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4. Service and Quality

This chapter analysis the unique differences of service compared to production. Knowing the differences the difficulties of applying quality methods into a service become present. Furthermore, the weaknesses of a common quality approach of medical service are understood. Finally, a new approach to model quality for medical service is outlined.

4.1 The Nature of Service1

Meyer defines the nature of service as the following:

The objects of sale given by any service provider are productive powers of persons or object systems, especially machines, which are directly applied on the customer or their objects (external factors) on the bases of given internal factors. The aim of the service is to cause a demanded change or to ensure a wanted condition.2

This definition of service contains three elements, which characterises all kinds of services. Only if the three elements are given, will it be a service. If one element is missing the object of sale is only similar to service. The three elements will be explained in the following.

4.1.1 First Service Element: Supply During Production

The service providing unit directly acts on the customer or on his object. Service does not produce an object of transfer (product), which is carrying the provided qualities to the customer. Production and supply are identical.

Service can be classified, by whether it is provided by men or machines, and whether it is done on the customer or his object. If people are not directly involved in the service and it is not done on the customer himself, situation seems most similar to handle as to selling a product, although it is still a service. A fully automatic car washing machine visualises this type of service. Here, it seems most easy to apply unbiased quality measurements. Applying quality concepts originated for products to this kind of service makes almost no difference.

However, in ambulant medical care, the service is always applied on the customer, namely the patient. Applying quality concepts from industry will probably not be possible without adjustment. Depending on whether the service is mainly produced by machines or by physicians, this task will again differ. Quality of fully machine driven laser surgery will be easier to control as in manual radial keratotomy.

4.1.2 Second Element: Immateriality of the Offered Performance

The nature of service is always immaterial. The service is always only a promise of performance at the time of making the deal. The service provider can only offer their potentials, never products. Pure process or outcome views on service can therefore not be sufficient. They might play an important part in further investigation.

4.1.3 Third Element: The Integration of an External Factor

Service always requires the integration of an external factor -either the customer or his object- to the production process. The integration of an external factor, especially if it is the customer, induces four major consequences and dimensions when handling quality aspects in service.

dimension I:
internal individualisation, and the ratio between personal service and machine service

dimension II:
customer orientation of internal contact factors

dimension III:
integration of the customer or his object (external factors)

dimension IV:
interactivity of external factors, especially customers

4.2 Specific Tasks of Quality in Service

The first element, -supply at the time of production-, leads to first peculiarities of services. At the time of making the contract of purchase the customer cannot test or even examine the quality of the service. He can only estimate the potential qualities of the service provider and hope that a certain quality will be reached. On the other side, the service provider can hardly give a promise that a certain quality will be reached as he often does not know the exact condition of the external factor, i.e. the process carrier. In our case the ophthalmologist does not know for certain, how the eye will heal after surgery. The promise that a certain quality will be reached becomes even more difficult, if the service applied depends on human performance. For once there are intra-individual changes, the individual performance will depend on daily conditions (daily output, sympathy, temper). Secondly, the individual performance will be different due to experience, skill, and knowledge.

The second element, -immateriality-, will make unbiased quality measurement difficult, and the reputation of quality measurements even harder. Immateriality means missing the availability of the performance's storage.

The third element, -integration of the external factor-, most profoundly effects quality aspects of service. The quality of the performance will depend on the external factor:

1. The quality is not under total control of the service provider. It is unlikely that the external factors will be identical. For instance, different shapes of the external factors will influence the outcome.

2. That outcome is connected with the external factor, implies that quality can not be purified by sorting out defects after the service process. A replacement of unsuccessful service is also impossible. Only the offer of a possible improvement or the reduction of price is possible. This feature is of upper importance when service is applied on the customer himself.

3. Moreover, if service is applied directly on the customer, the process of integration will be of interactivity and the formal outcome will depend on this interactivity.

The interactivity also implies that the performance is not only a production process, it is also a process of consuming and an experience by the customer. Many aspects of quality will be transitory and pass away, they cannot be reconstructed. One could suggest that medical care is not a night-club, that is to say, that actively consuming the service is not the aim of medical care. However, it is an important feature in medical care, because as patients don't have the knowledge to judge the quality, the experience during their stay makes a strong impression, Hopefully to the benefit of the institution.

