An Indian Tragedy, An Indian Solution - Perspective of Managing Service Quality in Emergency Medical Services in India

8/12/2019 An Indian Tragedy, An Indian Solution - Perspective of Managing Service Quality in Emergency Medical Services in India

1/9


2/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 G

"""#$%&'(#)*+, [ISSN 2159-6743 (Online)] 9:; :? @>:A!> BC!>(B D!;4C G- =;4AC< 8- GH8G

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"3

4+)56+72&8+ /9 :'"'*&"* .+)8&7+ ;1'0&2, &"


3/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 I


care should typically be provided by an emergency medical team consisting of doctors trained tointernational standards on trauma life-support techniques, nurses, trained ambulance personnel andparamedic units requiring highly advanced skills and specialized equipment. Improving service qualityin emergency medical care will help to save lives and minimize disabilities in patients after recovery(Rehberg, 2007). More important however, is to ensure that people are aware of the existence of theemergency medical service. Garg, (2012) noted an EMS that people are not aware of is as good as

nonexistent (para. 7). Gargs notion is particularly relevant to the poor, indigent and illiterate.The increasing rates of urbanization and industrialization in India suggest that providing efficient

post trauma care is an important area of concern in India. Current statistics are difficult to obtain but theNational Crime Records Bureau in India reported that in 2010, at least 10.1% of deaths were due toaccidents and injuries. A total of 678,326 cases of Un-Natural Accidents caused 359,583 deaths andrendered 503,932 people injured during 2010 with a male to female victim ratio of 78:22. Most of thevictims of accidents were in the economically active group aged between 15 and 44 years. This group ofpeople accounted 60.7% of all persons killed in accidents in the country during the year. This is a majorarea of concern and hence efforts need to be made effectively to prevent accidents, and secondly, toincrease the service quality of emergency medical services in India (NCRB, 2011). These statistics shouldbe treated with caution, however, because they underrepresent to reality on the ground; they do notreveal the true picture. A Report of the Committee on Crime Statistics by the Social Statistics Divisionof the Central Statistics Office in 2011, revealed Minimisation and Suppression of Statistics , Favours to High

Ups, Monetary Considerations, Under Pressure from goons, gangs, mafias or other influential sectionsas someof the reasons for under-, or non-reporting accidents and injuries in India (CSS, 2011, p. 18-19).

Government policy focuses on the prevention of communicable diseases rather prevention of trauma.There are no government agencies to plan, finance, or draft legislation to establish an efficient nationalintegrated trauma care system in the country. This is specifically lacking in rural areas where accuratestatistics may be limited and under reporting common (Joshipura et al., 2003). Furthermore, there islimited provision of accident and emergency care unit systems in the major cities and towns (Garg, 2012;Wegman, 1996). Meeting the golden hour goal (first hour after injury) and the platinum hour goal (firstten minutes after injury) determines the effectiveness of treatment in the trauma patients that isfrequently missed in India (Medindia, 2012). Delayed pre-hospital care such as delayed first-aidtreatment, delayed inefficient transfer of the victim to the hospital from the accident site and medico-legalissues can lead to deterioration of the patients conditions leading to complication (Gururaj, 2005).

Additionally a systematic triage system to evaluate the trauma victim is followed only by fifty-fourpercent of the hospitals. This is compounded by resource shortages because state public health carepolicy falls short for the majority of trauma cases that leads to inefficient trauma-care service to thosepeople who cannot afford the cost of investigations and the admission costs in specialized hospitals(Joshipura et. al., 2003). Consequently, the poor and indigent are deprived of necessary post trauma careand treatment because they cannot afford the treatment cost. Often the hospital where the patient may beadmitted depends on the hospital fees that the patients family can afford and not on the type of injury(Joshipura et. al., 2003). The mortality rate among low-income group is as high as 63%, compared to 55%among the middle-income group and 35% among high-income groups (Mock et al.,1998).

The better survival and functional outcome among injured patients in developed countries can bepartly attributed to high-cost equipment and technology (Narayan, 2011). Much of this high-endtechnology is unaffordable and unavailable to victims to the poor. Improvement in the outcome oftrauma patients can result from improvements in the organization of trauma care services in the form of

focused systems in specific geographical areas (Sasser et al., 2006). Better organization of systems mayreduce the time between injury and the definitive treatment thereby reducing morbidity and mortality. InIndia, such a trauma system is almost non-existent and even if present in some urban areas, lacks thecohesive effort required (Joshipura, 2006).

