Obstetrical Care and Patient Loyalty: Part 2

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2 Obstetrical Care and Patient Loyalty: Part 2 Service performance can be linked to patient loyalty. By lames W. Peltier, Thomas Boyt, and lohn A. Schibrowsky Health care researchers increasingly are recognizing tbe importance of "relationship marketing" moving beyond measuring patient satisfaction and perceived quality of care to developing a better understanding of patient-provider relationships. Long documented in literature on service-quality issues, relationship marketing focuses on developing longterm, patient-provider "bonds." Its ultimate goal is to build mutually committed relationships, then loyalty to the health care institution. Despite the benefits of understanding and building long-term, patient-provider relationships, little researcb has been done on tbe factors that influence patients' loyalty to a health care institution. Much of tbe health care research instead focuses on understanding wbat affects "overall patient satisfaction" and perceptions of "overall quality of care." Moreover, almost no research on market- X E C U T I V E HIGHLIGHTS This article is the last of two in a series identifying tbe elements of obstetrical care that most influence patient loyalty, and ultimately, long-term financial viability for the providers of obstetrics services. While in Part, the authors focused on the relationship between overall patient satisfaction and perceived overall quality of care to patient loyalty, in Part 2 they address specific factors in the birthing experience that contribute to patient loyalty. In particular, the authors focus on the importance of social bonds and structural bonds in the loyaltyenhancing process. ing obstetrics care bas examined how perceived service performance affects patient loyalty to tbe provider. Tbe healtb care industry would benefit by having a better understanding of bow to develop and nurture longterm, patient-provider relationships, but there is little consensus on the best means of measuring patient loyalty. (Refer to the 994 Mac- Stravic reference in tbe Additional Reading list, page 9.) In our previous article, "Obstetrical Care and Patient Loyalty" (Part ) in the Fall 999 issue of Marketing Health Services, we selected three patient loyalty measures that have clear financial ramifications for institutions providing obstetrical services. These included the likelihood of: ) coming back for obstetrics services if needed: 2) using other health care services offered by tbe provider; and 3) recommending the obstetrics care provider to others. Our findings sbowed, bowever, tbat overall satisfac- MARKETING HEALTH SERVICES 3

3 tion and overall quality of obstetrics care should not be viewed as replacements for any of these behavioraliy oriented measures of patient loyalty. In this article, we go beyond overall satisfaction and overall quality and develop a better understanding of how specific service-performance variables affect each ofthe three patient loyalty measures. Unlike Part of this.series, wbich examined physician care and nurse care separately, this analysis focuses on tbe "issue areas" likely to affect patient loyalty. DIMENSIONS OF OBSTETRICS CARE Considerable yet conflicting research has been done on dimensions of health care in general and obstetrical care in particular. Consistent with our study in Fart. many researchers bave separated issues pertaining to physician care and nurse care. Others have focused on issue areas regardless of caregiver classification. In this study, we do both. Specifically, we organize the service-performance variables into five dimensions, tben assess patients' perceptions of how well physicians and nurses performed on these performance variables. In an earlier issue (see tbe 998 Peltier. Boyt. and Schibrowsky reference in Additional Reading, page 9), we illustrated how patient-provider relationships are built on two types of bonds: ) social bonds, which are built through personal interactions between patients and their caregivers, and 2) structural bonds, which are developed when patients feel they're involved in the care-giving process. Customer-provider relationships with strong social and structural bonds lead to mutually committed relationships resistant to competitive overtures. Tbe five dimensions to be addressed are:. Patient-Caregiver Social Interactions Social bonds are relational elements based on a belief that most service-related encounters are the first und foremost social encounters. Inherent in the creation of social bonds is the level of "interpersonal trust" tbat patients have for their caregivers. Unlike trust for the expertise and skills of caregivens. interpersonal trust is a function of interactions between patients and caregivers. regardless of tbe specific care outcomes. The extent to wbich patients bave interpersonal trust is in part a function ofthe patients" perception of: their physicians and nurses care for tbem; their caregivers" degree of friendliness; the level of support their caregivers provide; their caregivers' degree of honesty; and their caregivers" treatment of family and friends. Strong social bonds can create a relationship in which price is less important, the likelihood that the service provider will be given the opportunity to re.spond to competitive overtures increases, and the motivation to remain in the relationship is enhanced. 