Identification of Success Factors for Indian Healthcare

This Paper aims at evaluation of Critical Success Factors (CSF) and its attributes in Indian healthcare. Various problems of health care industry through analysis of factors and its attributes using factor analysis, correlation and other framework parameters has been done. It was found that Human Resource Capability, Infrastructural Resources were the most significant CSFs apart from Operational process, Team management and culture. Surprisingly findings revealed that factors namely Top Management and Leadership were least significant. As there is no clear framework for excellence in healthcare, where stakeholders are an integral part of complete service, developed CSF and its connectivity to attributes may help to resolve the service level issues of Indian Hospital.


INTRODUCTION
Healthcare is necessity irrespective of demography, culture, income, age and gender. India is second largest populous country with a population of 1.27 billion and growing at 1.25 percent spends about 4-5 percent of its GDP on healthcare (world bank). Expectation of people are increasing day by day forcing the healthcare service provider to address internal and external expectation of stakeholders. However, lack of understanding of the factors responsible for excellence and dearth of patient has created an ambiguous scenario in healthcare system. Reasons can be attributed to growing population, lack of infrastructure, paucity of trained work force, changing disease profile, inefficient expenditure and inaccessibility of healthcare. Indian healthcare establishments have poor operational strategies, waste management and disposal policy. This compels hospital managers to take appropriate decisions to improve the integration of information systems by referring to technological, environmental and organizational dimension. (Hung et al., 2015).
It is essential that the organizational culture should encourage and supportteamwork and cross-functional evaluation of performance to help employee and organization (Chow-Chua and Goh, 2002).
The expectations of the stakeholders have constrained the service provider to address competitive trends and service related issues like treatment time, cost effectiveness, cleanliness, hygiene, patient care and comfort, privacy issues and infrastructure. In the health care industry, almost all the hospitals usually provide the same type of services, but mainly differ in quality of services (Cheng and Tang, 2000). The study emphasizes on various issues in all those major areas in which the hospitals deal by exploring the major factors like Top Management and Leadership commitment, Team Management and culture of the organization, Operational and clinical process management, Human resource capability of the organization, and infrastructural resources available.

LITERATURE REVIEW
Scenario has changed from merely treatment in hospital to quality treatment as service expectation and technological advancement has changed the expectation of patient and their family. Padma et al. (2014) has put basic factor, which lead to patient dissatisfaction if not fulfilled, but do not lead to satisfaction if fulfilled. One-dimensional factor cause satisfaction if their presence is high and lead to dissatisfaction if performance is low, which is directly connected to patients need and want. Excitement factors lead to patient satisfaction, which do not lead to dissatisfaction if absent. Indifferent factors neither cause satisfaction when provided nor dissatisfaction when missing. Koumaditis et al. (2013) has held leadership responsible for organizational and infrastructural facility. Rateb et al. (2016) has listed top management commitment with highest score amongst training and education, continuous improvement and teamwork. Hariharan et al. (2004) has put patient care through better medical, nursing and paramedical in service using cross-functional approach. Drotz et al. (2014) has suggested support from Leadership in decision making through decentralization of authority, sharing of power, and active participation. Goh et al. (2013) has put safety of patient as the teamwork culture of the organization. Mosadeghrad (2013) has highlighted 50 % of the variation takes place due to incoherent culture and compatibility. Talib et al. (2011) emphasized on first impression formed at the very first service rendered that include effective food management, hygienic food and environment, confidence, treatment cost, patient focus, complaint resolution etc. Garg et al. (2014) suggests it is important for healthcare organizations to manage their staff retention in order to prevent intellectual lost and additional training cost for new employees. Sabry (2014) has found training has the highest significant correlation with quality of the service not the infrastructure as it is presumed to be an existing facility. Whereas, Dutta et al. (2014) has emphasized on physical infrastructure such as bed, equipment, tackling emergency services. Talib et al. (2015) has put India's healthcare sector needs to scale up considerably in terms of the availability and quality of its physical infrastructure as well as human resources so as to meet the growing demand and to compare favorably with international standards.

THE RESEARCH PROCESS
Measuring instrument was developed for Indian hospital -Patients, Doctors, Nursing staff, Support staff, and Management were the prime focus of study. The Service Quality practices adopted by the hospital, Doctors, Support staff and perceived by the patients and their family were studied. The gap between perceived and expected service quality was analyzed. To develop an instrument for measurement -hospitals with minimum 50 beds were taken into consideration. The Doctors, Nurse, Paramedical staff, Support staff, Management and Patients were interviewed personally from Mumbai, Bhopal, Delhi, Patna, Lucknow, Darbhanga and Kolkata along with other stakeholders were explained the necessity of this study. Expectations of patients discharged from hospital and their concerns and experiences recorded. The strong and weak factor relation model proposed by Shrivastava (2006) was taken into consideration.
The purpose of this research was to correlate the Service Quality Critical factors. This correlation was checked after the constructs were found reliable and valid. Twenty-nine healthcare attribute requirements for effective Service Quality practices and five constructs from forty-three hospitals were generated.

