Determining medical service improvement priority by integrating the refined Kano model, Quality function deployment and Fuzzy integrals

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1 Afrcan Journal of Busness Management Vol. 4(12), pp , 18 September, 2010 Avalable onlne at ISSN Academc Journals Full Length Research Paper Determnng medcal servce mprovement prorty by ntegratng the refned Kano model, Qualty functon deployment and Fuzzy ntegrals Tsu-Mng Yeh Department of Industral Engneerng and Technology Management, Dayeh Unversty, Tawan, R.O.C. E-mal: Accepted 20 August, 2010 In recent years, owng to the rse n consumers conscousness wth regard to health care qualty, hosptals are constructvely probng nto the factors affectng patents satsfacton. Ths s to enable them dentfy techncal tems of medcal servces and to see t as a prorty to utlze these tems. Usng qualty functon deployment (QFD) wth the Refned Kano model, ths study ams to prortze above all the use of varous medcal servce techncal tems as an mprovement drected towards hosptals compettveness. Wth the outpatent servces of a hosptal as the emprcal case study, ths study frst collected the servce requrements of the patents and classfed them usng the Refned Kano model to decde the weghts of each patent s servce requrements, then found out the dfferent medcal servce techncal tems whch the hosptal provded to satsfy the servce requrements, and utlzed the Fuzzy Integral approach to calculate the mprovement ndex of each medcal servce techncal tem n order to determne the prorty of mprovement. Wth the Refned Kano model analyss t s found that there are three hgh value-added qualtes, seven crtcal qualtes, fve necessary qualtes, another fve hghly attractve qualtes, four less attractve qualtes, and two care-free qualtes. Further analyss of the QFD proposed the prmary medcal servce techncal tems as staff tranng, faclty safety, hosptal locaton, cordal servce, equpment mantenance, and advanced medcal equpment. Ths study presents a smple and feasble approach for hosptals to confrm the servce demands of patents, to determne the mprovement sequence correspondng wth patents demands under lmted resources, focus on the most attractve demands and the prorty tems for mprovement, n order to enhance compettveness n an effcent and effectve way. Key words: Medcal servce qualty, refned Kano model, qualty functon deployment, Fuzzy ntegral. INTRODUCTION Both servce and manufacturng ndustres place hgh mportance on qualty, whch can affect customers satsfacton and thus the wllngness to make a purchase (Olver, 1980). Qualty s a key determnant of consumers satsfacton (Gremler et al., 2001; Omar and Schffman, 1995; Radwn, 2000), and t has also been recognzed as a strategc tool for attanng operatonal effcency and mprovng busness performance (Jan and Gupta, 2004). Although the medcal ndustry s dfferent from general servce ndustres, the hgh servce qualty s stll a key success factor. In addton, scholars have ndcated that patents and ther famly members should be consdered as consumers for medcal servce provders (Mlakovch, 1995). It s also mportant to manage consumers perceptons of medcal servce qualty, as hgher apprasals are closely related to satsfacton, and wll thus nfluence the ntenton to use a servce agan n the future, a fact that s ultmately reflected n the fnancal performance of medcal organzatons (De Man et al., 2002). As a consequence, promotng medcal servce qualty to satsfy patents demands s a prmary am for hosptals that seek to be more successful. In the past, patents went to hosptals smply for medcal treatment, so that such nsttutons emphaszed ther

2 Yeh 2535 professonal medcal technques. Nevertheless, wth the enhancement of lvng standards and ncrease n the publc general medcal knowledge and demands, patents pay more attenton to ther health and expect hgher qualty medcal servces, and ther assessments of qualty of hosptals are no longer lmted to medcal technques. Lenonen et al. (2001) ndcate that servce qualty, from the patents vewpont, requres that medcal staff express respect, empathy, and concern, as well as more tradtonal tems, such as professonal sklls and servce atttude. In addton, patents wll trust and rely on a hosptal more once they experence satsfactory medcal servce, and wll contnue to go to t for future medcal treatments. Nonetheless, certan dfferences exst n the cognton of medcal servce qualty held by hosptals and patents (Arasl et al., 2008). It s thus necessary to develop a systematc approach to fnd out the real requrement of patents, as ths lead to greater customer s satsfacton and ultmately make the hosptal more successful (Fu and Chang, 2002). Identfyng patents opnons s crtcal for the evaluaton of medcal servce systems (Polluste et al., 2000). Ths study thus ams at understandng patents requrement and classfyng these nto dfferent