2. Patient-Physician Communication The birthing process is one in which patients crave information. Before tbe birth, many women spend countless hours seeking out and reading material about changes their body will undergo, potential problems that might arise. the experience of labor and delivery, and the drugs to which they might be exposed. And curegivers often play a big role in tbe information acquisition and explanation process by providing specific information, distributing meaningful written materials, and directing their patients to other information sources. The degree to which patients feel that their caregivers have closed the information gap has been shown to influence their overall satisfaction with the birthing experience. Tbe impact that perceived information accessibility has on patient loyalty has been neglected in the literature. To a certain extent, patient-provider communications are also part of social bonding. For example, providing detailed information to patients certainly can increase the level of trust that they have for their caregivers. Patient-pnivider communications reflect trust in caregivers' ability to understand their health needs and, as a result, provide quality care. Specific service areas include listening to and answering patients' questions, understanding patient needs, explaining care, and spending adequate time with patients. 3. Communication Between Caregivers Caregivers' communication with patients is not their only information exchange throughout the birthing experience. Obstetric patients also need to know that their caregivers are exchanging relevant information on their patients" birthing needs. Unlike communications between patients and physicians, communications between caregivers generally are free of social bonding considerations, instead, the main purpose of communication exchanges between service personnel is to improve the quality of care for patients. 4 WINTER 999/SPRING 2000

4 4. Decision Input and Control Other research in obstetrics indicates that patient participation in the decision-making process is one of the main issues pertaining to patients" level of satisfaction. Consistent with relationship marketing theory, we contend that allowing patients the opportunity to shape their care will lead to strong "structural" bonds, then to loyalty. The decision-making process for many health care situations may not provide much opportunity for patient input (e.g., radiography). On the other hand, obstetrics care, including gynecological services, often begins before pregnancy and can continue for years afterward. As such, opportunities for patient participation are relatively frequent. In this study, we"re not interested in specific control issues (e.g.. natural vs. medicated childbirth). but focus instead on three decision areas: the amount of decision control available; the variety of choices offered; and the ability to change patients" minds with respect to physician or nurse care choices. 5. Facility Issues The importance ofthe physical design and layout ofthe health care environment has not received much attention in obstetrics research. Physical layout issues could relate to any number of specific components, including the prelabor. labor, delivery, and recovery facilities for patients, as well as waiting facilities for friends and family. THE STUDY We used data from the same study reported on in Part I for this analysis. The research objectives specific to this article are to: Assess the ability of service-performance variables to predict each of the three patient loyalty models. Determine the service-performance perceptions that are most strongly correlated witb each of the patient loyalty measures. Identify factors for improving patient loyalty. We conducted three data analysis procedures. First, the service-performance variables were regressed against each of the patient loyalty measures. In addition to the physician and nurse questions reported in our first study, general serviceprovider statements (e.g.. "My caregivers treated me well"') and questions related to hospital facilities also were included in the regression analysis. Tbis analytic stage was conducted to determine if a "predictive"" model could be developed for each ofthe patient loyalty measures. Second, based in part on a factor analysis of the data, the questions in each ofthe service-performance dimensions were summed, and standardized scores were calculated. These summed dimension scores then were applied to each of the loyalty measures. Last. the service-performance variables were correlated with each ofthe patient loyalty measures to assess their individual impact on patient loyalty. FINDINGS