4.3 Summary

The quality of service is a very complex phenomenon. It will be determined by the customer or its object, the external factors, and by the service provider itself. The more persons directly involved in the production process, the more difficult it will be to interpret the quality reached. Medical care represents this most difficult situation, as customer and service provider are human beings. The quality depends on the potentials and interactivity of the two, the patient and the physicians. The attained quality can not be isolated from the process carrier, in our case the patient. Therefore the go trough rate is 100 % by definition. Quality in medical care has always been of a very subjective character, the patient will, whether he wants to or not, influence the quality and feel quality subjectively. The following figure will summarise the nature of service and its implication for quality as discussed so far in this chapter.

4.4 Service-Oriented Quality Models

Three different quality models for service are outlined.
4.4.1 The Common Model of Donabedian3

The model of Donabedian is most commonly applied in medicine. It was first presented in 1966 and specifically designed for medical service performance. Donabedian divides quality into three categories: structure, process and outcome.

This contains the qualification of all personnel, the technical equipment, the organisational working conditions, and the possibility of using the supplied performance by the customer.

Bottlenecks in personnel can bring poor quality. Insufficient or outdated technical equipment can lower the quality of service.

This refers to the entirety of activities during the actual service production. The delivered quality is measured by comparing the individual actions of the service provider with others or with standards.

This stands for the change of the actual or future health condition of the patient. The quality of outcome in medical care is most difficult to measure, as a stable final outcome is usually reached a long time after the patient has left the institution.

Donabedian (fig.9) assumes a linearity between the three components. The connection between the process quality and the resulting outcome seems obvious. However, the understanding of how structure quality effects the process quality is rather unclear.

structure process outcome

4.4.2 The Image Model of Grönroos4

Grönroos builds his model starting after the service has been done. The customer will compare the given service with the service. The result of this comparison both will be the experienced service. Grönroos divides the given service into two quality dimensions: technical quality and functional quality.

technical quality
The former can be rated without difficulty. It will best be described with the question: What will the customer get? Know-how, machine performance, computer systems and problem-solving ability.

functional quality
The latter stands for the nature of service. It will answer the question: How is the service presented? Contact with customer, appearance, behaviour, atmosphere and service-oriented basic attitude. Rating this dimension of quality will be far more difficult as it is of subjective nature. Technical quality and functional quality will be perceived through the already existing image of the service provider.

The image represents a kind of delay function of the technical and the functional quality. The image filters the perception during the process of the actual quality of service.

Figure 13: The Model of Grönroos

4.4.3 A Pragmatic Development Towards the Model of Meyer

Looking at the nature of services, taking the Model of Donabedian as a mental base, and modifying and adding elements, one can easily understand the Model of Meyer.

The Model of Donabedian divides service into structure, process and outcome. However, the connection between structure and process seems unclear. That is to say, that best equipped technology in medicine (= structure quality) does not necessarily result in good process quality, or in good outcome quality. The most important element of a service, the customer, somehow, does not appear in this model at all.

Grönroos builds his service model from the eyes of the customer, comparing the expected quality with the given quality. He realised the importance of the image in service. However, he still missed the integration of the customer into the model.

Taking into account the definition of service and its resulting three elements of service, the Model of Meyer will reflect the double-sided nature of service. The influence of the customer towards gained quality will be represented. Meyer wants to show the whole progress of service and its developing quality, but he also wants to define subqualities in order to obtain clear areas for creating quality. The importance of each area of subquality will depend on the kind of service. [MM87p.191]

Here, the Model of Meyer will be developed in steps, modifying the Model of Donabedian and making the necessary changes and additions. Although this might be in contradiction to Meyer, this will be didactic and guarantee easy understanding . Moreover, this approach takes into account current quality assurance. The Model of Donabedian is most commonly used in medicine. Physicians can build on their existing knowledge of quality understanding. Starting with this model, making changes and additions, will implicitly unfurl the needed improvements. Besides, it outlines the parts in common of both models. Today's implemented quality assurance programs in medicine can then be seen, as partial actions of the more widely developed Model. On the other hand, developing Total Quality Management for specific tasks and situations in medicine, one might then consciously simplify the Model of Meyer.

