Abstract
The purpose of this paper was to conduct an exploratory study of the indicators of patient perceived value (PPV) and their classification in the context of Chinese medical care. The paper starts with a review of previous research on PPV worldwide. Then it builds an indicator system of PPV with 34 indicators in the Chinese medical context followed by extracts from previous studies, expert discussions and a pre-survey. Thirdly, it defines the 29 most important indicators of PPV by targeted depth interviews and questionnaire. Finally, the indicators are divided into three categories by an empirical analysis of the sensitivity of patient perception of different indicators. The 29 indicators were defined to provide an indicator system of PPV in the Chinese medical context, and these indicators could be divided into strong perception factors, medium perception factors, and weak perception factors. Previous studies carried out by researchers outside of China are also applicable in China, but the indicators of PPV show different inherent characteristics and patterns in China’s medical situation. This is an exploratory research in the Chinese medical context. The vast differences of educational levels of the patients led to some misunderstanding of our questionnaire questions. Simpler but more detailed explanation of the indicators should have been provided to achieve a more accurate result. Moreover, some indicators are undetermined indicators. It is for sure that other factors also have impact on this discrete distribution, which calls for more attention and improvement in the future studies. The improvement of the service quality of a hospital is a steady process. The implementation of management strategies can be quite energy and time consuming. Therefore, sufficient attention should be paid to different functions of the different indicators of PPV so as to take more feasible approaches in the management of the hospital. This paper has devised an indicator system of PPV in the Chinese medical context and has categorized the indicators by their functions.
Introduction
Most scholars believe that patient perceived value (PPV) is the patients’ overall assessment of the utility of medical service based on perceptions of what is received and what is given. 1 – 3 ‘What is received’ hereby refers to the overall benefits gained from the medical service whereas ‘what is given’ means the total cost of the medical care. 4 In the actual medical context, patients receive services of professional medical treatment, good medical environment, etc. from the hospital; they also spend time and money and take some risk as well. PPV is the patient’s overall assessment of the hospital made by trading off the acquisition and the costs. Many researchers indicate that PPV has significant and positive effects on patient satisfaction and loyalty.3,6– 8 Only the hospitals who keep offering high-level service can win the persistent satisfaction and loyalty of patients.
Nevertheless, theories about the components of PPV and the classification of indicators are proposed by researchers outside of China and the conclusions of practical research are drawn on the basis of a non-Chinese medical context. Indigenous research on the indicator system of PPV is rarely seen in China. Based on the previous research on PPV and the actual circumstances of the medical environment in China, this paper focuses on the exploratory research into the components of PPV and the classification of indicators in the context of Chinese medical care.
The indicator system of PPV
The study of PPV started approximately in the 1990s. Most of the researchers believe that PPV is a multidimensional concept with three to five dimensions and the differences only appear when talking about details of the constitution of those dimensions.
Cengiz and Kirkbir 1 believe that PPV contains various dimensions, such as functional values (facilities, service quality, price, expertise, etc.), emotional values (originality and control), social values and others. Pan and Chen 9 divide PPV into five dimensions, namely quality, emotion, price, reputation and information acquisition. Moreover, they have conducted two questionnaire investigations respectively. Their first investigation examines the different degrees of PPV in one particular hospital and the second in several hospitals. As concluded in their research, medical quality is the most important dimension of PPV in both investigations and emotion ranks second; patients pay much less attention to the dimension of facility and price. Based on the theory of customer perceived value, O’Connor and Shewchuk 3 constructed a model to describe the patient perception of service quality in the medical environment. This model summarized four dimensions of PPV, namely medical reliability, medical responsiveness, medical indemnification and medical empathy.
In China, similar medical study on PPV began in the early 21st century. These researches mainly concentrated on discussing the initial concepts, without going any further, that is, to the level of PPV.
The indicators of PPV in previous research
The indicator system of PPV in China
Different indicators have different contributions to the overall perceived value. Some indicators play a very important role in patient perception, while others do not. Patients are very sensitive to the changes of the former but not so sensitive to the change of the latter, which can be proposed as the phenomenon of sensitivity of patient perception. As a result of studying the sensitivity of patient perception of different indicators, these indicators are divided into strong perception factors, medium perception factors, and weak perception factors.