types of qualty based on the Refned Kano model. Patents opnons can serve as references for the enhancement of medcal servce qualty and the general mprovement of hosptals. Prevous studes examned tems for mprovement ndependently. Ths study combnes QFD and the Fuzzy Integral approach to calculate the weghts of techncal tems of medcal servce whch hosptals provde to meet patents demands, n order to sequence the mprovements and propose specfc drectons for such actons. LITERATURE REVIEW Medcal servce qualty In the relevant lterature, medcal servce qualty smply focused on the professonal technques of doctors and nurses. However, the concept of medcal servce qualty has gradually evolved to nclude the vews of patents. Shh (1978) regards medcal servce qualty as contanng the perceved qualty of medcal servce technques and the perceved qualty of medcal servce management. Qualty of technques ncludes the qualty of dagnoses and treatments. The qualty of management refers to the qualty of communcaton and dscusson between doctors/nurses and patents, and patents cooperaton. Hyde (1986) ndcated that medcal servce qualty ncludes understandng and satsfyng patents demands, relablty, zero defect servce, approprate envronmental packagng, clear and defnte nstructon manuals, goodeffcency performance, punctualty, and effectve servce feedback. Fsher (1990) evaluated and dvded medcal servce qualty attrbutes nto three tems: (1) a sold envronment, ncludng the evaluaton of outpatent watng rooms, seats, stores, and lounges, as well as patents satsfacton wth watng and doctors dagnoss tme; (2) atttude to medcal servce, ncludng whether or not patents were able to see the same doctor, wllngness to see a dfferent doctor, beng treated by nterns, beng able to communcate the dsease condton wth doctors, atttude of medcal personnel, and f doctors were careless; and (3) general atttude of doctors, ncludng doctors beng wllng to spend tme n understandng patents dsease condton and explanng t to them, and whether patents trust doctors professonal abltes. In addton, Bowers et al. (1994) consdered fve factors whch patents use to evaluate medcal servce qualty, as follows: empathy, relablty, reacton, communcaton, and concern. In studes of medcal servce qualty, Chang (2006) found that medcal personnel were more concerned wth ther professonal abltes, whle patents emphaszed more dsplays of concern and good nterpersonal nteracton. Westaway et al. (2003) also dscovered that patents consdered nterpersonal nteracton as very mportant, ncludng medcal personnel beng able to lsten to, encourage, assst and support patents, and treatng them n consderate and frendly ways, as well as stressng the mportance of the facltes and equpment n hosptals such as the tolets n watng areas, general cleanlness, and seats n lounges. Shoshanna et al. (2005) reported that patents emphaszed the communcaton wth medcal personnel, and specfcally the medcal staff beng able to react to ther demands, as well as the cleanlness of wards and bathrooms n hosptals. Rao et al. (2006) presented the prorty of patents demands as the doctor s behavor and atttude, the effectveness of medcne, the medcal personnel s behavor, and the supply of medcal nformaton. Accordng to the prevous studes outlned above, medcal servce qualty can be evaluated from three aspects, as follows: professonal medcal technques, staff atttudes, and the envronment. In addton, patents pay more attenton to the feelngs that arse n the servce process, as well as to the provson and condton of medcal facltes and equpment. Consequently, hosptals cannot merely focus on medcal technques, but must also take servce qualty and medcal equpment and facltes nto consderaton, so that they can mprove patents satsfacton. Kano model and refned Kano model Kano Model, presented by Kano et al. (1984), presumes that satsfacton does not necessarly occur when all the relevant qualtes are possessed, and that s possble for customers to experence dssatsfacton or no feelng at all. The Kano Model, ntally appled n product development n the manufacturng ndustry, classfes qualty nto fve

3 2536 Afr. J. Bus. Manage. attrbutes, as follows: (1) attractve qualty attrbutes, whch customers are satsfed wth f present, but not dssatsfed f absent; (2) one-dmensonal qualty attrbutes, whch are postvely and lnearly related to customers satsfacton that s, the greater the degree of fulfllment of the attrbute, the greater the degree of customers satsfacton; (3) must-be qualty attrbutes, whch absence wll result n customers dssatsfacton, but presence does not sgnfcantly contrbute to customers satsfacton; (4) ndfferent qualty attrbutes, the presence or absence of whch results n nether satsfacton or dssatsfacton; (5) reverse qualty attrbutes, whch presence causes customers dssatsfacton, and whose absence results n customers satsfacton. In Kano Model, the