first step: potential quality instead of structure quality
Donabedian defines the subquality structure quality. He implies that somehow structure quality will cause process quality and finally influence the outcome quality. In practice this definition has been misleading. As already mentioned, best equipment does not necessarily improve the outcome. Defining this subquality, structure quality, separating it from the process quality, leads to the belief that structure quality could be for its own sake. In contrast to process quality (which will also be lived by the customer), a given structure never produces a quality in itself. Structure can only serve to create better process quality and better outcome; to determine what kind of structure will actually bring better process and outcome quality, one has to look the whole service from behind. Changing the structure, buying better equipment, will at first lower quality, it might then improve the quality. Structure must always be seen in a view of process, the weakest part determines the strength of the whole. New equipment in a structure with poorly skilled staff will most probably be of no benefit. If the staff is in a good condition, missing equipment can be the bottleneck. The elements of structure, that is to say, the quality of human resources, technical equipment and organisational structure, should not be counterbalanced. Referring to quality (not quantity) they cannot compensate one another.

Meyer defines potential quality of the service provider as one subquality of his Model. Basically structure quality and potential quality refer to the same thing. However, replacing structure quality with potential quality in the Model of Donabedian will be the first methodical improvement. It will keep in mind that the former structure quality is only a potential quality and never for its own sake. Secondly, one becomes aware that the elements of potential quality must be well balanced to be effective and efficient.

Comparing partial potential qualities between different service providers only makes sense in identical circumstances; that is to say with equal service procedures and equal rest potential quality. Needed potential quality must be determined looking backwards from the outcome of process, depending on this situation some missing equipment will be a significant bottleneck or not.

In the authors opinion, much money has been wasted for "improving" structure quality (unbalanced) for its own sake. Of course, the actual situation of medical care in many western countries does not promote the efficient use of equipment resources. For instance, artificial boundaries between ambulant and stationary medical care does not allow adequate resource sharing. Often structure quality seems to be reduced to owning the latest equipment. It seems most readily accepted by physicians: comparing equipment does no personal harm to anyone, problems are materialised and it is very easy to make some kind of equipment norms. Equipment has even been abused as a status symbol. Of course, structure plays an important role in TQM but it can not be reduced to: Who has got the latest equipment and who distresses his patients with he most technical diagnostic procedures? Potential quality keeps in mind that structure is no quality in itself. Equipment is only a part of structure. The quality of human resources (their skills!) and the process organisation towards reaching the best process and outcome must be of the same dimension as the equipment to gain high over all potential quality.

second step: potential quality of the service provider
Meyer divides the potential quality of the service provider into potentials of specification and potentials of contact. Referring to dimension I and dimension II respectively, as defined in 4.1.3.

dimension I: potentials of specification
The kind of combination of staff and equipment should depend on the customer. High specification allows high specific quality. However, depending on the degree of specification, flexibility on the variety of customers is getting lost. Offering Refractive Surgery in a typical universal ambulant one-physicians-practice will probably not offer sufficient specification to deliver up-to-date quality. A private clinic for Refractive Surgery only offering the PRK laser procedure might be too specific, limiting the customer's selection, and will be inflexible towards changing concepts.

dimension II: potentials of contact
These are the specific service potentials. It will be of utmost importance to take care of all subjects and objects the customer comes into contact with. The nature of service provokes the attitude of the customer to take these as surrogates for measuring the potential quality. The experienced contact is highly image shaping. Specially mentioned need to be the persons in direct contact with the customer. The ability to calm a patient during ambulant laser treatment will highly improve the objective outcome and even the experienced process quality.

The following picture outlines the two modifications of the Model of Donabedian towards the Model of Meyer.

Figure 13: Potential Quality in the Model of Donabedian

third step: potential quality of the customer
The basic attitude of the customer, his emotional, intellectual and physical constitution towards co-operation during the production process, highly influences the quality of the service [MM87p.193].