Methodology
Based on the above analysis, a questionnaire was designed for an empirical survey of PPV in the Chinese medical context, including both the assessment of the 29 indicators summarized from previous research and the overall value in patient perception from the respondents’ own evaluation. The Likert five-point scale method was employed in the questionnaire. Ten hospitals in the Zhejiang Province of China were chosen for surveying outpatients and inpatients on a random basis.
Sampling and data collection
The following hospitals were surveyed for the data: Taizhou Hospital (including three branch hospitals: Linhai Branch, Luqiao Branch and Jiaojiang Branch); Taizhou First People’s Hospital; Dongyang People’s Hospital; Yiwu Central Hospital; the First People’s Hospital of Zhejiang; the Second People’s Hospital of Zhejiang; Ningbo Branch of the Second Hospital ofZhejiang; Hangzhou First People’s Hospital. Four of these hospitals are Upper First-Class hospitals, another four are Lower First-Class hospitals and the other two are Upper Second-Class hospitals. The sample hospitals are the most typical ones and thus accurately represent the medical context in China. The sample patients are almost equally selected from different departments of those hospitals. The respondents are randomly chosen inpatients and outpatients, with face-to-face questionnaire as the main research method.
The total number of questionnaires delivered was 3070; 2841 of them were valid and the effective recovery rate was 92.54%. Of those valid questionnaires, inpatients account for 52.8% of them and outpatients for 47.2%; 44.8% of patients were male and 55.2% female. It can be argued, on the basis of the descriptive statistics result of patient characteristics, that such a sample represents the actual medical context perfectly in current China.
Data analysis
SPSS18.0 was employed to analyze the collected data via approaches including means analysis, correlation analysis, regression analysis and significance test (p ≤ 0.05). The specific steps are as follows:
In the case of indicator A1, sample patients who marked ‘1’ were screened out, then their ‘overall assessment of the perceived value’ marks, A1 {a1, a2, a3, … . an} was averaged: Steps 1 and 2 were repeated to analyze each factor from A2 to A19 to get B2, B3 … B19. A correlation analysis was made of the obtained data set B1. If the related coefficient was greater than the significance level (p < 0.05) there was a correlation between A1 (the corresponding factor of B1) and the patients’ overall perceived value; otherwise, there was no correlation between them. Linear regression was applied to calculate B1’s regression coefficient, namely B1’s slope. This slope represents the degree to which A1’s evaluation affects the overall assessment. In other words, the extent of the change of influential factors of the perceived value affecting the overall value, which we call the sensitive degree. By repeating steps 4 and 5 and analyzing the data from B2 to B19, the sensitive degrees of A2, A3 … A19 were obtained. If the sensitive degree of the perceived value factor is greater than 0.5, it is labeled as a strong factor; if the sensitive degree is between 0.3 and 0.5, medium factor; less than 0.3, weak factor.
Sensitive degree analysis of doctors’ professional skills
Correlation coefficient
It can be seen from Table 3 that the correlation efficient between doctors’ professional skills and the overall perceived value is 0.992 and the significance level is 0.001, so there is a correlation between the two. That is to say, the patients who gave high marks to the doctors’ professional skills have higher perceived value. The sensitive degree between the two is 0.657, which indicates that doctors’ professionalism is a strong factor.
Results
Ranking of the sensitive degree of the factors
Correlation coefficient r is significant at the 0.05 level.
Correlation coefficient r is significant at the 0.01 level.
The classification of the indicators of PPV
The classification of the indicators of PPV
The popularity and the reputation of hospitals are the two most important factors in measuring their quality, while doctors’ professional level and accurate diagnosis represent the core value of the medical service. Therefore, these factors become the strong indicators of PPV, which accords with the previous research. Strong indicators play a very important role for the overall perceived value of patients. The management strategies of hospitals should focus on the improvement of medical technology and hospital reputation so as to maintain their core competitiveness.