Predicting Patient Loyalty In our first study, tbe overall satisfaction and overall quality care measures weren't good predictors of referral loyalty (r-square =.244). repeat caregiver usage intention (r-square =.056), or intention to use other services from the health care provider (r-square =.056). In this study, we used regression analysis to assess the direct relationship between the service-performance variables and the three loyalty measures. As shown in Exhibit I. using the serviceperformance variables instead ofthe "overall/surrogate'" measures greatly improved our ability to predict the loyalty measures. The model's ability EXHIBIT Comparing overall model to individual service-provider question model Referring obstetric care to others Using provider again for obsteirica! services Using other health care services offered by provider Variance explained individual measures,834,258.3 Variance explained overall measures Percent improvement MMHI MARKETING HEALTH SERVICES 5

5 EXHIBIT 2 to predict was particularly accurate for referral loyalty, with a variance explained at 83.4%. The service-performance variables also sigtiificantly improved our ability to predict intetit to use the provider again for obstetrics (variance explained = 25.8%), and likelihood of using future healtb care services offered by the provider (variance explained = 3.%). Compared with tbe previous study, the use of individual service-perfonnance variables in this study resulted in a net gain in variance of 59% for referrals, 20.2% for intent to repeat use of obstetrics services, and 25.59c for intent to use other services offered by the healtb care provider. Service-Performance Dimensions and Loyalty Next, measures ofthe five noted service-performance areas patient-caregi ver social interactions, patient-pbysician communications, communication between caregivers, decision making input and control issues, and facility issues were developed. (See Exhibit 3.) Exhibit 2 provides the correlation coefficients for each of the five service-performance dimensions and the tbree loyalty measures. Unlike tbe relatively low predictability of tbe overall satisfaction and overall quality measures found in Part I, all of tbe summated service-performance dimension measures in this analysis were significantly correlated witb each of tbe patient loyalty measures. Correlation between obstetric dimensions/issues and patient loyalty Patienl-Physician Refer obstetric care to others Communications (alpha-.93).533 () Patient-Caregivef Social Interactions (alpha-.87) Decision-Making Input/Control (atpha-,92) Facility Issues (alplia=.79} Communication Between Caregivefs (alptia=.82) All correlations signilicant at p< (2).478 (3).434 (4).423 (5) Return for obstetrics.270 (3}.285 (2).352().94(5).204 (4) Return for otber services.238 (3).25 (2).35().228 (4).39(5) Patient Referrals All of the service-performance dimension measures were highly correlated witb patient-referral likelihood. The three highest correlations were for patient-caregiver communications (r -.533), patient-caregiver social interactions {r =.59), and decision input and control (r =.478). Repeat Use of Obstetrics Care Although the correlation coefficients were lower, all of the service-performance dimension measures were correlated with the likelihood of reusing the hospital's obstetrical care. The highest correlation was between the control/decision input dimension and the decision to come back for obstetrics care (r =.352). Patient-caregiver social interactions bad the next highest correlation (r=.285). Use ofthe Health Services The findings for the likelihood of using other health care services offered by tbe healtb care provider mirrored those found for tbe intent to reuse obstetrics care. Specifically, the highest correlation was between the control/decision input dimension and this measure of loyalty (r =.35), followed by patient-caregiver social interactions (r -.25). Individual Service Performance and Loyalty The last step in the analysis was to assess tbe relationship between individual serviceperformance variables and the three measures of patient loyalty. Exhibit 3 shows the correlation coefficients for each of tbe service-performance variables and the patient loyalty measures. The 0 highest correlations for each loyalty measure are also provided. In referral loyalty, tbe five highest correlated service-performance variables were: ) decision control given by physicians; 2) physician's level of caring; 3) decision control given by nurses; 4) satisfaction with nurses' answers to tbeir questions; and 5) the perceived quality of nursery care. Tbe five highest correlations for returning for obstetrics care were; I) decision control given by physicians; 2) tbe number of choices physicians gave them; 3) perceived quality of nursery care; 4) decision control given by nurses; and 5) satisfaction with physicians' answers to tbeir questions. The five highest correlations for returning for other health services were; ) decision control given by physicians; 2) tbe number of choices physicians gave them; 3) the extent to wbicb nurses listened to what they had to say; 4) decision 6 WINTER 999/SPRING 2000