Framework of Service Quality Model of Emergency Medical Service

Services tend to be intangible, inseparable from their provider, perishable and inconsistent in their delivery(Walker & Baker, 2001, p. 2). These qualities make services high in experience and credence qualities.Patients therefore have greater difficulty in evaluating medical services generally and trauma services


4/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 J


specifically. Noting the unique nature of services, Levitt (cited in Gronroos, 2001) describes a service as apromise of satisfaction (p. 3). As such, trauma services promise both implicit and explicit influencepatient expectations. Brown, Fisk and Bitners (1994) seminal work in clearly allied service satisfactionwith service quality, although the two do not share common definitions of terms nor is there clearunderstanding in the literature of how the two relate.

Parasuraman (cited in Walker & Baker 2000), whose research has provided a framework for

measuring service quality in this paper, defines service quality as the gap between the consumersexpectations and their perceptions of how the service is performed(p. 1). Quality is therefore likely to be valueled in terms of perceived quality and availability of service to patients. It therefore follows that perceivedvalue in a trauma unit is a measure of the extent to which the medical service delivered meets thepatients expectations. The nature of a service means that the patient is physically present throughout thecare delivery process. Both the service outcome, as well as the service process influences the perception ofvalue. The perceived quality can be aligned with a continuum of unacceptable quality at one end andideal quality at the other with graduations of quality in between. This implies that prior expectations arecompared with actual service delivery and the service outcome and it is this comparison that leads toperceived value. Thus, it is important that the management of the care service process occurs throughmanagement of standards and controls be they regulatory or provider specific (Dorrian, 1996; Ghobadian,Speller & Jones, 1994).

Quality is not a singular but a multi-dimensional phenomenon. It is not possible to ensure

organization specific quality without determining the salient determinants of quality specific to a service.There are a number of models including those of Gronroos (1983), Lehtinen and Lehtinen (1991), andParasuraman (2002). Gronroos (2001) argues that service quality comprises three dimensions namely: thetechnical quality of the outcome, the functional quality of the service encounter and the corporate image.Lehtinen and Lehtinen also identify three dimensions namely physical quality, corporate quality andinteractive quality. They argue that it is necessary to differentiate between the quality of the process ofdelivery and the quality of the outcome of the service (Ghobadian, Speller & Jones, 1994; Martin, 1999,Walker & Baker, 2000). Garg (2012) further suggested that the reputation of a hospital often dependsupon the quality and promptness of its emergency medical services.

These attempts to identify the service quality determinants lack sufficient detail but are useful in theseparation of measuring both process and outcome in terms of quality. Other researchers such asParasuraman and Ghobadian, Speller and Jones have proposed more detailed quality determinants (e.g.,see Ghobadian, Speller & Jones, 1994; Zeithhaml, 2000) wherein the importance and utility value of eachdeterminant is dependent on the nature of the service. Technical quality, functional quality and serviceimage form components of a service quality. Technical quality is the quality received by the patient whenthe patient interacts with the service that leads to an evaluation of the service by that patient. Thetechnical outcome determines the functional quality that reflects the views of the actual service itself. Thetechnical and the functional quality of the service lead to building up of a service image in a broaderstakeholder context including those with no experience of the service delivery. Tradition, ideology, wordof mouth, pricing and public relation also contribute towards the building of that image (Gronroos, 1984).Thus service quality is subjective and interpretative in the context of emergency medical services ratherthan having an absolute clinical perspective.

An analysis in terms of the current state of emergency medical services, using the general model ofservice quality structure as proposed by Parasuraman, et al. (1988), is shown as Figure 1. Emergencymedical services quality has impact on all the three phases of its interaction with patients. RATER and

the three phases of emergency care have been chosen for this review because of its simplicity andappropriateness to the characteristic demands from emergency medical services. The dimensions of theRATER Model include reliability, assurance, tangibles, empathy, and responsiveness (Nitin Seth, et al.,2004).


5/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 K


Figure 1.The RATER Model- Service Quality Dimensions Applied to Emergency Medical Services.Note. Adapted from Parasuraman et al. (1988) and Nitin Seth, S. G. Deshmukh and Prem Vrat (2005).

