Background

Services in general now account for over 70 per cent of production and employment in many developed countries (Moore, 1999). More importantly, services account for 46.7% of GDP in Thailand with health sector services accounting for nearly 3.73% of this (indexmundi.com, 2011). Etzel et al. (2001) indicates that services are “identifiable, intangible activities that are the main object of a transaction designed to provide want-satisfaction to customers”. Similar but distinct definitions prevail in the literature most notably, Parasuraman et al., 1985; Bessom (1973); James (2005); and Grönroos (2001), and service quality appears to be one of the major concerns facing health managers today (Williams et al., 1998; Gupta and Chen, 1995). For Thailand, the pressures from international competition in private health matters, through the challenges created by low-cost health services in the public sector, has presented health service management with the problem of how to improve health service performance and consistently meet client demands. However, there does not appear to be a reliable research focus on the examination of branding (Chapleo, 2007), loyalty (Chebat and Slusarczyk, 2005), or the effects of service quality in Thai hospitals and the need to illuminate how to satisfy diverse and perhaps ever changing client requirements (Dale, 2003).

Hospital Loyalty

The relationships between service quality and loyalty have been sparsely researched in health industries. However, a late study, Lemon and Wangenhiem (2009) suggested that there is a dynamic and reinforcing link between service perception and the usage of loyalty programs. Further, a health-related loyalty program indicates an individual’s personal willingness to continue buying/using the specific health service and to recommend the overall service/brand to others (Kleeburg et al., 2008). Satisfaction in health services is perhaps primarily influenced by several factors including the consumer needs and responses and type of the delivery channel. Polatoglu and Ekin (2001) inferred that new service users and heavy users of health-related services were more satisfied with services uptake when compared to other client groups. Further, it has been argued (Joseph and Stone, 2003) that the ability to deliver services using appropriate technology (during assessments), appears to be correlated with high satisfaction with services deemed most important to clients. Thus, notions of loyalty prescribes that there is a relationship between the medical needs, demands and requirements of the client and their continuing positive perceptions of hospital services that overtly influence an increase in client satisfaction levels (Brunero et al., 2009). Further, health brand loyalty (choosing a health provider on the basis of reputation) appears to be considered by some researchers as a function of the frequency of visits (Chan, 2000) and related continuing benefits – normalising and placing the client loyalty in context (Too et al., 2001). Other researchers suggest that loyalty results from genuine preference (Stewart, 1998), but factors such as ignorance, inertia, dependence and convenience can also have an influential impact on loyalty (James, 2005).

Service Quality

The dimensions of service quality are diverse (Grönroos, 1987) and relate to both the basic service package and augmented service offering. Service quality has been described (Parasuraman et al., 1988) as the consumer's personal judgment about an organisations overall level of excellence or superiority. Webster (1989) and similarly, Grönroos, (1984), defines “service quality” as a client evaluation on how well the service level delivered matches customer perceived expectations on a consistent basis. However, marketers have developed the notion of conceptually distinguishing between two approaches when considering service quality: objective quality involving some tangible characteristic; while perceived quality involves a subjective response (Holbrook and Corfman, 1981) and likely to differ between customers (Parasuraman. et al., 1988). A useful contribution in developing models for measuring service quality (Johnson et al., 1995) is where service quality characteristics were identified and categorised into hygiene factors; enhancing factors; and dual threshold factors. These factors appear to be associated with the consumers understanding of the service development and delivery process and also indicate that service delivery cannot be viewed as an isolated event as antecedent features appear to cloud the clarity of consumer judgements. This raises the context for the first research question - What is the client perception of staff service capability for loyalty program members?

The Thai health industry has developed very positive moves towards liberalisation. Consequently, increased international competition is seen as driving the context of service quality towards meeting consumer needs with more focused health provision packages and the development of more sensitive marketing practices. There appears little research has been published that inquires into how international hospitals have been influenced in developing closer links with their clients in Thailand through loyalty programs. Therefore, the challenge of matching service quality outcomes with health client requirements has never been more difficult or more necessary in Thai health services. There would appear to be a number of studies (Beatty et al., 1996; and Gwinner et al., 1998), that examined the nature and importance of benefits (residual and actual) service clients had derived from longer-term relationships with service providers and these can also be applied here to hospitals in Thailand. However, an examination of these studies suggests that these are not the only crucial factors as the nature of hospital services requires more than just the managerial determination of service standards; it requires an adept management style that allows different perceptions from different parties to the service act to be amalgamated so that all service elements match consumer expectations and demands; and in turn match service quality through delivery to those client expectations and that the clients trust the hospital to consistently deliver on specific contractual service promises (De Chernatony and Riley, 2000). This raises the context for the second research question - What is the character of health service experiences for loyalty program members?