6 EXHIBIT 3 Correlation between service-performance issues and patient loyalty Refer obstetrics care to others Return for obstetrics Return for other services Dimension Correlation Coefficient Rank Correlafion Coefficienf Rank Correlation Coefficient Rank Patient-Care giver Social Interactions Physician's level of caring Nurses'level of caring Honesty of nurses Honesfy of physician Level of support given by nurses Friendliness of physician Nurses' treatment of family/friends Level of support given by physicians Friendliness of nurses Physician's treatment of family/friends , ,26, ,24, ,72, Patient-Physician Communications Nurses answered your questions Nurses listened to what you had to say Physicians listened to what you had to say Amount of time physicians spent with you How well physician understands your needs, How well physician answered your questions How well physician explained care How well nurses explained your care Amount of time nurses spent with you How well nurse understands your needs, ,248,256,9,65,67,230,79,67 n,s. n,s Communication Between Caregivers Physician communicated with nurses Nufses communicated with physician Nurses communicated with support staff Physician communicated with support staff 44, , ,4 n,s..48 Decision-Making input/controi issues Decision control physicians gave them Decision controi nurses gave them The number of choices nurses gave them The number of choices physicians gave them The ability to change mind with nurse care The ability to change mind with physician care, ,30, ,252.92,277 n,s. 4 Faciiity Issues Nursery care Noise control Decor Privacy Cleanliness Furniture , ,83,33 MARKETING HEALTH SERVICES 7

7 THE DEGREE TO WHICH PATIENTS FEEL THAT THEIR CAREGIVERS HAVE CLOSED THE INFORMATION GAP HAS BEEN SHOWN TO INFLUENCE THEIR OVERALL SATISFACTION WITH THE BIRTHING EXPERIENCE. control given by nurses; and 5) satisfaction with nurses' answers. Several key findings are particularly noteworthy. First, consistent with Exhibits and 2. referral loyally had higher correlations with the serviceperformance variables than did the other two loyalty measures. Second, except for nursery care, the correlation rankings for returning for obstetrics and returning for other health care services were similar. Third, consistent with structural bonding principles, the decisionmaking input and decision control given by caregivers was the most important servicepertbrmance variable for all three loyalty measures. Last, the individual service-performance variables comprising the deci.sion-making input and control dimension measure were the most highly correlated with the patient loyalty measures. IMPLICATIONS Beyond Patient Loyalty Surrogate Measures Our findings support the contention that health care researchers need to go beyond using overall measures of satisfaction and quality care as surrogates of patient loyalty. While overall quality and overall satisfaction were highly correlated with obstetric service-performance measures, their link to patient loyalty was relatively weak. In this study, we were able to explain a much greater portion of the variance in all three of the patient loyalty measures by using service-performance dimen-^ sion measures rather than the overall measures of quality and satisfaction. Moreover, the serviceperfonnance variables that most highly correlated with satisfaction and quality of care differed greatly from those that were highly correlated with patient loyalty. Unfortunately, much of the research in health care management lacks patient loyalty measures that assess service performance. This study clearly demonstrates that patient-loyalty management is significantly different from patient-satisfaction management and quality-of-care management. Comparing Patient Loyalty This study clearly shows that measuring obstetrics care is a multidimensional process. Each of the five obstetric dimensions we identified was significantly correlated with the different patient loyalty measures. Failing to understand the multidimensional nature of the evaluation of the birthing experience or performing poorly on any of these dimensions can have negative, long-term consequences affecting patient loyalty. In contrast, a positive birthing experience generates favorable word-of-mouth, enhances the likelihood of having future births al the health faciiity, and can increase market share for future (nonobstetrical) health services. Somewhat surprising was that the serviceperformance variables could explain such a high percentage of referral loyalty, yet only a moderate percent of loyalty relating to future obstetric use and the use of other health care services. One reason the service-performance variables were most closely related to referral likelihood is that this measure isn't as likely to be confounded by external influences. On the other hand, the likelihood of using the hospital's obstetrics care or other health