. Moreover, the dynamism and progress of demand for better service is a ubiquitous
phenomenon. Therefore, the actual service is less able to meet the demand for the service. Thus,
the core argument is concerned about that the service quality management setting of BLH lacks
adequacy to satisfy the health service requirements and demands of the customers.
1.4 Objective of the Study
The main purpose of the study is to examine the service quality management setting of Black
lion Hospital. Within this broad issue the adequacy and the challenges in SQM will be discussed.
This broad objective has also four specific objectives that the paper desired to address. These are:
• To know the service quality management system of BLH;
• To identify the changes and continuity in SQM system of the Hospital;
• To identify the stakeholders and components of service quality management and
• To articulate the challenges in providing quality service.
1.5 Research Questions
Due to the dynamism and changes in the condition of SQM system and service provision
activities of BLH, studying the setting of SQM from the year 2000 to present is imperative. For
this purpose, I have forwarded a general and, three specific questions. The general question is
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refers to that “what are that service quality management setting of BLH? In addition, the specific
questions of the study are stated as follow:
• What is the system of service quality management?
• What are the changes and continuity in SQM and related issues?
• Who are stakeholders and components of service quality management of BLH?
• How and why the inability to provide adequate services BLH?
1.6. Significance of the Study
This research would help to identify the post-2000 service quality management setting and
practice of BLH. More specifically, the study enables to know the change and continuity of the
practice of service quality management. It enables to identify the areas of services in need for
improvement. It helps to assess the customers’ feelings and service delivery satisfaction as well
as the challenges to the service quality. The research enables the reader to know the components
of service quality management setting of the state hospital.
1.7. Methodology
Both quantitative and qualitative study design will be applied for the investigation because that
the data are the mix of descriptive type (qualitative literatures) and numerical (quantitative) one.
In order to achieve the objective of the study, I used purposive sampling (deliberate selection of
few service providing Medical Doctors and experts who are in the quality management position)
for interview because I believe that the targeted individuals have knowledge about the area of the
study. For the questionnaire, to get informants from the customers of the hospital, sampling is
used. Accidental sampling (sometimes known as grab, convenience or opportunity sampling) and
is used to access 78 and 62 emergency and outpatients clients respectively. Accidental sampling
is a type of no probability sampling which involves the sample being drawn from that part of the
population which is close to hand. In the three building there are 800-850 beds and single
respondents are selected from each floors the inpatient take bed. The nurse and doctors who
assigned to care the patients are also given response to the questionnaires.
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Both the primary and secondary sources will be applied to same purpose. As primary source,
interview has conducted with 3 persons who are two Medical Doctors are attended in BLH for
both their undergraduate and specialization and one Managing Director (1) in Black Lion
Hospital). Furthermore, 70 questionnaires are distributed for customers, medical employees and
administrative officers. As a secondary source of data, magazines books and government
documents will be reviewed.
1.7. Scope of the Study
The study covers the issue of Service Quality Management Setting in black Lion Hospital with
focusing to the post-2000 period. Here, the major focus of the research is the assessment of
Service Quality Management Setting in the case of Black Lion Hospital to examine the
challenges for the adequacy of services.
1.8. Limitation of the Study
The long time pending and the bureaucracy to get the officers for interview are considered as the
top of the limitation. The cancelation of appointment time by the officials is the constraints to
access the targeted key informants. The other problems are the difficulty to organize and collect
the diversified literatures related to the issue. Moreover, it is true to say that the time shortage to
conducting the research is a limitation in the study.
1.9. Organization of the Study
The research has organized into four chapters. The first chapter contains the introductory part. It
includes the background: statements of the problem, the core argument, objectives, research
questions, significance, methodology, and limitation, scope and organization of the study.
Second, the literature review embraces the definition and conceptualization of service quality
management, components of health service quality management and service quality management
setting component in BLH. In this part, different publications will be reviewed. The third chapter
describes the stakeholders in and practices of quality management in BLH. This section has also
contains the issue including, the stakeholders before and after 2000; the change and continuity of
practices and the entrenchment of Balance score card (BSC) in QM practice. In the fourth
chapter, all the data will be presented and analyzed. The general characteristics of the
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respondents and the variables of health service quality management will be discussed and
articulated. The findings and conclusion are the last part of the study
CHAPTER TWO
LITERATURE REVIEW
In this part, the concept of service and quality, Service Quality Management (SQM), the
components of health service quality management are discussed. For this discussion different
publications have reviewed.
2. 1. Concept of Service, Quality and Service Quality Management
Before the assessment of service quality management saying something about quality and service
is important because that it is not possible to understand service quality management without
having knowledge about the terms (service and quality).