Service quality is perhaps by its very nature a dynamic concept – both in terms of consumer perceptions, as well in practical application (Oliver and Rust, 1993). It has been proposed (Avkiran, 1994) that perceived service quality is a global judgement or attitude relating to the superiority of the service; whereas satisfaction is related to a specific transaction. Thus, consumer perceptions of service intent are important in the construct of service quality. Underpinning this possible service quality construct appears to be the notion of customer value (Tseng et al., 1999). In addition to this, service quality should not be considered an engagement in a static process (Chalermratana, 1996), but a process that encompasses pre-service elements, during-service elements, and post-service elements. This appears to be the chief theoretical foundation of the service quality models first introduced in 1984-5 by Berry et al., (1985); Grönroos, (1984); and further Zeithaml et al. (1990). In this respect, Parasuraman, et al. (1985; 1988) appeared to first develop a rationalised framework of service quality gap construct dimensions and that are cited and discussed widely - although later issues raised by other researchers demanded changes to the original model.

As early as 1985, it was recognised by Parasuraman et al. (1985) that underpinning the nature of service quality is the dissatisfaction gap between what the company promises and what is received and delivered to the customer. Thus the hygiene and enhancing factors (Johnson et al., 1995) are brought to bear significantly in the service quality arena. Customer satisfaction is thus becoming an increasingly salient topic in many firms and in academic research (Söderlund, 1998). In this paper, customer satisfaction and levels of service quality are not considered different constructs, but are shaped to inform the client’s response in the complex health service arena in which they operate. Service quality experiences can be seen as a measure of how well the total service package meets the clients expectations (Ghobadian and Terry, 1995). Consequently, service quality reflects and encompasses a consumer’s perception of service delivered, and that customer satisfaction is considered an outward indication of a consumer’s tendency to be positive to a company’s service provision (Parasuraman et al., 1988). In a health service environment, which is now increasingly competitive, providing exceptional client service has emerged as a differentiator (based on Sanes, 1996) that in itself significantly influences the level of service quality and ultimately client satisfaction (Li, 1997). Differentiating service brands therefore leads to more positive perceptions of service quality as individual clients perceive the health treatment as being special and individually focused on their special needs. However, service encounters offer the opportunity for health staff to reinforce client service requirements and needs, but often the reverse is true. As client experiences service from a myriad number of service providers, they develop a zone of tolerance when evaluating service quality and this appears to be the extent to which clients recognise and are willing to accept a level of variation in the service provision (Mukherjee and Nath, 2005). This is an important realisation, as clients now engage more and more with different service providers and that consumers do not expect that all service providers will produce to the same standard every time (Bitner et al., 1990). Further, distinct and heightened consumer demands may be attributed to rising levels of consumer expectations of service quality (Fitzsimmons and Fitzsimmons, 1998). Emphasising present practices, and orientations of the service encounter Dale (2003) is an important dynamic in understanding the effect of service quality levels on client perceptions of health service delivery. This raises the context for the third research question - What is the impact on hospital management of loyalty program member service responses?

Methods

To gain a deeper understanding of the issues generated within the Thai health service context and to consider more implicitly the issues and questions raised, this empirical groundwork utilised an interpretive approach (Walsh et al., 2008) to understand the perceptions of health service experiences of client loyalty card-holders as repeat service actors. These clients would have an on-going loyalty commitment gained through engaging with the health services over time, as revealed through the hospitals own loyalty program and are therefore well suited and experienced as informed agents regarding the research orientation. The research used a semi-structured questionnaire, which provided an appropriate element of context and flexibility (Cassell and Symon, 2004). Given the lack of appropriately focused research in this area, this methodology is seen as suitable for creating contextual data for the purpose of forming richer theory development (Cayla and Eckhardt, 2007).

The population for this study were all hospital loyalty card holders/clients of an international private hospital who attended at the general medicine service counter(Carman, 1990) - which provided general, non-emergency services to hospital patients. Consent was given from the hospital research ethics committee to conduct this research and communicate directly with hospital loyalty card-holders. The hospital has invested many tens of millions (Baht) in the provision of the latest specialist machines and facilities which has helped provide world-class diagnostic and medical assessment facilities including up-to-date on-site MRI and CT scanning. The hospital also provides a comprehensive range of allergy testing and an extensive haematology laboratory catering for the full range of blood tests with a number of fully automated computerised clinical laboratories that offers a comprehensive range of diagnostic modalities. These facilities also include a wide range of clinical departments (28); state-of-the-art operating theatres; that inherently employ local doctors and specialists from many disciplines.