care.services in the future might be a function of whether the patient has moved out of the service area, changed insurance carriers, changed health care provider, or obtained or lost insurance coverage. Although we predicted loyalty with relative accuracy in terms of future service usage, we recommend that these measures be phrased so as to overcome these potential confounds (e.g., imply free choice). Conceptually, referral likelihood may be the best measure of loyalty in that providing a referral to others makes referring patients '"accountable" for the obstetrics care that others will receive. Psychologically, this accountability requires a strong level of commitment to the health care provider. Improving Structural Bonds A consistent theme among all of the loyalty measures is that women want to play a role in "structuring" their birthing experience. This decision-making input and control manifested itself with regard to physicians, nurses, and the number of choices available. Failing lo provide women with the ability to make choices can negalively affect the patient-provider relationship and loyalty, which can have long-term financial consequences for the health care provider. Improving Social/Interpersonal Bonds Care Health care is a social experience. As such, the 8 WINTER 999/SPRING 2000

8 trust patients have in their caregivers was shown to have inniienced their loyalty to their health care provider. This trust was based on the patients* confidence that their caregivers are committed to the patient-provider relationship and the caregivers communicating with other caregivers on what's best tor the patient. Al! too often these relationship-building activities are overlooked by care providers. The hectic pace of the health cure environment creates situations where social bonditig and/or communications with patients often are neglected. Even with time constraints, however, making caregivers aware of patients' evaluation of the birthing experience should positively affect their loyalty to the health care provider. The findings show that simple activities such as soliciting questions from patients, being friendly, and showing empathy will affect patient loyalty. In addition, patients need to know that their caregivers are communicating with each other on how to best provide them with care. Facility Issues Finally, the physical environment plays an important role in the evaluation of the birthing experience (though this point seldom is discussed in the literattire). It also has an impact on loyalty. We found two facility issues particularly important: nursery care and noise control. Mothers need to feel confident that the health care facility is providing a safe and well-controlled environment for newboms, and a visit to the nursery facilities is a good place to start. MORE RESEARCH NEEDED This series on the relationship between obstetrics care and patient loyalty has illustrated the need to better understand how patients evaluate the birthing experience and the impact of this evaluation on patient-provider relationships. The findings underscore a number of unanswered questions such as: What are the best measures of patient loyalty? Are there other aspects of the evaluation of the birthing experience that affect loyalty? How does loyalty to specific caregivers differ from loyalty to the health care institution? Because obstetrics care is a major health care experience and an extremely involving process, answers to these questions will further our understanding of patient loyalty. ADDITIONAL READING MacStravic, Scott (994), "'Patient Loyalty to Physicians," Journal of Health Care Marketing, 4,4 (Winter), Marshal], Brenda S. and RajshehkarG. Javalgi (995), 'The Market for Obstetrical Services: An Integrative Approach to Building Relationships," Journal of Services Marketing, 9 (), McAlexander, James H. and Dennis O. Kaldenberg (994), "Service Quality Measurement," Journal of Health Care Marketing, 4 (September), Murray, Ian. Anne Wilcock, and Lisa Kobayshi (996), 'Obstetrical Patient Satisfaction," Journal of Health Care Marketing, 6 (Fall), Peltier. James W., Thomas Boyt, and John A. Scbibrowsky (998), "Measuring Service Quality Across Health Care Encounters: A Relationship Building Approach," Marketing Health Services, 8 (Fall), Turner, Paul D. and Louis G. Pol (995), "Beyond Patient Satisfaction," Journal of Health Care Marketing, 5 (Fall), Zifko-Baliga, Georgette M. and Robert F. Krampf (997), "Managing Perceptions of Hospital Quality," Marketing Health Services, 7 (Spring), AUTHOR INFORMATION James W. Peltier is a professor and the chairman of the department of marketing at the University of Wisconsin, Whitewater. He's also on the editorial review board of Marketing Health Services. John A. Schibrowsky is an associate professor and the chairman of the department of marketing at the University of Nevada, Las Vegas. Thomas Boyt is an assistant professor of marketing at the University of Nevada, Las Vegas. MARKETING HEALTH SERVICES 9

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