Figure 2 illustrates the emphasis in managing service quality at each phase of emergency medicalservices: Phase One being the awareness, trust and initial accessing the care, Phase Two being the inhospital care and Phase Three discharge and rehabilitation.


6/9


7/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 M


public trust, reliability and awareness of access is to be achieved. It follows that a regulated skill-basedtraining program for doctors as well as paramedical staff in emergency medical services procedures isimplemented to organize and integrate pre-hospital services with definitive care facilities (hospital) sothat a patient is shifted to an appropriate facility in the shortest possible time, regardless of the ability topay. A systematic triage protocol should be made mandatory in all trauma units (Joshipura, 2008).

Conclusion

From the above review, it has been highlighted that in India there is significant work to be done in thefields of medical treatment and quality of patient care. The field of trauma care and emergency medicinehas not progressed uniformly in the country and it is still at a primitive stage. The importance of reliableemergency medical services cannot be over emphasized, especially where the government has theresponsibility of caring for a majority of the population.

Service quality of the trauma care system in India can be improved by increasing resources availablefor the treatment of the trauma victims. The technical quality should meet the functional quality ofhospital services thus enhancing image of the trauma care system and trust from citizens (Nitin Seth etal., 2004). The United Nations General Assembly and the WHO have implemented an action plan ADecade of Action for Road Safety 2011-2020 by member nations and thus the quality of emergencymedical services generally rather than road safety specifically, should be considered a high priority and

different mechanisms for its implementation throughout the country needs to be devised.


8/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 N


References

A)/O"- .P QP- ?&6R-

412).8

I J/2)1K)2).8 91*1%/:/*.?FFUVW- JI\LLP

@)/")//6- DP U8VNJWP ! 6+)X&5+ d1'0&2, Z/%+0 '"% &26 Z')R+2&"* &ZY0&5'2&/"6P G40,L/1* 3,40*12 ,+ 910H/.)*%- FMUJW-

IL\JJ

@)/")//6- DP UGHH8WP (7+ Y+)5+&X+% 6+)X&5+ d1'0&2, 5/"5+Y2_ ! Z&62'R+c 91*1%)*% 5/06)'/ >412).8- FFUIW-8KH`8KGP

@1)1)'e- @P UGHHKWP -*$40)/( )* -*7)1N O *1.),*12 L/0(L/'.)6/? -* P1'H%0,4*7 Q1L/0(N P407/* ,+ B)(/1(/? =+O ^+07&_(7+ ='2&/"'0 D/ZZ&66&/" /" 4'5)/+5/"/Z&56 '"% B+'027- 4&"&62), /[ B+'027 '"% ?'Z&0, Q+0[')+P

B&"%162'" (&Z+6P UGH8HWP 91* 7)/( 1( R &,(L).12( 0/+4(/ &): .0/1.:/*.#+72&"+"- ;P- T >+72&"+"- 9P U8VV8WP (O/ !YY)/'57+6 2/ .+)X&5+ g1'0&2, &Z+"6&/"6P P UGH8HWP ./Z+ &"6&*726 /" 5/"5+Y21'0&h&"* '"% Z+'61)&"* 6+)X&5+ d1'0&2,-3,40*12 ,+

J/.1)2)*% 1*7 C,*(4:/0 5/06)'/(?FVU8W GV\JGP

4')2&"- DP >P U8VVVWP (7+ B&62/),- CX/012&/" '"% S)&"5&Y0+6 /[ .+)X&5+ 4')R+2&"*- 910H/.)*% -*./22)%/*'/ 1*7

Q21**)*%- FVUMW IGJ`IGNP

4+%&"%&'P UGH8GWP P >P U8VNNWP .C_ ! Z102&Y0+\&2+Z 65'0+ [/) Z+'61)&"* 5/"61Z+)

Y+)5+Y2&/"6 /[ 6+)X&5+ d1'0&2,P3,40*12 ,+ J/.1)2)*%- .Y)&"*- 8G\JHP


9/9

!" $"%&'" ()'*+%,- '" $"%&'" ./012&/"345$"2/67 +2 '0 V


S+%+" 4P- .51)[&+0%

Documents

An Indian Tragedy, An Indian Solution - Perspective of Managing Service Quality in Emergency Medical Services in India