2.1.1. Quality
According to the American Society for Quality (2004), “quality” can be defined in the following
three ways: First, based on customer’s perceptions of a product/service’s design and how well
the design matches the original specifications. Second, the ability of a product/service to satisfy
stated or implied needs; third, the achieved result by conforming to established requirements
within an organization (Ibid). The satisfaction of customers/ clients and extent to meet the
established high standards of services can be the yardstick point to talk about quality. There are
several elements to a quality system, and each organization is going to have a unique system
because that the quality variables may differ from organization to organization. Furthermore, the
most important elements of a quality system include participative management, quality system
design, customers, purchasing, education and training, statistics, auditing, and technology
(www.bussinessballs.com/dtrireresuorces).
According to American Society (2004), health service has six dimensions of quality on which the
framework is based are; safety, effectiveness, appropriateness of care, consumer participation in
health care, access to services and efficiency of the health care (health services must ensure that
resources are utilized to achieve value for money).
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2.1.2. Service
Service is refers to “any activity or benefit that one party can offers to another that is intangible
and does not result in the transfer of ownership of any physical object” (Dictionary of
Business,1996:454). According to Crowther, Kavanagh and Ashby (2006), service is a business
performs work or supplies goods for customers, but does not make goods. Services can be
delivered by any organizations that are government of non-governmental and private one.
Indivisibility, customer participation, intangibility and simultaneity (consumption and supply
occur at one time) are the manifestation of service. Thus, quality service implies that the service
which meets customer demand and pre-established standard. In regard to the concept of
healthcare/ health service quality, “the most durable and widely cited definition of healthcare
quality was formulated by the Institute of Medicine (IOM) in 1990” (Buttell, Hendler, and
Jennifer Daley, 2007:62). According to the IOM, quality consists of the degree to which health
services for individuals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge (Lohr, et`al, 1992). For these writers,
provision of healthcare service is aimed enhancing the chance of desired health outcome for
populations. The service delivery is also needs professional knowledge.
2.1.3. Service Quality Management
Management is the control and making decisions in an organization (Crowther, Kavanagh and
Ashby 2006). leading, staffing, monitoring and evaluating of an organization`s activity are also
the element in management processes. Therefore, it is possible to conceptualize Service Quality
Management (SQM) as the management of the provision of intangible benefit (performs work or
supplies goods for customers) and the regulation and follows up of compatibility of services with
the pre-established requirements.
Furthermore, SQM is explained in the following manners. It is the activities that healthcare
organizations design and implement more effective organizational support processes to make
change in the delivery of care possible (Lohr, et`al, 1992). In the practice of SQM and healthcare
managment, Lohr, et`al, (1992) argues that, according to the IOM, setting performance standards
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and expectations is essential element to improving patient safety. According to QMO,2011),
health service quality management is the activity of managers and healthcare professionals to
plan, develop and implement successful continuous quality improvement/management programs
in their organizations and health care regions. The final purpose is to enhance the delivery of
quality health care services that are accountable to clients of the system, the government and the
public.
In general, the concept of SQM is refers to the management of safety, availability /access and
effectiveness of services as well as the process of ensuring to meet the established standard of
services.
2.2. Components of Health Service Quality Management
In regard to health service Quality Management components, the health quality framework of is
based on the six dimensions of quality that have been selected to encompass aspects of care
relevant to patients and providers of health services. These are safety, effectiveness,
appropriateness, consumer participation, efficiency and access. This arrangement is applicable to
other health institution located in developing and developed countries
The focus of health performance monitoring in recent years has been primarily on activity and
financial efficiency (NSWHEALTH, 1998:7). Clearly, activity and efficiency remain important
but these need to be matched with attention to the other dimensions of quality of healthcare, with
accountability for budget and quality being viewed as equal performance indicators of health
management (ibid).
In regard to health service, everyone connecting with the health system, including consumers,
policymakers, clinicians, and managers have an interest in the quality of care provided. What is
needed is an overarching, coherent framework for managing the quality of health care in a
systematic way in Black Lion Hospital.
According to Buttell, Hendler, and Jennifer Daley (2007), IOM’s Committee report outlined an
agenda to improve proposed six components of quality in healthcare as follow:
Safe: Avoiding injuries to patients from the care that is intended to help them. Effective:
Providing services based on scientific knowledge to all who could benefit and refraining
from providing services to those not likely to benefit (avoiding underuse and overuse,
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respectively). Patient centered: Providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient values guide
all clinical decisions. Timely: Reducing waits and sometimes harmful delays for both
those who receive and those who give care. Efficient: Avoiding waste, including waste of
equipment, supplies, ideas, and energy. Equitable: Providing care that does not vary in
quality because of personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status.
Therefore, the management of Health Service Quality is emphasized on the planning,
controlling, monitoring, and etc the activities that are related to safety, effective, patient centered,
timeliness, efficiency and equitable.
NSWHEALTH (1998) adds that, effectiveness, appropriateness, consumer participation, and
access as the components of quality health care service. Consumer Participation in health care:
Not only do consumers have a fundamental right to participate in health care delivery, but such
input should have considerable benefit (ibid).
