CitationDownload as .RIS
Emerald Group Publishing Limited
Copyright © 2001, MCB UP Limited
Are you looking forward to your surgery?
Are you looking forward to your surgery?
The answer is probably no, although you hope the surgery will be good for you. But you do not really know, do you, until it is too late? The quality of the surgery might not be so good after all; it might be the wrong thing to do in the first place; it might be that the operating team is not top quality; and it might be that there are unexpected side-effects.
Why is the quality of health care such a problem?
Health care is one of the largest service sectors in every country. It is perhaps the most complex service sector there is. It offers womb-to-tomb services and interferes with every aspect of our lives. Some are lucky and do not need its services so frequently; for others there is a continuous service need. The services are associated with pain, fear, insecurity and sometimes excessive cost and waiting time. And for many, the services are not there when they need them.
The range of health services is enormous, from advice on fuzzy symptoms and prescriptions for medication to trauma surgery and continuous treatment of chronic disorders. The health sector includes doctors and other staff, hospitals, insurance companies, pharmaceutical companies, makers and distributors of machinery and consumables, and more. Its decision makers are politicians, government officials, hospital administrators, doctors and, eventually, the patient.
Patient – what an awful word! According to dictionaries a patient is a person who waits without asking or getting irritated; suffers, bearing the suffering with pride without complaining; and being treated (passively) by a doctor or dentist. This is a miserable creature. It does not sound like the consumer of the third millennium. Words carry loading and connotations so I suggest we dump the word patient in favour of medical consumer.
Although the medical quality in limited areas is sometimes excellent and often high, it is low in general, and the medical consumer has reason to be dissatisfied. The main reason is not lack of money or staff, or wrong organizational structure. It is that the medical establishment, "school of medicine", is primarily treating symptoms and not the root cause; that medicine is caught in a narrow belief system which the medical profession considers "science" but is rarely science; that it is caught in simplistic methods (A causes B) and has added words like placebo to avoid the real thing and to "explain" its ignorance with pseudo-psychological rhetoric about the consumer imagining a disorder ("Our tests do not show anything") and perhaps getting better through belief in a pill which turned out to be a sugar pill.
The health services sector is in distress. The cost is excessive, whether paid by governments, private insurance, out of the consumer's pocket, or a combination. Medical consumers find that they are not getting what they need. Some consumers persist, dazzled by hopes and by the medical establishment's claims that they are in the best hands, those of trained doctors and nurses working with scientifically proven state-of-the-art methods. Others use their common sense and take charge, reading, increasingly consulting the Web, trying alternative therapies. Herzlinger (1997, p. 69) writes that in 1990, US medical consumers turned to conventional physicians in 388 million instances, but the visits to providers of unconventional therapies were in excess of that: 425 million. There are signs in many countries that the number of alternative consultations keep going up. These are the consumer votes that the medical establishment should not ignore. They do not, but they do it erroneously, trying to impose restrictions on the alternatives.
As everywhere, in quality management we need to find the root cause, and not just the symptoms; we need prevention and measures taken at an early stage, and not just waiting until quality defects are manifested in the final product; we need monitoring of the outcome to make possible continuous improvement, and not bombastic self-praise; we need to abandon non-functioning paradigms and shift to new, and not vehement protection of the status quo. As services are co-produced between providers and consumers we need dialog and communication, treating the consumer on a one-to-one, equal basis. We need not only to listen to the customer but also to interact with the customer as has been shown time and again in the service literature (Gummesson, 1999; 2000; Grönroos, 2000). The quality of a service is just as much the outcome of what consumers do and how providers and consumers interact, as it is of the providers' doings.
But is not all this being taken care of by medical research, a high profile area for the marketing of not only medical advances but of more dreams than the perfume industry? No, it is not. Again the basic problem: it is only research within the simplistic paradigm of established "medical science". But are not the doctors also paying attention to service quality demands of better communication and relationships with medical consumers in the service encounter? Yes, to some extent, but they still consider themselves the experts and the patients the ignorant amateurs. So the issue is reduced to one of persuading and smiling, and thus the effect is limited. There are exceptions to this, but they are still the exception and not the rule.
The title asked: Are you looking forward to your surgery? If you are going to do it at Shouldice Hospital in Toronto, Canada, you may very well be looking forward to it.
"It's like a country club", says a patient. This does not mean it is extravagant. It is simple and straightforward. Most patients are paid by their insurance, part of social security for Canadians or private insurance for others. If you suspect you have a hernia, you log in to www.shouldice.com and you can do the diagnosis yourself. You do not need to pay a doctor for it, it is simple, anyone can do it.
Shouldice invests in continuous improvement of the Shouldice method of hernia surgery and medical excellence of their staff and have done so for 55 years. They are a single-service clinic with 12 surgeons doing 7,000 hernia operations per year. Here I will just dwell on one unconventional and imaginative activity that supports sustainable quality development.
At the same time as they boast about an almost nil recurrence rate – one out of 200 operations, which is as close to zero defects or Six Sigma that you can possibly get – they invest in a long-term relationship with the hernia services consumer. Everyone who has had surgery at Shouldice becomes a member of their alumni club, gets a newsletter, and is invited once a year to a banquet in Toronto, to which 1,000 to 1,500 members sign up. There are two super reasons for this strategy. First, Shouldice follows up its patients for continuous learning. One of these follow-up occasions is the banquet where every participant is examined before the dinner and his or her current hernia operation status is entered into the medical record. Second, former patients are their best part-time marketers, free of charge; Shouldice gets most new patients through referrals and word-of-mouth.
Although the Shouldice case is almost 20 years old by now, it is the classroom favourite in service quality (Harvard Business School, 1983; Richard Ivey School of Business, 1997). It is a favourite because the Shouldice story tells some eternal quality truths that do not blow away with the fads. It tells the importance of being long-term, of management commitment, of continuously developing methods and skills, of relationships, and of follow-up.
It is all common sense, isn't it?
Evert GummessonProfessor and Research Director School of Business, Stockholm University, Sweden
Grönroos, C. (2000), Service Management and Marketing: A Customer Relationship Management Approach, 2nd ed., Wiley, Chichester.Gummesson, E. (1999), Total Relationship Marketing, Butterworth-Heinemann, Oxford.Gummesson, E. (2000), "Sustainable service strategies: lessons from health care", Proceedings from QUIS7, ISQA, International Service Quality Association, New York, NY and Karlstad, pp. 171-80.Harvard Business School (1983), Shouldice Hospital Limited, Boston, MA (case).Herzlinger, R. (1997), Market-driven Health Care, Perseus Books, Reading, MA.Richard Ivey School of Business (1997), Shouldice Hospital Limited, London, Ontario (case).
Aim for prevention and measures taken at an early stage.
Monitor outcomes as effectively as possible to promote continuous improvement.
Abandon non-functioning paradigms.
Treat the consumer on a basis of equality – promoting dialog and communication.
Taking Shouldice as an example, search to be long term; continuously develop methods, skills and relationships; follow up.