horzontal coordnate represents the degree to whch the qualty attrbute s suffcently fulflled. The more t approaches the left, where the qualty attrbute becomes nsuffcent, the hgher the degree of defcency s; whle the more t approaches the rght, the hgher the degree of fulfllment s. The vertcal axs ndcates the satsfacton that customers feel wth regard to the qualty attrbutes. The hgher t s, the more satsfacton shown; whle the lower t s, the more dssatsfacton shown. Based on Kano Model, Yang (2005) developed the Refned Kano Model, as shown n Fgure 1, categorzng qualty nto eght elements, as follows: 1. attractve qualtes, ncludng hghly attractve qualtes whch are the best tool to achevng greater market compettveness, and low attractve qualtes, whch have less ablty to attract customers, so that frms can decde on the mportance of provdng them based on the cost; 2. one-dmensonal qualtes, ncludng hgh value-added qualtes, whch make a hgh contrbuton to customers satsfacton, and whch promote the overall servce qualty, so that frms should provde as many tems wth these attrbutes as possble, and low value-added qualtes whch cannot be gnored by frms, because of ther contrbuton beng less amng to prevent customers dssatsfacton caused by nsuffcent servce standard; 3. must-be qualtes, ncludng crtcal qualtes whose related tems should be suffcently provded because of ther mportance to customers, and necessary qualtes that frms should provde to a certan servce standard to prevent customers from beng dssatsfed; and 4. ndfferent qualtes, ncludng potental qualtes whose tems can become strategc weapons for frms to attract customers, and care-free qualtes, whch are not taken nto account n cost consderatons, n order to effectvely deal wth lmted resources. Prevous scholars appled Kano Model to varous servce contexts, lke banks, laundres, supermarkets, restaurants, toursm and so on (Schvaneveldt et al., 1991; Sa Moura and Sarava, 2001). Ths study wll examne hosptal servce qualty usng a questonnare survey and Kano Model, adoptng majorty decsons to classfy attrbutes and to gather patents perceptons as to whether or not attrbutes are fulflled as references for the servce qualty mprovement n hosptals. In case the mportance of qualty tems and the characterstcs of attrbute classfcaton are not effectvely sequenced as tems for mprovement, the Refned Kano Model (Fgure 1), presented by Yang (2005), s appled to modfy the mportance rankng and qualty tem classfcaton. Qualty functon deployment, QFD Qualty Functon Deployment (QFD) s a systematc approach that ntegrates customers s voce nto the product development process, and Bossert (1991) consdered that t can transform patents requrements nto technque to meet customers expectaton. Chen and Weng (2006) approved the use of QFD to acheve hgh customers satsfacton, through the stages of product plannng, engneerng, and manufacturng, thus transformng customer s voce nto the fnal product. A qualty house, as the basc tool of QFD proposed by Bossert n 1991, and shown n Fgure 2, prmarly ncludes: 1. Customers expectatons, whch are also called customers thoughts, demand attrbutes, or the voce of customers (VOC), whch are placed on the left sde of the qualty house and are manly used to descrbe customers demands and expectatons; 2. Techncal specfcatons, also called the voce of engneerng (VOE), located n the celng of the qualty house, and ths s the strateges or techncal servces drawn up by relevant departments n the enterprse wth mutual coordnaton and communcaton; 3.The relatonshp between customers wants and techncal specfcatons, whch s the body of the qualty house, s used to llustrate the degree of the relatonshps among customers demands and engneerng technology; 4. Compettve analyss as done by customers, whch s n the rght sde of qualty house, and s manly used to calculate the weghts of customers demands through customers emphass degree, and marketng key wth regard to each demand tem, so as to understand the prorty of customer demands; 5. The correlaton between techncal specfcatons, whch s located n the roof of the qualty house, s manly used to explan the relatonshp between varous engneerng technologes; 6.Techncal specfcaton prortes, at the bottom of the qualty house, fnds the prmary demand tems for mprovement, after calculatng and sequencng the mportance of customers expectatons, and can be regarded as a tool to decde on the ntroducton of technques and the allocaton of resources. In recent years, QFD has been wdely appled n many studes, such as Costa et al. (2000) appled t to food ndustry to fnd the advantages and dsadvantages of mprovng ketchup, ultmately mprovng the latter. Gonzalez et al. (2004) focused on the mportance of bank servce qualty and customers satsfacton whle explorng nternal and external management and applyng QFD to the development of nnovatve servces. Dkmen et al.

