CASE STUDY

The Three Day Saga at All Saints Hospital

This case study draws attention to two aspects of services marketing: (a) The importance of configuring a services marketing mix with due care to the people, process and physical evidence dimensions, and (b) The analysis of a service failure situation and finding solutions to the same by using the Servqual Gaps model. The case brings out these aspects through a poignant narrative of the unfortunate death of the protagonist's brother-in-law, due to what was perhaps a situation of inadequate diagnosis and treatment at a well-equipped multi-specialty hospital.

That fateful day, Nath breathed his last at All Saints Hospital, located in one of the major cities in South India. In retrospect, the journey from the time of his accident to death provided enough opportunities and indications that Nath could have been saved from death. Kumar (Nath's brother-in-law) was revisiting the whole episode and wondered as to why he did not take corrective measures to save his sister the agony of heart-rending bereavement.

The Fateful Accident

September 19, 2006, a pleasant winter morning, and Kumar was whistling his way to his office. He had several reasons to be happy. His son had performed well and had secured a distinction in his school. Kumar's appraisal too went very well and he was expecting a promotion. He was, however, jolted from his pleasant reveries and was shocked by a call on his mobile informing that his brother-in-law had met with an accident and was at the All Saints Hospital.

Kumar belonged to a big joint family of Kaveri Bai (Kumar's grandmother). The mega family was planning a get-together for quite some time and had decided on having the gala event in a week's time. The event included pooja andSrinivasa Kalyanam in the style of a marriage spread over a period of three days. Kumar had requested everybody in the family to participate actively in the function. Inviting friends and relatives was one aspect which the family members did individually on behalf of Kumar's grandmother.

Kumar's lone sister Silvia was happily married to Nath, an automobile diploma holder, who used to work at a renowned engineering firm in the city. Nath had recently retired and had volunteered to visit friends and relatives to invite them for the event. Nath was on his motorcycle on his "mission invitation," driving along the Outer Ring Road at 10.30 a.m., and was hit by a speeding Indica car, driven by a Software Professional (SP), evidently in his mid-twenties. This SP had recently purchased his car and was still a novice, not holding a permanent driver's license. The car, speeding from behind, hit Nath from the back and dragged him for about 5-6 meters before hitting the road divider. After this accident, Nath was still conscious and showed his pocket to the SP for contact details in case of an emergency. The SP took Nath to All Saints Hospital, one of the comparatively larger, well-equipped and reputed hospitals in the city. As he drove through, he established contact with Silvia and Adam, the lone son of Silvia and Nath.

The Commercialization of Healthcare

The healthcare landscape in India is changing quite fast. Increased privatization and corporatization of the healthcare sector has led to investment in hospitals being viewed purely as a commercial proposition. Medical insurance too has played a prominent role in making hospitals more business minded. Doctors who bring in business, in terms of customer lifetime value, are appreciated and rewarded, rather than those who cure the patient at one sitting by working out a permanent solution. Even hospitals getting grants from missionaries and other charitable sources are discretely told to shore up the bottom line.

The huge fees that the students pay when they get admitted to the private medical colleges are seen as investments; and an investor obviously looks at RoI (Return on Investment). Salary expectations of doctors have, therefore, gone up, as private hospitals offer better packages without any restriction on outside practice. The famous Hippocratic oath that a doctor takes when he/she is awarded a degree has almost got degraded to a hypocritical oath, akin to a politician's swearing in at the Parliament.

New business models, like medical tourism too have had their impact on the healthcare industry, by diverting their focus away from genuine patient care to services that provide high profit margin and publicity in the media.

All these changes have increased competition among the hospitals. In order to survive under such a competitive environment, hospitals are compelled to think of outsourcing several non-core activities, and making the doctors and support staff to `s-t-r-e-t-c-h' to their limits, in order to keep the overall costs low.

Entry into All Saints Hospital

When the SP took Nath to the hospital, the serious emergency on hand could not be understood by the person manning the car park and perhaps rightly so, since he thought that emergency cases will always come through ambulance services. Further, the security person at the emergency ward insisted that the car be parked at the car park before allowing SP to take the stretcher/wheel chair. After fetching an available wheel chair, the SP realized that he needed a bigger one and there was nobody to guide him. Car parking and security services were those non-core activities that the hospital had outsourced in order to focus on its core activities; and the personnel at these places were not sensitized to emergency situations and they always went by the rule book. The delay in these two places added a crucial 30 to 40 minutes and one wonders whether avoiding this delay would have had an impact on saving victim's life.