In a pre-appointment follow-up telephone call confirming the medical appointment, hospital loyalty card-holders were asked if they would be prepared to undertake an interview relating to their opinions regarding their service experiences as perceived by them and this reflected the criteria of theoretical purpose and relevance (Glaser and Strauss, 1967) which were applied to the population and using Glaser’s (2004) sampling processes where a total of 32 card-holders were thus determined as the resultant sample frame. This was also considered convenience sampling (Harrel and Fors, 1992). It was known which clients had given permission to be interviewed, and a semi-quasi intercept survey method (Suzuki, 2004) was adopted in order to approach these clients as they attended the general medicine service counter at the hospital, as the response rate for this type of method is typically more than 80% (Malhotra, 1996). 26 clients were ultimately interviewed (found by approaching 32 card-holder clients (81.25%) who still had a choice of whether or not to be interviewed - which were deemed an effective number that could be interviewed - given the constraints of travel time and client convenience. This was in line with a similar methodology study adopted on service quality by Colgate and Norris (2001) who used a sample size of 20. Each interview was audio recorded for future analysis.

Interviews were conducted in English (which were in-line with the demographics of the loyalty card population in that over 95% had stated in their application forms that they could speak English) and took approximately 30 minutes. All interviews were recorded on audio-tape after gaining explicit permission, and were later transcribed verbatim. The conduct of the interviews follows a similar process by Gray and Wilcox (1995), with each individual group being asked the same set of questions - modified through ancillary questioning (probes and follow-ups) as used by Balshem (1991). To increase the reliability of the data, the actual transcription was returned to each respondent – via e-mail - for correction, addition or deletion and return, which followed the process of validated referral (Reeves and Harper, 1981). Whole-process validity was achieved as the respondents were considered widely knowledgeable of the context and content associated with the research orientation (Tull and Hawkins, 1990).

Each interview was initially manually interrogated and coded initially using the Copernicus software according to sub-themes that 'surfaced' from the interview dialogue as indicated by Evernote - using a form of open-coding based on Glaser (1992a); and Straus and Corbin (1990). This treatment was also reinforced and extended through the use of thematic analysis conducted using the NVivo 9 - qualitative software package (Walsh et al., 2008). Each interview was treated and coded independently. In this way, no portion of any interview dialogue was left uncoded and the overall outcome represented the shared respondents views and perspectives through an evolving coding-sequence (Buston, 1999). Various themes were sensed from the use of this package, as well as from the initial manual-coding. This dual form of interrogation was an attempt to increase the validity of the choice of both key themes and sub-themes through a triangulation process. NVivo 9 was further used to explore these sub-themes by helping to pull together each of these sub-themes from all the interviews (Harwood and Garry, 2003). In this way, it was possible to capture each respondent's comments across transcripts (Riessman, 1993) on each supported sub-theme and place them together for further consideration and analysis.

The structure of the outcome is greatly influenced by the emergence of the key-themes and sub-themes. The preferred strategy for the analysis of the primary data was to use the stated research questions, which are used as a guide to providing the outcome (Yin, 1994).

Results

Theme Outcomes

The various themes developed from the main interviews are presented in Table 1 below, and are essentially broken down into six (6) key-themes: Staff Related; Service Process; Technology; Product Related; Customer Related; and Service Package Related distributed across four (4) sub-themes: Service Expectations; Service Delivery; Service Design; and Service Management. The placement of the sub-themes has been influenced by context of the key theme (Avkarin, 1999). The respondent characteristics can be seen in Table 4, below. This is included so readers can view the characteristics, although these are not considered in the discussion.

The outcomes are stated below where the discussion focuses on the sub-theme elements within each key theme and the subsequent performance enablers and are presented in Table 2, below. The discussion format used in this paper reflects the respondents voice through a streamlined and articulated approach for reporting Gonzalez, 2008; Carpenter, 2008; and Daniels et al. (2007), whilst focusing on each of the raised research questions. Table 3, below, shows the breadth of respondent illustrations/extractions as used in the reporting of this research.

Figure 1

Table 1 - Sub-theme observations

Figure 2

Table 2 - Research Questions and Major Themes

Figure 3

Table 3 - Respondent illustrations/extractions

Figure 4

Table 4 - Respondent Characteristics

Question 1 – What is the client perception of staff service capability for loyalty program members?