Access to services: Area Health Services should offer equitable access to health services on the
basis of patient need, irrespective of geography, socio-economic group, ethnicity, age or sex
(QMO, 2012). Appropriateness of care: It is essential that the interventions that are performed
for the treatment of a particular condition are selected based on the likelihood that the
intervention will produce the desired outcome. Essentially, the appropriateness of health care is
about using evidence to “do the right thing” to the right person, in a timely fashion
(NSWHEALTH, 1998).
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CHAPTER THREE
3. THE STAKEHOLDERS AND SERVICE QUALITY
MANAGEMENT SETTING IN BLACK LION HOSPITAL
In this part, the issues of stakeholders` participation in service quality management and service
quality management setting in Black Lion Hospital are the major concern. Within this topic, the
questions of “who are the stakeholders and how the service quality management system of BLH
sets?” are answered.
3.1. Stakeholders in Service Quality Management of BLH
Successful management of a quality service system involves many different aspects that must be
addressed on a continuous basis. For this purpose, the prevalence of several participants of the
management activities from different sections of the departments of an organization is
imperative. The plurality of practitioners would provide the mirror to see different aspects of
Service Quality Management.
When we see BLH, the stakeholders in Service Quality Management (SQM) of are the officers
of the quality control office, the nurses, and the emergency section, laboratory and infection
prevention department1. The representatives of the above mentioned department and sections of
the hospital have tasked to assess the reality of their respect departments and contribute inputs
for the better quality of services. Each of the departments except the quality control office (that
has four representatives) has a single representative in the quality management committee. The
reports of each department have taken into account the key performance indicators that the
hospitals` quality management office sets. The committees that established in accordance with
Ethiopian Hospital Reform Implementation Guidelines (EHRIG) have a role in evaluating,
controlling and monitoring the service quality of the hospital.
1 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013
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As to the respondents to the interview and open ended questionnaires, the consideration of
customers/ clients as stakeholder in quality management system is limited. However, one of the
key indicators of performance that established by the hospital is customer satisfaction. According
to QMO (2010, 2011, and 2012), with the desire to examine the satisfaction of clients, the quality
control office has been conducting a number of surveys on patients who undergo triage within 5
minutes of arrival in emergency room, and total number of attendances who remain in
emergency room for more than 24 hrs. As to report of QMO, if the emergency service providers
presented the patients for diagnosis, or for another day pending for less critical illness within
short period of time, there is possibility of satisfaction.
The nursing service directorate director admits that, the participation of stakeholders in quality
management system has no continuity. The managing director of the hospital also argues that
there is high participation of stakeholders at office level. But the managing director has declined
to comment on the continuity of stakeholders’ participation. The cleaners, guards and are not part
of the quality ser control committee. Service starts from the reception room and all the
practitioners of services are in need to be presented in service controlling system.
3.2. Service Quality Management Setting in Black Lion Hospital
For the discussion of this section, both the primary data which was acquired from the
questionnaires and interviews, and reports of the organization (BLH) are used. The service
quality management and control system of the hospital is under the supervision of Chief
Executive Organizer (CEO) and the activities carried out based on the KPI/ Ethiopian Hospital
Reform Implementation Guidelines` (EHRIG) requirements. All the quality measurement results
as well as improvement measures and proposals are expected to be submitted to CEO2. The
quality management and control activity of BLH has been exercised by the committee embraces
eight individuals. In this committee, four employees are from the quality control office, a nurse,
one person from emergency department, one from laboratory and the remaining person
represents the infection prevention department (ibid).
2 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013
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The exercise of quality control is implemented on the basis of EHRIG`s standards that articulated
in its charters. In the standards of EHRIG, hospitals expected to establish committees from
several sections of the hospital. However, BLH sets only the infection prevention, nursing
standard, drug and diagnostics and patient enrollment committees (Ibid).
For the management of quality of the services of the organization, Black Lion Hospital
established Key Performance Indicators (KPI). These are hospital management, outpatient
service, emergency service, inpatient service, maternity service, and referral services, pharmacy,
productivity, human resources, financial service and patient satisfaction (QMO, 2010, 2011 and
2012). The establishment of the key indicators can be considered as the part and parcel of service
quality control of BLH. Most of these indicators are discussed below.
As to the report of QMO (2011), one of the key performance indicators called Hospital
M3anagement focused on the total number of EHRIG Operational Standards for Hospital
Reform meet, number of new and repeat outpatient attendances at public facility and number of
new and repeat outpatient attendances at private wing. When high number of EHRIG`s standards
meet and outstanding number of new and repeat outpatient get treated in regular and private
wing, we can say that the performance hospital management is praiseworthy.
Outpatient Service: this is concerned to the number of outpatient ‘waiting time cards’ completed,
outpatient waiting time (in minutes) and number of outpatients not seen on same day as
registration during the reporting period ( QMO, 2010). To say that this indicators is outstanding,
there should be outpatient who get service within short period of time (in card room, diagnostics
and treatment).
Emergency Service focused on the total number of attendances who remain in emergency room
for more than 24 hrs, number of surveyed patients who undergo triage within 5 minutes of arrival
in emergency room, and the number of deaths in emergency room from patients who were alive
(i.e. any vital signs present) on arrival (ibid). These several indicators can be the quality indicator
to rate emergency service of the hospital.
