According to Fred Lee (2004) hospitals use clinical results and process improvement as a gauge of quality as this data can be readily measured and objective. However, Lee (2004) goes on to point out the patient judges the quality of care by individual perception. Therein a gap of what the patient's perception of quality care and how the healthcare providers perceive quality of care is created. The purpose of this paper is to discuss the Gaps Model of Service Quality while comparing the findings of the work done by Fred Lee in the book, If Disney Ran Your Hospital: 91/2 Things You would Do Differently.
Gaps Model of Service Quality
The Gaps Model of Service Quality was originally developed for application in the financial service sector. The model was designed to measure components of customer satisfaction by using five dimensions of real or potential gaps in service quality of a hotel (Saleh & Ryan, 1991). The model has been applied to hotels, as well as a number of service agencies, including banking, hotels, restaurants, and healthcare. Even though the services differ greatly, the model is easily adapted to any service industry (Parasuraman, Zeithaml, & Berry, 1985).
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Gap One: Customer's Expected Services
Berkowitz (2010) states that gap one is created when the patients expectation of service quality and managements perception of those expectations do not unit. Zeithaml, Parasuraman, and Berry (1990) note that in order to deliver or meet the customers' expectations the company must first understand what exactly the customer perceives as a need or want. An example of one gap is that patients expect not only expert medical care, but also an environment similar to that of a hotel. Administrators from Albert Einstein Medical Center consulted local hotels to seek advice regarding customer service. The hospital made improvements in food services, larger name tags, more information desk, and radios in numerous rooms (Zeithaml, Parasuraman, & Berry, 1990).
Gap One will widen if healthcare organizations primarily focus on operational issues instead of building relationships with consumers (O'Connor, Trinh , & Shewchuk, 2000). An example of closing gap one is seen in the airline industry. A study done by Gourdin and Kloppenborg (1991) revealed that while the airline industry perceived that providing beverage service on short flights was important to consumers; consumers do not value this service. The study revealed that consumers saw the hurried beverage service as an annoyance rather than a valued service.
A study was done (Deng-Juin et al., 2009) to exam patient satisfaction with cosmetic Lasik surgery. Using the SERQUAL instrument, research revealed dissatisfaction among patients having a procedure to the empathy of the staff. The patients repeatedly committed that even though this is a cosmetic surgery, it is still a medical procedure. The patients expressed disappointments in communication and empathy which was an expectation of the patient.
A study conducted by Young, Minnick, and Marcantonio (1996) compared the opinions of more than a thousand staff nurses, numerous nurse managers, and more than two thousand patients from 17 hospitals regarding certain aspects and perceptions of patient care needs. Interestingly, staff nurse and mangers did not agree regarding the needs of the patient. Moreover, the patients surveyed perceptions of patient care did not match those perceptions of nursing at large. This study clearly reveals the gap between nurses' perceptions and the patient's genuine values.
Hospitals can use the results from Press Ganey to seek any potential or real gaps between the patient's perceptions and the service delivered in the hospital seeking. Press Ganey Associates Inc (2011) advices hospital in ways to effectively use the data from patient surveys to fill the gap between patient perceptions of service and service delivery. Young, Minnick, and Marcantonio (1996) confirm that nursing units must look beyond any perceived self-reinforcing ideas of patient care and look to the actual values of the patients needs to succeed in delivering optimal patient satisfaction.
According to Johnson et al., 2008, including former patients and families in designing a healthcare system that would meets the needs of patients would close this gap. Including family and patients on hospital advisor boards would be a powerful tool in resolving this gap. The groups would be similar demographically to the patient population and will provide real-time input to patient needs.
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Fred Lee (2004) addresses this gap repeated as closing gaps between knowing and doing. The perception of the medical staff as a team is essential to patient satisfaction. Using the concept of a theatre, hospitals can meet the needs of the patients while providing the best of all possible hospital experiences under any difficult circumstance.
Gap Two: Customer-Driven Service Designs and Standards
Berkowitz (2010) describes gap two as the 'walk the talk' gap (p. 242) and gives as an example of customers expecting the telephone in a clinic to be answered within 10 rings. For this expectation to be met, the manager must set standards of service which mirror this defined quality need. Parasuraman, Zeithaml, & Berry (1985), explain Gap Two as Management Perception- Service Quality Specification Gap. The group interview executives from nationally recognized companies to determine constraints which either prevent or make service delivery difficult. One clear example of Gap Two came from an air conditioning (AC) repair company. The executives sited that most AC units break-down during the summer months which is the same time of year that employees request vacation time. Therefore, service delivery may be slow during peak repair times. An example of this potential gap is seen with the implementation of electronic health record (EHR) through-out the country. Buswell and Reid Ponte (2011) report that a well designed EHR will improve patient outcomes. However, care must be taken in implementing EHR or service delivery will be compromised. This compromise can leading to a gap between the service design and the standard of care provided.
A report issued by Press Ganey (2010) discovered that patient satisfaction scores across the country drop markedly in the months of January, February, and March. According to Press Ganey this drop is linked to winter blues in this patient population. The winter blues within this patient population coupled with increased occupancy rates and increased patient acuity lead to this gap in service. Hospitals must consider this data and gear process improvement effort in this area. Princess Alexandra Hospital considered the incidence of the effects of the winter blue on patient satisfaction scores, as described by Press Ganey, by implementing measures which shorten the time restraints in the emergency room and decrease wait times to schedule surgery. Princess Alexandra Hospital successfully maintained Press Ganey scores of 95 percent or greater due to these measures of improving services during the winter months (Queensland Government, 2009).