4 Yeh 2537 Satsfacton less attractve hgh value-added hghly Unfulfllment low value-added Fulfllment necessary crtcal Dssatsfacton Fgure 1. The Refned Kano model. Fgure 2. Qualty house model. (2005) appled QFD n the constructon ndustry and took the tems that customers stated they really needed nto the consderaton of housng desgn, so as to reduce the waste of resources on nvald tems as well as to rase customers satsfacton. Fnally, Utne (2008) utlzed QFD n a study on mprovng the catch of fsh n Norway. The current study ntends to wegh the prorty sequence of mprovement tems through usng a questonnare survey

5 2538 Afr. J. Bus. Manage. n hosptals, combned wth QFD to develop practcal suggestons to mprove patents satsfacton. Fuzzy ntegral The Fuzzy ntegral approach can be used n a comprehensve evaluaton approach wthout presumng the ndependence of evaluaton tems (Lee et al., 2000), and can be appled to assess the relatonshps among tems to deal wth evaluaton problems wth subjectve values. Before proceedng wth the use of the Fuzzy Integral approach, approprate Fuzzy measure needs to be selected to understand the relaton among varous evaluaton tems. Ish and Sugeno (1985) and Asa (1995) consdered Fuzzy measure as an approach wth nonaddtonal evaluaton, as t transforms the general bass probablty theory of weghng tasks nto probablty theory, and then takes the relaton of evaluaton tems nto account. Sugeno (1974) presented the Fuzzy measure to state the degree of the parameter beng a measure lmted by as the weght value of evaluaton tems. Prevous scholars have appled the Fuzzy Integral approach to varous felds of studes. Chou and Tzeng (2002) used t to defne Fuzzy measures and evaluate the green engneerng strategy of fshery product processng ndustry development usng the non-addtonal Fuzzy Integral approach. Chen et al. (2002) examned the relaton between publc opnon and governmental polces wth Fuzzy measures and the Fuzzy Integral approach and took the polcy of Tape Cty Government wth regard to gas-powered taxs as topc for emprcal research. Bosc et al. (2003) blurred SQLf wth the Sugeno Fuzzy Integral approach combned wth the SQL database. Patrca et al. (2007) predcted the tme array sequence of consumptve tomato prce n Amercan market by combnng a mmc neural network and Sugeno Fuzzy Integrals. Yan et al. (2009) appled a combnaton of the Fuzzy Integral approach wth Innovatve Product Concept Strategy Technology n the study of moble phone desgns. Snce subjectve opnons are collected, the questonnare survey used n ths study, the acqured prorty sequence and weghts combned wth QFD can not be reflected n qualty tems accurately. Accordng to the above studes, the Fuzzy Integral method can elmnate the weaknesses of the Lnear Model Theory and match the sprt of ndependent ponts to acqure more accurate values for the mportance of qualty attrbutes n Fuzzy Theory. Ths study, therefore, wll proceed wth the evaluaton usng the Fuzzy Integral approach and calculate the mportance of medcal servce technques wth the Fuzzy measure. RESEARCH METHODOLOGY Research model Ths study uses a qualty house n QFD as the analyss model and Fgure 3. Research model. ntervews medcal experts about the research topc n order to modfy the orgnal tems n the qualty house nto patent servce demands, medcal servce technques, a relaton matrx of patent servce demands and medcal servce techncal tems, and the mportance of medcal servce technques (mprovement sequence) for subsequent analyss. Ths study frst classfes patent servce demands wth the Kano Model and determnes ther weght based on customers value, then nvtes experts to analyze the relatonshp between patent servce demands and medcal servce technques, and fnally calculates the sequence of medcal servce technques by ntroducng the Fuzzy Integral approach nto the qualty house calculaton. The research model s shown n Fgure 3. Samples and questonnare desgn Patent servce demands n ths study are adapted from the medcal servce qualty demand aspects desgned by Carey and Sebert (1993); they nclude envronment and equpment, comfort and cleanlness, staff servce atttude, medcal care, complants, and servce results. Based on the sx aspects wth the questonnare desgn prncple n the Kano Model and adoptng a Lkert fve-pont scale, ths study desgns postve and negatve atttude questons to understand the respondents reactons when some qualty attrbute s fulflled or not. In order to clarfy for patents the meanngs contaned n the Kano Model, ths study modfes the classfcatons of Matzler and