Inpatient Service: To appraise the performance of inpatient service, the quality management
office measures “the number of patients discharged alive (including transfers out), number of
days between date added to surgical waiting list to date of admission for surgery, the total
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number of patients who were admitted for elective (non-emergency) surgery during the reporting
period, average number of operational beds during the reporting period and total number of
major surgeries (both elective & non-elective) performed during the reporting period on public
patients” (QMO,2011:3).
Productivity: This can be measure based on the availability and services of average number of
full time equivalent nurses/midwives, average number of full time equivalent doctors and
average number of Full Time Equivalent (FTE) specialist surgeons (excluding
ophthalmologists).
Maternity Service: In this aspect, the number of live births attended in the hospital, the number
of women who gave birth in the hospital, the number of abdominal surgical deliveries, and the
number of instrumental or assisted vaginal deliveries as well as the number of maternal deaths
(any gestational age) are the major focuses (ibid).
Referral Services: The number of emergency referrals made and the number of non- emergency
referrals made are the basis to evaluate referral services. Both types referral expected to have
appropriate and timely treatment.
Human Resources: According to QMO (2011), the number of physicians (GPs and specialists)
who left the hospital during the reporting period, number of physicians (GP & Specialists)
employed by hospital at the beginning of the reporting period, number of physicians (GP &
Specialists) hired during the reporting period, and etc are the component to measure the
hospital`s human resources performance indicators. The hospital has attempted to give better
service by increasing the quality and quantity of the physicians Doctors (General Physicians &
Specialists).
Finance services: Total hospital operating expenses during reporting period, government
operating budget allocation for reporting period, total capital expenses during reporting period
and raised revenue budget allocation for reporting period and others the elements to evaluate the
quality of financial services of the hospital (QMO, 2012).
Patient Satisfaction: here, the focus is, number outpatient and inpatient surveys completed and
the rating score of the satisfaction (ibid). According to the reports, surveys were conducted to
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rate the satisfaction of clients. The findings of surveys are expected to measure the satisfaction
levels.
To sum up, the improvement of the sum total of quality indicators is synonyms with the
improvement of the whole service quality management setting of BLH. The introduction of BPR
in bringing radical reform to Quality Management practice is one of the changes that have
occurred after 2000. However, the entrenchment of Business Progress Reengineering (BPR)
practice in the management service of the hospital has little significance. There are official move
to realize the implementation of BPR but it is in the beginning stage. Since 2012, based on the
BPR study and performance appraisal of the employees of Addis Ababa University, high
numbers of new workforces have deployed in BLH. Most of the department of BLH have
occupied with the tasks of realizing BPR.
Furthermore, the response of administrative staffs and employees assert that, Balance scorecard
(BSC) system (a strategy performance management tools-semi structured financial and non-
financial report) has not yet exercised in the management of services performances of BLH.
In recent years, as to the Managing Director of BLH, the service quality control activities of the
hospital have shown significant progress. Similarly, according to (QMO, 2010, 2011, and 2012),
there are efforts to change the rudimentary system of quality control to objective and scientific
form. Further, the situation of service provision in BLH before seven years was backward and,
now there are positive changes although it is not enough to meet the needs and demands of
clients3. There is also diversification of services which introduced after 2000s reforms.
CHAPTER FOUR
4. DATA INTERPRETATION AND DATA ANALYSIS
All data are presented and analyzed in this chapter. The chapter is divided into two parts: part I,
which deals with general characteristics of the respondents in terms of sex, age, educational
3 Interview with Tinsae H/Michael ( GP), a third Year Student in Orthopedics( Specializing) and a Former Student
in BLH September 20,2013
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qualification and the service years of respondents. In the second part of this chapter the variables
of service quality management setting and the whole system of service quality management of
BLH.
The relevant data collected from the sample respondents of the questionnaires, the documents
and the information gathered from the interviews (with service quality management workers and
professional service providers) in BLH are analyzed and interpreted. Hence, the basic questions
raised in the first chapter were given appropriate treatment.
Out of the total 70 questionnaires 56 (80%) were filled and returned. From these total
respondents (TRs), 37 and 19 are clients and employees/administrators of BLH respectively.
Based on the responses obtained from the above sources, the analysis and interpretation of the
data are presented in the following tables.
4.1. Demographic Characteristics and Areas of work of the
Respondents
Under this part, democratic characteristics of respondents are analyzed. The respondents were
asked to furnish their personal demographic information and their types of work during the
study. Their responses have been summarized in table 1 below that depicts respondents’
demographic characteristics. The demographic articulation has two categories in which the
demographic presentation of clients and the employees of BLH have discussed. In addition, the
types work the employees engaged in and Service of Employees have also given emphasis.