Identification of Success Factors for Indian Healthcare
Operational Process business need defined by customer, focus may be only on a particular laboratory or facility, effective and, hygienic food and environment management; confidence, treatment cost, patient focus, complaint resolution; value for the money spent, people, process, policy and technology to meet expectation, increased service level, customer retention and claim redressal system, focusing on managing process and not just the technical medical practice factors, waste in the process and impact on customer, waiting for a procedure, waiting for paper work, transporting of goods without purpose, unwanted movement of employee, processing unwanted steps, unwanted test;

Human
Resource Capability fundamental tools and techniques, quality initiative and involvement mandatory for promotion consideration, willingness to change, work in multidisciplinary environment, increases sense of job security, staff retention to prevent intellectual lost and additional training cost, certification as well as implementation, significant correlation with quality of the service, positive group culture and participation, multifunctional staff, autonomy and responsibility, time flexibility, cross trainingbetter process improvement and control, creativity and innovations -performance and rewards,

Infrastructural Resources
Cross-functional team, leadership behavior in staff, sustainable systems for continuous quality improvement, physical infrastructure such as bed, equipment, tackling emergency services; technological resources to overcome the problems; sports and recreation facilities, green/ecofriendly campus, bank facility in the campus, hygiene and maintenance, residential campus, cooperative store facility, adequate space provision, safety indicator gap, communication system, medical records management, engineering, accident and emergency, supply chain management, collaboration and teamwork to focus on safety, quality of physical infrastructure, maintain equipment to standard Categorization process resulted in an instrument strongly grounded through literature. The twenty-nine requirements were termed as independent variables as an effort factor for service quality. Flow chart for this research model is presented in Figure 1. The independent variables are ``service quality improvement approaches'' and ``productivity improvement approaches''. The independent variables such as Adequate test and diagnostic facility, Safety and comfort measures, Competent, Trained and experienced team, Patient focused and customer driven, Progress monitoring, Fair & transparent Appraisal system, Maintaining of patient privacy and confidentiality, Credibility of service administration, Visible safety rules & regulations are some of the outcome derived from those independent variables. All the attributes with their CSFs are presented in Table 5.
Factor analysis was carried out to check the content reliability and validity as given in Table 1 and Table 2 and communalities of attributes and its correlation is given in table 3 and table 4. Internal consistency of variable data was estimated using reliability coefficient such as Cronbach's alpha. Nunnally (1978) suggested that a Cronbach's alpha value ≥ 0.7 suggests good internal consistency. The overall Cronbach's alpha for independent variable was found to be 0.864, which indicated that the developed instrument was reliable. The KMO represents sample adequacy for factor analysis having eigen value ≥ 1; was found to be 0.690 to 0.754, which is above the minimum standard of ≥ 0.5 supporting the appropriateness of factor analysis to explore the listed attributes. The Bartlett's test of sphericity was highly significant (p < 0.000) significance value of Bartlett's test is 0.000, rejecting the null hypothesis that the important twenty-four attributes are uncorrelated in the population. This indicates sufficient number of samples for factor analysis (Kim and Mueller, 1978).

ANALYSIS AND RESULTS
This explains the total Variance. Component 1 accounted for 31.031 percent of the total 100 percent of 29 critical items taken simultaneously. Similarly component 3 and component 5 contributed to 6.35 and 3.09 percent of 100%. The authors had taken 5 factors which constituted 77.69 percent of the total hundred percent cumulatively. This was done on the basis of literature review and acceptance of Scree plot for such type of study. Scree plot suggested that those components which cumulatively constitute 50 percent of the total can be taken as the remaining other components do not have significant contribution towards the study and may be discarded. However, the authors chose to go up to 80 % representation of the components which included 24 items out of 29 items under consideration.

EMERGENT IMPLICATIONS
This study is found to be important to Hospital Administrator and Management, and Operational Process Team. All the learning outcomes of the study is focused on the Measures of Organizational effort towards excellence.

Hospital Administrator and Management -
Top and Middle Hospital Administrator should show their commitment towards Service Quality practices and take decisions judiciously for motivating other associated staff by encouraging them to participate in Service Quality initiative. They need to integrate Service Quality improvement practices into all business functions within the Hospital.

Operation (Doctors, Nurse, Paramedics) -
The practitioners need to demark the level of improving the service quality in their areas to fulfil the service gaps and improve upon those dimensions that contributes to service quality management. The Operation team should understand and realize market segments, customer preferences, customer needs and develop resembling solutions to bring flexibility in service delivery process. They need to measure service processes performance in physical terms (time, cost, profits) and identify components and processes that contribute to variations. Variations are inevitable but be reduced, minimized, or removed through teamwork and culture along with the desired training.

CONCLUSION
Policy and decision makers in any hospital assess the status of Service Quality level made available. This paper will allow the to understand responsible factors and factors that are critical to excellence for all stakeholders of healthcare. Stakeholders, both internal and external is integrated for excellence by incorporating Top Management, Human resource capability, Infrastructure, Operational process and Culture of the healthcare organization.
In this analysis, 382 valid responses were taken into consideration after analyzing the survey data of 587 respondent. To corroborate the results for further improvement and to increase the customer base -hospital need to do a great deal of further research in service areas by increasing the sample size of respondents. The authors hope that this paper will help healthcare service provider to integrate critical factors for excellence in service and quality.