The Emergency Wing

The emergency wing was overcrowded as usual and had a lot of patients and very few doctors. As a rule, All Saints allowed the patient and one attendant into the emergency area. This control was at the disposal of a security guard who could not converse in either the local language or English. The cost control measure at the hospital had forced these outsourced service providers to hire inexpensive personnel and they looked at the north-eastern part of India for such a solution. For the reasons explained earlier, doctors and support staff on emergency duty were overstretched and were looking tired.

The doctors and other staff on-duty examined the external wounds and administered first aid. They did mention to the family of Nath that Nath was fortunate since there were no head injuries. Nath always used to wear a helmet while driving his motorcycle. Further, one of the doctors on duty informed that further analysis and investigations would be taken up after the orthopedics department took a look at the patient. They did express their inability to shift the patient to the ward, due to non availability of beds. Responding to a question from the family regarding the need to shift the patient to some other hospital since beds are not available at All Saints Hospital, the doctors brushed this suggestion aside, stating that the patient was stable and that there was no need for such drastic action. The policeman, who had arrived by then to take a statement, was told by the doctors that this could be done on the next day.

In-Patient at All Saints Hospital

Nath was moved to the ward the next morning and the orthopedics department wanted a complete X-ray to assess the damage. Nath was to be moved to a stretcher from his bed and the nursing staff could not get the stretcher to match the height of the ward bed. When the staff tried to force Nath on to the stretcher, there was a snapping sound from the patient's body and he complained of severe pain. The staff then left the patient in the ward and returned with a mobile X-ray unit. Nath now complained of very severe back pain and it was near impossible to move the X-ray plate behind Nath's back, and this was done forcibly. Even then, the X-ray department was unable to capture a proper image and they perhaps thought that they should postpone the X-ray concerning the backbone. They started treating minor damages to the rib cage by plastering the damaged area suitably. The entire day went by doing some analysis or the other.

Several doctors and specialists were visiting Nath from time to time and were analyzing the problem in a straight jacketed manner. Family members of Nath felt somewhat concerned that no single doctor was responsible for the well-being of the patient, and they went about trying to seek help. Kumar then approached Dr. Thomas who was an acquaintance, and requested him to talk to those concerned, explaining the anxiety. Dr. Thomas spoke to somebody over phone and assured the family that Nath was under the best of care and advised them not to worry and be relaxed.

The next day, Silvia, after seeing a nurse struggling to read the patient's blood pressure, expressed concern regarding the capabilities of the support staff to the head nurse. The chief of nursing expressed the problems that she was facing in managing the nursing function at the hospital due to enormous work load and the compulsions of hiring low-cost inexperienced staff.

The Fatal Night

That night, after the regular check-up, Nath started vomiting what appeared like bile juice. Silvia had seen this happen to other family members before their death and she ran to the duty nurse, who visited the ward and said that there was nothing to worry. Upon further insistence, the nurse told Silvia to contact the duty doctor herself, as it was 10.30 p.m. already. The doctors whom Silvia met in one of the cubicles were not interested in taking a look at the patient, as they mentioned that they were from the nephrology department and they had nothing to do with this. In a few moments, Nath was no more and some doctor was woken up from his sleep. The doctor put Nath on artificial life support system for sometime and said SORRY.

It was shocking to everybody, including the police, nursing staff, and to Dr. Thomas, as to how this could happen. The next day, the doctors doing post-mortem perhaps thought that they needed to identify and disclose the reason for death to the family. It was written in the report that the back bone was broken and had punctured the lever/pancreas. Nath's family was wondering whether Nath got the treatment that his clinical conditions demanded. They were clueless regarding handling of the patient and the sound from the backbone, and wondered whether this could have been the cause. They also wondered whether, if the doctors had diagnosed the clinical conditions correctly, any surgery to the backbone could have saved Nath.

Kumar felt that he should have assessed the hospital better and thought that he was in a way responsible for the tragedy. He spoke to known acquaintances who gave a fairly good feedback about the hospital. However, his experience had given an indication that things are not all that good at All Saints Hospital. Kumar thought that he should have a detailed chat with Dr. Thomas on this. He narrated the whole story to Dr. Thomas.

Dr. Thomas's eyes were wet since he knew the family well. As he read the post-mortem report in detail, he mentioned to Kumar that he (i.e., Kumar) was not at fault. After Kumar left the scene, Dr. Thomas was sitting in his chair and was visibly disturbed. He was also the director in charge of the hospital's administration and was wondering as to how he should go about analyzing the services provided by his hospital and put the house in order. He also thought, if he was not capable of putting things right, he should give up his post.