Table-1(A). Demographic Characteristics of Respondent (clients) in BLH
Items Variables In number Percent (%)
A)Sex of Clients Male 20 35.7 % of Total Respondents(TRs)
female 17 30.4 % of TRs
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B) Age of Clients
12-25 11 19.6 % of TRs
26-35 13 23.2 % of TRs
36-45 6 10.7 % of TRs
Above 46 years old 7 12.5 % of TRs
C)Educational level
of Clients
Grade 4 to 8 5 8.90 % of TRs
Grade 8-10 7 12.5 % of TRs
Certificate &
Diploma
17 30.4 % of TRs
Degree 8 14.3 % of TRs
D)Types of Clients Emergency 10 17.9 % of TRs
Inpatient 13 23.2 % of TRs
Outpatient 14 25.0 % of TRs
Total Clients 37 66.1 % of TRs
Table-1(B) Demographic Characteristics of Respondents (Employees and
Administrators) in BLH
Items Variables In number Percent (%)
1) sex of Employees Male 8 14.3 % of TRs
Female 11 19.6 % of TRs
2)Age of Employees 26-35 9 16.1 % of TRs
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36-45 8 14.3 % of TRs
Above 46 years old 2 3.6% of TRs
3)Education Level
of Employees
Certificate &
Diploma
3 5.4 % of TRs
Degree 10 17.9 % of TRs
Masters and above 6 10.7 % of TRs
4)Job Description
of Employees
Management and
SQM
3 5.4 % of TRs
Physician & Nurse 13 23.2 % of TRs
Cleaner 3 5.4 % of TRs
5)Service of
Employees
1-4 years
6 10.7 % of TRs
5-10 years 4 7.1 % of TRs
Above 10 years 9 16.1 % of TRs
Total Employees 19 43. 9 % of TRs
As to table 1(A and B), the ratio of male and female respondents are equal. In the ratio of
respondents, there are fifty percent of male (35.7 % clients and 14.3 % employees) and fifty
percent of female (30.4% clients and 19.6% employees). Therefore, the proportion of both sexes
in the information of this research is highly considered. This implies that both sexes have
reflected their views in the data that are inputs for the research.
According to table 1(A and B), the clients and employees are 66.1 and 43.9 percent of the total
respondents (TRs) respectively. The above table (in item A and 1) shows the age groups of
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respondents and in which 19.6 % of the TRs ranged from the age of 12 to 25 (for clients) and no
respondents from the employees of BLH found in this age category. The age of 23.2 % clients
and 16.1 % employees of BLH are found in the range from 26 to 35. 10.7 % clients and 14.3%
employees are also 36 to 45 years old. The remaining 12.5 % respondents of service seekers and
3.6% workers of the hospital are 46 years old and above. From this data, we can conclude that
most of the respondents are capable to understand and analyze the condition of service that the
hospital delivered to them. Their age can enable them to give rational and constructive comment
and response to the questions stated in the questionnaires.
In regard to the educational backgrounds of the respondents, there are 35.8% Certificate &
Diploma holders. But, there are 21.4% respondents all of them are from the clients found in the
range between grades four and ten. 32.2% of respondents from both clients and employees are
degree holders. The other remaining 10.7 % respondents (employees) are in the level of Masters
Degree and above. Generally, nearly 80% of the respondents are professionals who hold
Certificate and Diploma Degree, Masters and above. Thus, the credibility of the response as well
as the rationality of the information they had provided are in a better position.
Concerning the clients` type, the table 1(A) (Item D) has three categories of clients which
include emergency, inpatient, and outpatient. Clients-respondents who are appeared in BLH for
only one day for emergence covers 17.9 % of TRs. This type of client may not observe different
forms of service delivery. Hence, the information they had tipped-off- has relatively less validity
but not irrelevant (because they can at least observe the single service quality). The other 23.2%
and 25% are inpatient (clients who take bed for inward treatment) and outpatient (patients who
come and go home for treatment for more than two times in BLH) respectively. These two types
of clients cover 48.2% of TRS and they have the chance to observe several aspects of the
healthcare service because they have stayed and appeared for several in BLH. Thus, the response
they had given during the research has more credibility.
Job Description and the position of employees in the sample respondents stated in table-1(B) (4)
and in which 23.2 %, 5.4 % and 5.4 % of TRs are Physician (GP) & Nurse, Management and
SQM staffs and cleaners respectively. This distribution shows that the presence of diversity in
19
occupations of respondents. Thus, they can observe different variables of quality serves. More
importantly, they are the practitioners of service system of the hospital.
In regarding to the service years of the respondents (employees), according to table 1(B) (5),
47.4% of respondent-employees or 16.1% of TRs are served in BLH for more than 10 years. The
remaining 10.7 % and 7.1 % of TRs are served from one to four and five to ten years
respectively. The majority of those sample respondents from the employees are seniors and
aware about the condition of service in Black Lion Hospital. This helps the research in acquiring
reliable information about the issue.
4.2. Assessment of Service Quality System of BLH
In this section several variables that are the attributions of quality have been discussed. The data
is gathered from both employees and clients of the hospital. The condition of quality service
delivery system, categories of observed problems continuity & improvement of supervision and
stakeholders’ participation in SQM Setting and others are the major themes.