Main Theme – Staff Related

Main Theme – Service Process

Question 2 – What is the character of the health service experiences for loyalty program members?

Main Theme – Service Environment

Main Theme – Technology

Question 3 – What is the impact on hospital management of loyalty program member service responses?

Main Theme – Client Related

Main Theme – Service Package Related

Discussion

Figure 1 below, maps the data from the derived relationship between the research questions, major themes and the client experiences (taken from Table 2). The model illustrates the conceptual development and relationships perceived to correspond to each research question and illustrates the performance enablers that allows the hospital to focus on these client views and how they influence their service perceptions.

Health services staff appear to utilise a responsive and caring approach in an observable service culture (Price et al, 1995) focusing on helping to satisfy a quasi-differentiated loyalty member card client audience. The evidence does appear to support the notion that the hospital provides a positive environment (Lockwood and Jones, 1989) that enhances the perceptions of client-staff interactions during service encounters (Smith et al., 1999). As such, the hospital also appears to support the outcomes in terms of the mediating effects of hygiene or enhancing factors Johnson et al. (1995).

Lack of the perception of queuing and its implications was seen as a confirmation of Lewis et al. (1994) as the evidence points to well trained health service staff with appropriate process knowledge that enhanced client confidence in processing records/financial/insurance transactions. This is an important outcome as it confirms the positive environment of client-staff interface processes that appear to enhance service quality perceptions (Carlzon, 1987; and Dale, 2003).

The evidence further suggests that hospital facilities managers listen to clients and provide an appropriate pattern of service provision (Bitner, 1992) relevant to their particular needs – and complements similar outcomes reported by Fry et al. (2005) when using benchmarking techniques in services. This would be particularly important when large number of international clients attend the hospital.

Further, of issue for the hospital are technological developments that support hospital operations in direct contact with the customer such as e-management that foreign clients recognise as being used elsewhere as a process/technology norm. This mirrors the outcome of Reed (1998) and Chan (2000) in terms of process tractability and coherence. Technology provides flexibility and cost-effectiveness which appears to be a key factor in ensuring the survival of the hospital in a competitive environment and may also assist in a more effective distribution (Rosenthal and McEachern, 1997) of service provision.

Figure 5

Figure 1 – Mapping of Outcomes, their Relationship to the Research Questions and Client Experiences

The client perception of enhanced service distribution reflecting a proactive hospital process/facilities design stance indicates how the client perceptions of service quality are influenced by the hospital surroundings (supporting Fry et al., 2005).

Previous experience with the hospital services does appear from the evidence to have a positive impact on client expectations and appears to support the suggestions of Mukherjee and Nath (2005) on consistently meeting client expectations (Carlzon, 1987).

Complaints appeared to be a source for learning for the hospital management as complaints are necessary (Tax and Brown, 1998) and provides further support for the loyalty–satisfaction relationship (Ahluwalia et al., 1999). Further, staff training levels were perceived by clients as more than adequate – especially when dealing with personal issues and privacy requirements and also defined hospital processes consistently.

Clients viewed the service promise as a conspicuous and an inherently important part of the service contract. This research outcome supports the deduction that those organisations emphasising improved client services will lead to enhanced client loyalty (Moon and Stone, 2003). The evidence further suggests that the service ethic and promise does appear to be adequately transferred from top-management to other service staff and that appropriate in-house training programmes are working to ensure the hospital moves in the right direction.

The evidence further suggests that hospital loyalty card-holder clients are willing and able to evaluate the service provision of the hospital and the effectiveness of service uptake was raised by many respondents as staff and the hospital system appeared to be unified towards ensuring a positive and effective client experience (Oliver, 1997) leading to further discrete loyalty behaviour patterns (Bitner and Hubbert, 1994). The outcomes of assessing the nineteen (19) performance enablers considered to positively support the main/sub themes show hospital management attempts to ensure client communication and the meeting of client medical needs consistently.

Conclusion

The evidence presented here suggests that hospital client loyalty-card holders have established views about what constitutes effective health service practice; expect that they ordinarily receive the level of service which is directly pertinent to their needs. Elsewhere, these views need to be explored further by other hospitals in Thailand in order to ensure that client views are taken into consideration when developing improved or new health service products, changing the health systems and its management through responses to competitive forces and highlighting the increasing importance of the international consumer in Thailand’s health services industry. The service experience outcome explains how well the total service package of the hospital meets the clients expectations (Bitner and Hubbert, 1994) as further supported by Ghobadian and Terry (1995).