Issues for Discussion/Teaching Note

Broad outlines are provided here in the form of discussion questions and possible solutions, in order to guide the reader towards achieving a general understanding of services marketing. However, the material provided here is neither complete, nor final and binding.

Discussion questions:

1. Do you think competition in the hospital industry is the reason for the kind of situations seen in this case? Analyze this from the points of view of:

 Business process outsourcing

 Demand management

 Broadened definition of competition.

Competition is like oxygen and the hospital industry cannot wish this away. When we start analyzing the case, the following issues come to the fore.

It is, of course, necessary that non-core activities be outsourced to keep the costs low. Activities, such as security services, car parking and cafeteria, are often outsourced to external services providers. Hospital, being a service industry, `people', `process' and `physical evidence' are important components of the marketing mix. When people come to the fore of an activity, variability comes into play and this should be used as a differentiator in a competitive environment. The importance of contact personnel at the servicescape and how it can really make or mar the image of a firm and its business prospects cannot be underestimated. The contact personnel should, therefore, be trained well, as some of the common behaviors among service personnel such as apathy, brush off, coldness, robotism, rule-bookism and runaround, irk customers and should be consciously avoided.

Only after ensuring these aspects, should hospitals outsource the non-core activities. People manning these activities should be aware of what is happening in the system. Training is necessary to sensitize them to the internal environment that they are in. They should be made aware that the "rules are there to facilitate a process and not to choke the system." Training is perhaps needed as to how to selectively break the rules if it can assist the objective of facilitating the process.

Understaffing in critical areas, like medical care and nursing, would be detrimental to the hospital. Internal customer focus in a services scenario is crucial for the survival of a hospital. Adequate rest is necessary for the medical and nursing personnel in order to be efficient. Service personnel generally exhibit high, moderate or low passion for service. Hospitals need those doctors and staff with a high passion for service, so that reactions like "It is not my job" or "We are understaffed" will not be let out at the service points. Training for moderate and low passion personnel will have to be planned, if for any reason, the hospital is not able to get adequate number of high passion staff. In fact, customer delight is a very important facet for ensuring revisits, recommendations and word-of-mouth publicity in a competitive scenario.

If the hospital identifies an imbalance in work load, say at the emergency wing, doctors and support staff from other areas should quickly re-align and move to deliver services at the demanded section. Doctors and staff, despite their specializations, should have basic multitasking capabilities and the inclination to do so. Otherwise, the hospital (in the event of its staff and beds being fully occupied) should have the heart to direct the patient to another hospital after administering first aid.

The term `broadening the competition', refers to healthcare and tourism being clubbed together. The very idea of combining these is to provide better value to the customer. It is not that tourism should take priority at the expense of quality of service at the hospital. To quote the eminent management guru, Peter F Drucker, "The purpose of an organization is to be responsible and not just growing the wealth of shareholders."

2. Having recognized a serious service lapse in this case, how should Dr. Thomas capture the customer expectations, develop and deliver quality services to the hospital's customers?

The conceptual model of service quality or the Servqual Model (Refer Exhibit) by Parasuraman, Zeithaml and Berry could be used to answer this question.

Dr. Thomas should get a clear understanding of customers' expectations (CE) in a language that the customer understands and not just in the medical language. Knowledge of CE comes out of past experience, word-of-mouth and external communication. He needs to analyze the gap between CE and the hospital's view of CE. This is the Knowledge Gap (Gap 1).

From this, Dr. Thomas should focus on developing standards and correct processes. This was missing at the hospital. Proper processes and standards, when established, will ensure fault free service delivery. Nath's backbone problem could have been noticed earlier. This Gap is the Standards Gap (Gap 2). How well these standards, systems and procedures are understood by the service personnel and how they will be delivered is the next aspect. This is the Delivery Gap (Gap 3). Based on the quality of service received, patients will develop a perception about the hospital. The gap between their perception and expectation is the Service Gap (Gap 5). There is also a gap between external communications of the service provider to consumers and the service delivery, which is the Communication Gap (Gap 4).

The Servqual factors of Reliability, Assurance, Tangibles, Empathy and Responsiveness (referred to as RATER) could also be discussed here.

-- Sukesh Kumar B R
Faculty Member, 
IBS-Bangalore.
The author can be reached at
sukheshkumar@hotmail.com or 
sukeshk@ibsindia.org