Table-2:- Tabulation of Clients` Responses in BLH
Variables Levels and Options In Number In Percent (%)
I) Quality
Service
Delivery
Weak 14 25.0 % of TRs
Good 13 23.2 % of TRs
Very Good 8 14.3 % of TRs
Excellent 2 3.6% of TRs
II) Categories
of Observed
Inability Discharging Responsibility 10 NCC
Favoritism and lack of Openness 4 NCC
Material Shortage related Problem 16 NCC
20
Problems Lack Skilled Manpower 3 NCC
Unreasonable Delay of Service 11 NCC
Have No Observed 6 NCC
Total NCC 66.1 % of TRs
Key: - TRs denotes the Total Respondents of this Research and, NCC means Not Convenient
to Calculate
In this section, the assessment of service quality system of BLH is carried out on the basis of the
responses of respondents to the questionnaires (for both closed and open ended questions). These
data are also tabulated above in table 2 and below table 3 according to its convenience for
discussion and analysis.
4.2.1. Categories of Observed Problems
The data analyzed in this section is given only by clients of BLH. However, the administrators
and employees have had stated some problems for the open ended questions. In voting the
categories of observed problems, one respondent may state two or more problems according to
his experiences. That means he/she would states lack of skilled manpower and unreasonable
delay of service as a problem simultaneously. Thus, this condition constrained to calculate the
exact percentage of voters’ for a specific problem in terms of TRs. Numerically, 10 and 4
respondents observed the prevalence of “favoritism” and lack of openness and the inability of
employees to discharging responsibility irrespectively. High number of respondent (16) observed
or suffered from material shortage related Problems. Unreasonable delay of service is the other
problem of the hospital that admitted by 11 respondents. Some 5 respondents most of them are
new arrived in BLH for emergency services haven’t observe anything problem.
The above data shows that material shortage and related Problems, inability of service givers to
discharging responsibility as well as unreasonable delay of services are the major problems that
the clients faced in their stay in BLH. Under the violation of responsibility, client observed that
employees in card room, emergency section and other wards failed to execute professional ethics
21
(showing bad gesture, inability to give response, intolerance and unreasonable
boredom).Therefore, this conditions have a drawbacks in service system of the hospital that
patient would face additional psychological challenges. The patients may disappointed and feel
mal-treated.
The minor number of respondents has also faced problems that resulted from lack skilled
manpower and favoritism and lack of openness in service delivery of the mentioned hospital.
Here, as to the respondents, justification for their response that students are made try and error on
patients and personal relations is the prerequisite to get prior service respectively. If it is so, the
condition has a severe impact in the service quality of BLH.
Furthermore, the respondents from employees to open ended questions asserted that sampling,
diagnostic and treatment materials (including some low cost machines) are unavailable.
Therefore, patients are obliged to attend another hospital for diagnosis or sample tests. For the
same respondent, the problem that resulted from the failure to discharge the given responsibility
is undeniable.
When the referees from other hospital send to another private hospital for complementary
diagnosis and or sample check the patient may not afford to pay for the diagnosis/ laboratory
services. Consequently, they would leave the hospital untreated. It has also costs their time and
the condition is the anti-thesis of the principle of efficient and timely healthcare service.
In responding the open-ended questions, both clients and employees say that, water shortage,
electric power cut and hygiene problems are the common circumstance. According to my
observation, the problems are common in the city of Addis Ababa and other hospitals and thus, it
is the resulted in another health complication for patients. But there are expectations that
hospitals are life saver institution and for this purpose they should have to have different water
and electric lines to guarantee the day to day availability. To ensure the availability and supply of
electric power and water, the availability of Generator and high volume water tankers are the
prerequisite in opera\ting hospital serves.
As to the clients, the challenges/problems to patients started in Card Room and the extents have
widen in diagnosis and treatment service as well as in service to give bed for in patients. A
number of respondents argue that after the arrival in BLH by referral, the hospital re-send them
22
to get diagnosis and to give sample in private hospital. The chance to get bed for inpatient is also
too narrow and long time pending is a ubiquitous act. This is disappointing but normal
phenomenon in BLH. When referral hospital sends the referees to other private hospital, the cost
of attending complementary treatment in private hospital is a challenge for patients. Therefore,
long time pending, additional cost for supplementary and complementary treatment in private
hospital as well as the material shortage, bureaucratic, and ethical problems in side BLH would
disappoint clients. Leaving the hospital without treatment would be possible. The general
observation of respondents affirms that due to the above mentioned challenges and other several
reasons the accommodation capacity of BLH and the demand for service are incompatible.