Medium indicators lie between the strong indicators and the weak indicators. Although they are less influential than the strong indicators, there is an evident correlation between changes in them and PPV. With the diversification of patients’ needs, these factors will play a more significant role in the overall perceived value. The impact of the medium indicators should not be ignored. As is well known, medical resources are in short supply currently in China; patients pay too much attention to medical effects and thus neglect the value of some medium indicators. From the viewpoint of hospital management, this phenomenon also makes for a low rate of medical resource utilization. However, with the gradual opening up of the medical market, patients become more and more rational in their options of hospitals. In order to sustain competitiveness, hospital managers should attach importance to these medium indicators.
The crowdedness, easy access to hospital via public transport, actual span of waiting time and the level of hygiene in the hospital have a barely linear relation with PPV and these become weak indicators. According to interviews with patients, some believe that those factors have reduced the perceived value while others think that a crowded hospital with longer waiting times indicates that the hospital is popular and has a good reputation. Those patients tend to have better perceived value with the same factors. Since most patients do not possess much relevant medical knowledge they do not care whether or not doctors abide by the rules. The clarity of hospital bills also has no obvious influence on PPV. In general, patients pay hardly any attention to these two factors.
Most people might assume that treatment effect should be the most important factor in the medical service and that it should be a strong indicator in PPV. However, this research reveals only a weak correlation between the treatment effect and PPV. Based on the talks between the researchers and the patients, it is found that those subject patients are all under the treatment and they do not really have a clear understanding of their treatment effect. Their expectations of the treatment effect also differ greatly from each other. Therefore, the treatment effect has a weak correlation with PPV.
Perceived risks, the service of receptionists and the privacy of the medical environment are the undetermined indicators. Because of the high level of expertise, the requirement of professional knowledge and skills ofthe medical service, and the individual differences of the patients themselves, the same question triggered very different responses among patients. Their individual characteristics, their perception of the severity of the disease, their own expectations of the treatment, the type of disease and the current stage of the disease all exert great influence on the perception of the medical risks and privacy. This can also explain why the answers show a diversified trend. Compared with the doctor and the nurse, the receptionist’s role is only that of a guide. It is possible that the receptionist's services are not recognized by all the patients completely; therefore, the evaluation of the patients about their services shows a discrete distribution. It is certain that other factors also have impact on this discrete distribution, which calls for more attention and improvement in the future studies.
Conclusion
Theoretical and managerial implications
This paper is a preliminary exploration of the components and the classification of the indicators of the PPV in China’s medical context. It examines the applicability of Western research results in China, and also shows the inherent characteristics and pattern of PPV in China’s medical situation. This research is fairly productive. The improvement of the service quality of a hospital is a steady process. The implementation of management strategies can be quite energy and time consuming. Therefore, in an actual reform process, hospitals should adopt different management measures according to different PPVs so as to obtain better results with less investment.
Limitations of study and future research
Of course, the current research is immature and can be improved in some aspects. For example, the design and the explanation of the indicators could be expressed more simply to achieve better understanding among less educated patients. More efforts will be made in the future to deal with these problems and to present simpler, more objective and detailed explanation and classification of PPV, so as to contribute to the research on PPV and to provide decisive criteria for the improvement of hospital management strategies in China.
Footnotes
Funding
This work was supported by the General Program of National Natural Science Foundation of China [grant no. 70872099].
Conflict of interest statement
The authors declare that there is no conflict of interest.
Author's Biographies
Hui Qian is an Associate Professor at Zhejiang University City College, P.R. China, who is also the Dean of Department of Public Administration. He received his PhD in Management from Zhejiang University. His research interests focuses on business strategy, theory of organization evolution and hospital management.
Guobo Li is a Master graduate, who studied at School of Management, Zhejiang University. He is interested in the research of marketing, especially the study of doctor-patient relationship.
Haixiao Chen is the Dean of Taizhou Hospital, which is an Upper First-Class hospital in Zhejiang Province, P.R. China. He has extensive experience in hospital management and doctor-patient relationship research.
Daliang Zhang is a Professor in School of Management, Zhejiang University. He has extensive experience in both qualitative and quantitative with specific areas of expertise including theory and research in customer value and customer innovation; business model innovation; doctor-patient relationship and knowledge transfer; hospital management.