Fred Lee (2004) defines dissatisfaction as a way to build a better mouse trap. Guest come to Disney for an escape from reality. Disney, in turn, provides an environment of courtesy and delight with an ensemble of cast and characters to please any imagination. Hospitals must glean wisdom from Disney by having talent or habits which reflect a courtesy, safe, and healing environment for patients. Walk the walk is a theatrical term which speaks well to the Disney Corporation and hospitals across the country ability to close the gap of customer service expectations.
Gap Three: Service Delivery
Parasuraman, Zeithaml, & Berry (1985), describe Gap Three as Service Quality Specifications- Service Delivery Gap. The analogy of a repairman delivering exceptional service to the customer is a direct reflection of the company is used as an example. In a later study, Zeithaml, Valarie,Â Berry, Leonard,Â andÂ Parasuraman,Â (1996) point to a clear finding of strong investigational data supporting the improvement of service quality by individuals will increase favorable intentions of customers, while decreasing the unfavorable intentions of customers. The emergence of patient family centered care is an example of this gap. Davidson et al. (2007) address the stress of having family members in an intensive care unit (ICU) at all times is for the medical staff caring for the patient. The medical staff must communicate well with patients and families for patient-centered environment to thrive.
ED Management (2009) highlights an emergency room (ER) department in Indiana. The manager of the department routinely shares the Press Ganey scores of the department. The staff then makes recommendations for areas of patient safety which can be improved. Moreover, each time a patient is discharged from the ER, staff members ask the patient questions regarding the patient's stay in the ER. Any concerns or problems are then addressed immediately.
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Fred Lee (2004) adopts an interesting concept of customer service by looking at the four levels of motivations. Level one is compliance and focuses on "doing what someone makes me do" (pg. 132). Level two is willpower and the focus is "doing what I believe I should do" (pg. 133). Level three is imagination and the focus is "doing what I want to because I feel like it" (pg. 134). Lastly, level four is habit and the focus is "doing what comes naturally" (pg. 134). All Disney employees or cast are encouraged to use these motivations to develop exception customer service habits. Likewise, hospitals must use the power of imagination to motivate the healthcare team to provide exceptional care of each patient. Imaging the thoughts and emotions of patients allows the healthcare team to genuinely see the patient's needs.
Gap Four: External Communications to Customers
Parasuraman, Zeithaml, & Berry (1985), describe Gap Four as Service Delivery- External Communication Gap. Industry must be cautious not to promise more services than can be delivered. Berkowitz (2011) discuss the relationship of promotions and increased customer expectation. An understandable example of hospitals offering 'fast track' programs for ER visits. The expectation of the patient is a shortened ER visit while the reality of the program only shortens the registration time, then followed by a long wait. The gap between a promised shorter wait in the ER and the actual long wait will lead to customer dissatisfaction.
ED Management (2009) describes the approach of one ER to eliminate any misunderstandings of services provided with patients. The staff readily addresses any imperceptions in real time to hopefully avoid negative Press Graney scores and poor patient satisfaction. The manager notes that once the patient has left unsatisfied, it is difficult to repair the deficits in service with the patient.
Lee (2004) notes, customer experience are more important than customer service. Disney endeavors to obtain and maintain customer loyalty. Loyal patients speak to others in the community and return to the hospital for care when needed. Hospitals must decide to measure loyalty of the patient rather than the satisfaction of the patient. In doing so, hospitals can use the right yard stick to determine customer loyalty. Hospitals must provide more than scripts for staff, but an entire experience which can be viewed scene-by-scene. Every patient room is a scene and every healthcare member has a role to play.
Gap Five: Expected Service/Perceived Service
Berkowitz (2010) notes a direct relationship between Gap Four and Gap Five as the customer sees a promotion and forms individual perception of services provided. Parasuraman, Zeithaml, & Berry (1985), describe Gap Five as the Expected Service- Perceived Service Gap. The solution to high-quality customer service is meeting or exceeding the customer's expectations. An example from this article is a repair person that not only repaired the appliance, but also explained what he was doing as he worked. Furthermore, the repair person went on to explain exactly how the problem was caused and how the consumer could do the repair if it happened again.
An example of Gap Five in healthcare can be addressed by delivering quality patient-family centered care. Steiger and Balog (2010) speak to patient perception of care during the current difficult economic times. Patients frequently perceive healthcare quality will be reduced. However, numerous hospitals including Mayo Clinic have strengthened bonds with patients and families by providing an environment which puts the patient and family in the center of the care.
Using quarterly Press Ganey scores from 25hospitals, Glickman et al., (2010) concluded increasing overall patient satisfaction scores should be more about increasing quality of care and less about making the patient happy. Quality of care must include actions that are measured by clinical performance. Quality improvements such as discharge planning or nursing care can be directly influenced by Press Ganey score.
Lee (2004) points out, Disney encourages cast to have a healthy dissatisfactions for current standards of customer service. "Good is not good enough" (pg.161) and "We can always do better" (pg. 161) creates a culture of exceptional service to guest. Correspondingly, hospitals must develop a culture which echoes that of Disney. Healthcare members must not see dissatisfaction in the workplace as a destructive force which creates anger and dissention among staff, but as a force which can bring healthy change to the environment.