Table-3 Responses of Respondents from BLH Employees
Variables levels In number In (%) in Terms of TRs
A) Quality of BLH Service
Delivery
Weak 4 7.1 % of TRs
Good 10 17.9 % of TRs
Have No idea 5 8.9 % of TRs
B) Continuity &
Improvement of
Supervision
Weak 7 12.5 % of TRs
Good 10 17.9 % of TRs
Have No Idea 2 3.6 % of TRs
C) Stakeholder
Participation in SQM
Weak 4 7.1 % of TRs
Good 10 17.9 % of TRs
Very Good 2 3.6 of TRs
Have No Idea 3 5.4 % of TRs
23
D) Practice of Balance
Scorecard
Not yet practiced 15 26.8 of TRs
Have No Idea 4 7.1 % of TRs
Total 19 43.9 % of TRs
Key: - TRs denotes the Total Respondents of This Research
In this section, quality of BLH service delivery, continuity and improvement of supervision of
SQM, stakeholders` participation in SQM setting and the practice of Balance Scorecard are the
major subjects. Problem articulation, the other critical variable that is vital to discuss the
condition of services is discussed above.
4.2.2. Quality Service Delivery
According to table 2 (1) and 3(A), 32.1 % (25% clients and 7.1% employees) of the respondents
said that the delivery quality service in black Lion Hospital is weak. In the same table the
responses of 41 % (23.2% clients and 17.8% employees) of respondents asserted that the service
quality of BLH is good. 14.3% and 3.6% clients termed the service quality of the stated hospital
as very good and excellent respectively. The remaining 8.9% of respondents, all of them are
employees have refrained from saying something about the quality of services in the mentioned
hospital.
To analyze the condition, this response tells us that significant numbers of clients and employees
(32.1%) have suffered from the weak service delivery practice of BLH and therefore, the hospital
has lacks some required quality services. The respondents that recognized the prevalence of
quality service are exceeding 50% of the respondents. Therefore, although there are some
weaknesses in service system, there are improvement and satisfactory condition in the whole
system. Similarly, the responses to the open ended questions asserted that there is gradual
improvement of service quality in BLH.
Finally, the some employees were reluctant to give response for the questionnaires although I
had get permission to questioned them and inform the purpose of the questionnaire. The
24
reservation to slam or approve on the presence of quality service may be also resulted from fear
of the consequence criticizing the system.
The interviews and some answers for the open ended questions informs the research that there
has been newly introduced services, quality improvement, and the application of information
technology as well as new way of performance measure. This is marked by the reform activities
of BLH after 2000s4. Hence, this condition has value in enhancing quality services.
4.2.3. Continuity and Improvement in the Supervision of SQM
Regarding the continuity and improvement in the supervision, the questions in the questionnaires
are forwarded only for employees of BLH in view of that they are the direct practitioners and
subjects of the supervision. According to table 3 (B), 7 out of 19 respondents termed the
continuity and improvement of Supervision in the hospital as weak. Out of 19, 10 respondents
asserted the prevalence of good continuity and improvement of Supervision of service quality.
The remaining two respondents have no idea about the Issue.
To see the implication of the responses, the simple majority of the respondents (employees)
recognized the presence of good quality of quality supervision and improvement. Thus, although
it is still less satisfactory, the continuity of same practice would help the further improvement of
service delivery. However, BLH has some drawbacks in controlling and supervision activities of
the health care services5. The weakness that observed by a seven respondents is a challenge to
ensure clients` satisfaction.
In general, the service quality, the supervision and the system have brought change after the
2000s continues reform activities. The reports of QMO of BLH have supported the above claims.
Currently, the hospital stared to implement the system of Business Reengineering process with
the aim to ensure worth mentioning service quality. The condition shows that there are praise
worthy activities but not sufficient.
5.2.4. Stakeholders` Participation in SQM Setting
4 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013
5 Interview with Anteneh M(GP), First Year Student in Specializing Radio and a Former student in BLH, September
29/2013
25
The stakeholders of the SQM setting are different departments of the hospital include, nursing
department, QMO, infection prevention office, pharmacy, emergency and laboratory sections6.
The responses of Administrators and QMO staff members to the open ended question have
asserted the above composition of stakeholders in SQM setting.
Concerning the levels participation of the stakeholders, the data is gathered from only the
employees. As stated in table 3(C), according to 4(21% of the respondents) out of 19
respondents, the practice is weak. From the same number of total respondents, 10 (52.6% of the
employees-respondents) of them rated the level of the stakeholders’ participation as good. Two
respondents asserted that there is very good implementation of stockholders` involvement in
service quality system of BLH. The remaining three respondents have no idea about the issue.
Based on the above data, we can state that the mentioned stakeholders` participation in service
quality control system of the hospital is in a better position. However, there are stakeholders that
ignored in the system. Hence, the participation of representatives of janitors, guards, clients and
others have given less emphasis.
4.2.5. Practice of Balance Scorecard (BSC)
Although the federal government of Ethiopia has given great concern for the implementation of
BSC, BLH has lag behind in introduction the system. According to table 3 (D), the absolute
majority of the respondents (15 out of 19) have affirms that the system of BSC has not yet
practiced. The interviews with the concerned guys have also asserted this claim. There are 4
respondents out of 19 that do not have knowledge about the system at all. This has also an
impact in obtaining objective financial and non-financial report to measure the performance of
service quality. The administrators have also informed me that BSC will be introduced and
implemented.