Meyer divides the potential quality of the customer into potentials of integration and potentials of interactivity. Referring to the dimension III and dimension IV of Chapter 4.1.3 respectively.

potentials of integration
In the case that the customer is a patient, it seems even more obvious that the outcome strongly depends on his attitude. The direct assistance of the patient during the process can be positive, neutral or negative to the quality reached. The patient's attitude will pre-determine the quality.

potentials of interactivity
If the service is provided to a group of people, they can stimulate each other or frustrate one another. These potentials strongly predetermine the process quality of a service. Just imagine how the atmosphere of a ballroom dance is influenced by its people. However, potentials of interactivity even influence the quality of outcome in ambulant medical care. Any mistake of the physician, mentioned by a patient in the waiting room, will alert the group of patients, whereas positive experience will stimulate the other patients. In medical care potentials of interacivity are also facilitators in image shaping. Of course, the potentials of interactivity in ambulant medical care should not be actively manipulated for image reasons. However, depending on the architecture of consulting rooms potentials of interactivity can be provoked or rather diminished.

Individual patients' explanations of a refractive surgical procedure are very time consuming. Forming groups can highly reduce explanation time. However, the potentials of interactivity must be managed carefully. Negative interactivity can easily influence the necessary attitude for integration, or even cancel the contract. Small groups and shaped groups can lower the risk of potential negative interactivity. The following picture illustrates the change in respect to Donabedian.

Figure 13: Further Modification Towards the Model of Meyer

fourth step: process quality in the Model of Meyer
In the process of service, the service provider is applying his performance on the customer (e.g. or his objects). The customer integrates himself in this production process in a unique manner, either to his advantage or to his disadvantage. Thereby the potentials on both sides will be realised. The potentials of the customer in integration and in interactivity can strongly influence the process. In the case of a patient, the lack of assistance can even hinder the proceeding of the process. The process quality will be the result of many interactions between the service provider and the customer. The contact potentials of the service provider now play an important part. How do the personnel act towards the patient? The atmosphere of the institution, its lighting, air-condition and style greatly influence the behaviour of the customer, that is to say his integration and interactivity. The management of contact can greatly improve the integration of the customer and the interactivity in- between customers. This ability of partly controlling the patient's behaviour is demonstrated by the two arrows inside the ring representing the process quality, in the picture further down.

The behaviour of the patient should be followed continuously to prevent an undesirable development. Further actions must be adapted to the customer situation. Knowing how to manage the contact the patient can usually be kept in the planning process. However, sometimes actions need to be changed or even cancelled.

Fifth step: outcome quality in the Model of Meyer
Outcome can be divided into two areas of quality in respect to time. The direct process outcome and the quality of consequence outcome. The former can be fixated to a certain point of time, shortly after the service. The latter, however, will cover a long period of time. Usually it can only be measured and realised when the quality has gone. For instance, you only realise the success of a break repair in a car until the breaks stop working. Years after surgery a patient can suddenly suffer some undesired consequences. This consequence quality is also part of the stability definition in the system theory mentioned in the second chapter. The Model of Meyer has now been completely built, having taken the Model of Donabedian as a starting base. The following picture will illustrate the completed Model of Meyer.

Figure 13: The Complete Model of Meyer

4.5 Adequate Organisation of the Service Process

Specification and contact are the two potentials of the service provider, e.g. the clinic, in offering best integration and interactivity of the customer during the service. The process of service must therefore be designed to fulfil adequate specification and contact. In respect to specification and contact there exists three ways of organising a production process. They are named site building, group and workshop production.
4.5.1Principal Types of Organising a Production Process5

site building organisation
This means that all production devices are taken to one site. This is usually done because the production can not be done elsewhere. This is most typical in road working and house building. However, many services work with this type of organisation. Home visitations of doctors to handicapped patients are common in medical service.

group/line/flow organisation
1. group production means that production devices for similar products, e.g. process carriers, are placed together. Often the process carrier is transported with flexible devices from one station to the other.
2. In line production the manufacturing devices are moreover placed in accordance to the course.
3. In flow production all working stations are strongly fixed in sequence and the process carrier is passed on automatically.