6 Interview with Atnafu Deresse, an Acting Quality Control Office Head, September 25,2013
26
FINDINGS, CONCLUSION AND RECOMMENDATIONS
Summary of the Major Findings
The main objectives in undertaking this study were to know the service quality management
system of BLH; to identify the changes and continuity in SQM system of the Hospital; to
identify the stakeholders and components of service quality management and to articulate the
challenges in providing quality service.
Accordingly, in the attempt to achieve the above objectives the study tried to find solutions for
the following basic questions. What is the system of service quality management? What are the
changes and continuity in SQM and related issues? Who are stakeholders and components of
service quality management of BLH? How and why the inability to provide adequate services
BLH?
To address the established questions, I reviewed relevant and related literatures, designed and
employed descriptive survey research method, collect data from the samples of BLH by taking
representative sampling through the accidental, stratified and random sampling techniques. The
data gathered from questionnaires, interviews and documents analyzed and based on the analysis,
the paper stated the following major finds.
The service quality management system of BLH is has hierarchical arrangements that
the committee on service quality management submits all the reports to the chief
executive organizer. The committee has embraced representatives from several
sections of the hospital like, laboratory, pharmacy, emergency and others. The QMO
has key indicators of quality includes, inpatient and out patient measurement, finance,
referral, pharmacy service and a number of others.
Regarding the changes in SQM system of the Hospital, after the continuous reforms
in 2000s, there are newly introduced services, quality improvement, and the
27
application of information technology as well as new way of performance measure.
The structural organization of BLH and some cultural-routine service delivery
practices are among the continued element of the system. The organization has also
determined to get rid this and other weakness.
The stakeholder of the SQM setting are different departments of the hospital include,
nursing department, QMO, infection prevention office, pharmacy, emergency and
laboratory sections. There is limitation in Stakeholders participation. The
participation and consideration of customers/clients, cleaners in BLH, supportive
staffs as key stakeholders have given less emphasis.
In health institutions, effectiveness, efficiency, safety, accessibility, productivity,
appropriateness and consumer participation are the dimension or components of
service quality management. In this aspect, BLH has been working on several
components of service system with employing KPI.
In BLH, the research proves that there are challenges as well as problems in the
provision of quality service. These are “favoritism” and lack of openness, the
inability of employees to discharging responsibility, Material shortage (electric power
cut, diagnostic and sampling machines water shortage) related problems and
unreasonable delay of services. Furthermore, lack of required man power and the
inability of the hospital to accommodate the patients requesting healthcare services
are the observed challenges of the delivery of quality services. It is undeniable that
these problems are the manifestation of weak service quality and therefore BLH has
been facing this.
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Conclusion
Black Lion Hospital is one of the few referral hospitals of Ethiopia and it is the treatment and
educational centre. Since 2000s the hospital has attempted to bring outstanding changes in
service delivery for its clients. For this purpose, it has undertaken a number of reforms. There
was effort to increase the number and the skill of specialists, and general physicians. It has also
been working to introduce Business Reengineering Process for the sake of bringing radical
reform in the whole system. But there is still problem in service delivery system.
Concerning to the service quality management setting of BLH is has hierarchical arrangements
that the executive organizer are the highest decision making person with taking into account the
reports (inputs) that several departments of the organization submit to him. In respect to quality
service, the committee on service quality management submits all the reports to the chief
executive organizer. The committee has embarrassed representatives from several sections of the
hospital like, laboratory, pharmacy, emergency and others. These are also the stakeholders in
quality service control and management settings of the hospital. The QMO has key indicators of
quality includes, inpatient and outpatient measurement, finance, referral, pharmacy service and a
number of others. The coming of new service quality indicators has also brought change in
service delivery system. The changes are reflected in the increment of the number of clients who
get service and the types of services that the hospital delivers.
In contrary to the positive changes, the research has discovered some problems like the inability
of employees to discharging responsibility, material shortage (electric power cut, diagnostic and
sampling machines water shortage) and unreasonable delay of services. The lack of
accommodation capacity the patients requesting healthcare services are also challenges in the
delivery of services.
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Recommendations
Based on the findings the paper forwarded the following recommendations.
Healthcare organizations and the professionals affiliated with them should make continually
improved patient safety a declared and serious aim by establishing patient safety programs with
defined executive responsibility.
In the quality service management system, the participation of stakeholders including the
cleaners, clients, food provision section of the hospital and others are the basic tasks which need
to be done.
The electric power cut, diagnostic and sampling machines water shortage lead to question the
efficiency, effectiveness, appropriateness as well the quality of services. Thus, BLH has to work
in improving the mentioned weaknesses.
As educational and service institution the hospital has to work on building man power who can
give priority for professional ethics and values in discharging the required duties.
The recommendation of employees and clients coincided that BLH is in need for purchase the
machines that are vital for diagnostic, sampling and treatment services. Furthermore, the general
service provision system has limitation and recommended to be improved.
30
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