The short production time, the transparency of the production and only a small administration are the advantages of these "newly discovered" organisation structures.
Few flexibility and limited economy of scales are the common disadvantages.

specialised workshop organisation
This means that similar production devices are gathered into one workshop. The process is split into small specialised units. Process carriers must therefore pass through various workshops.

Flexibility in respect to the variety of different process carriers and economies of scale provoke this type of organisation. However, missing transparency about particular process chains and the costs of co-ordinating and transporting the different process carriers from one workshop to the other are easily neglected. Moreover, the time each process carrier stays in production is taken for granted. Capital is needed to finance the queues and the repositories inside the production process. Nevertheless, even if these direct costs can be low, the potential risk to loose customers because of slow delivery can be even more important.
4.5.2Consequences for Service Organisation

Each way of organising the production has its generic advantages and disadvantages. However, depending on the situation only one combination of organisation types will be best. When organising a service there are two circumstances which will strongly effect the efficiency of the organisation type. The fact that supply takes place at time of production and that the customer must be integrated, indicates that the passage through time can not be taken for granted. In any ambulant medical service the process carrier will be a living patient. In production the workshop organisation can be most efficient, especially when the process carriers are cheap and production time is secondary. Instead in a service, a highly split workshop production will seldomly be adequate nor human, as the process carriers are of people and time is important factor. In respect to customer orientation workshop organisation will not be recommendable to ambulant medical service.

However, workshop organisation in ambulant medical service has been common. The main reason for that has been a lack of competition; in developed countries due to state regulations and in less developed countries due to missing medical infrastructure. The costs of waiting patients had no effect to the institutions. However, ever increasing competition will enlighten the true costs of workshop organisation in medical service. Moreover, work which until recently had to be divided can now be integrated thanks to the availability of equipment which can be handled by anyone without specialisation. Nevertheless, necessary specialisation and high costs of certain equipment will still give workshop organisation a limited place in ambulant medical care.

Site building organisation would be most customer friendly in medical service. In practice, this form will be limited to circumstances where the patient can not leave his home. So far the cost of visiting the patient with only limited instrumental devices are too high regarding usual patients. In our case of a selective eye treatment this type of organisation is not to be considered anyway.

The group organisation is process carrier orientated, which is to say that the manufacturing devices for one product are put together. Their close location lowers the logistic effort and the duration of production time is short. Taking into account that in any service the supply takes place at production and that in medical service it is the patient who needs to be integrated, group organisation seems essential for any ambulant medical service. It is not only the modern Japanese style of organisation, it is the typical way of how hairdressers have always handled their customers. This form of organisation seems so natural that it is hard to explain. Instead, a hairdresser who would work in a workshop organisation would split washing, cutting and styling. The customer would have to wait three times, walk to three different stations for each phase and would be handled by at least three types of specialised people. The hairdresser would need extra staff to co-ordinate the process. for each client.

Group organisation is the most natural form for any service. If all customers always have to pass the same process, the devices can be organised in line. However, changing from group organisation to line or even flow organisation brings inflexibility to changing customer conditions. In ambulant medical service there is no need for fixed transportation as patients can walk.

In ambulant medical care group organisation can be limited by the cost of special technical equipment which needs to be used as often as possible and therefore must be shared by various patient types to bring down costs. A strict group production or even line production would not allow this sharing as two process lines would cross one station. A solution would be to introduce time shifts for different process types. Patients asking for Refractive Surgery could be brought together on certain days of a week allowing for best group organisation and efficient use of all resources.

Organisation is always somewhat in-between integration of work and specialisation of work. In service integration of work will always be a goal as it reduces the time spent by the customer during service. Moreover, as the customer is always observing, short pleasant stays will improve the reputation and the experienced quality. A site building organisation would be the best choice in service, as the customer can stay in his own environment. Today this approach is an impossibility be out of space due to cost and limited resources in normal circumstances. Group organisation will be the second best choice in service offering a short stay at the institution. Workshop orientation should be replaced by group organisation, if economically possible. In ambulant medical care the organisation should be architectured in group organisation. Workshop organisation can be a second orientation to keep costs down. Applying parallel group organisation with time shifts will be the best alternative in ambulant medical service to "yesterdays" pure split workshop organisation.

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