6 Yeh 2539 Table 1. Two-dmensonal qualty attrbute classfcaton table. Negatve Very satsfed Postve Satsfed Far Dssatsfed Very dssatsfed Very satsfed Invald apprasal Attractve qualty Attractve qualty Attractve qualty One-dmensonal qualty Satsfed Reverse qualty Indfferent qualty Indfferent qualty Indfferent qualty Must-be qualty Far Reverse qualty Indfferent qualty Indfferent qualty Indfferent qualty Must-be qualty Dssatsfed Reverse qualty Indfferent qualty Indfferent qualty Indfferent qualty Must-be qualty Very dssatsfed Reverse qualty Reverse qualty Reverse qualty Reverse qualty Invald apprasal Hnterhuber s (1998) two-dmensonal qualty attrbutes nto fve levels, as follows: very satsfed, satsfed, far, dssatsfed, and very dssatsfed (Table 1). Importance s dvded nto very unmportant, unmportant, far, mportant, and very mportant, scores of 1 to 5. Satsfacton s dvded nto: very dssatsfed, dssatsfed, far, satsfed, and very satsfed, also wth scores of 1 to 5, respectvely. Demographc data gathered n the questonnare ncluded sex, educaton, occupaton, monthly salary, and dvson. The questonnare subjects were the outpatents n a regonal teachng hosptal; a total of 150 questonnares were dstrbuted, and 137 vald responses were returned, gvng a total response rate of 91.33%. Qualty house model Havng understood patents satsfacton and mportance ratngs wth regard to medcal servces, the mprovements and the mprovement sequence of medcal servce technques are obtaned by usng a qualty house wth the followng procedures. Step 1: Defne patent demands for medcal servces. Located n the left sde of qualty house, patent demand tems, whch patents consder more mportant, are found through the ntroducton of the requred qualty tems nto QFD. Step 2: Decde the weghts of the qualty attrbutes that patents demand. Wth the mportance and satsfacton of patents wth regard to each servce demand thus obtaned, the followng qualty characterstc sequence s transformed nto standardzed weghts as the weghts of the demand tems. 1. Data transformaton between mportance and satsfacton. Usng the results of the calculated questonnare data, transform t nto dvsons based on zero. Frst deduct three from the mportance and satsfacton value as the new evaluaton standard value, and then sequence the data. The data range of mportance and satsfacton s transformed from the prevous dvson (1 to 5) nto the dvson (-2 to 2). 2. Satsfacton and dfference ndex: Wth the prevous transformed mportance and satsfacton values, calculate the satsfacton and dfference ndex of patents requrement tems. The satsfactory atttude s the product of patent s mportance multpled by satsfacton after beng transformed, whle the dfference ndex represents the dfferences between the patents mportance and satsfacton sequences. The satsfactory atttude actually means the weghted sum of satsfacton; and dfference ndex s the dfference between the actual performance of hosptal servce qualty characterstcs and the qualty standard requred by patents. Wth the evaluaton of the ndex, the prorty sequence of patents requrements can be determned, and ths can assst n the plannng of servce mprovement. The qualty characterstcs sequence evaluaton whch determnes the prorty sequence of patent requrements s based on the followng two crtera. (1) When the dfference between dfferent knds of qualty, partcularly n negatve values, becomes smaller, these qualtes need pror mprovement. (2) If the dfference ndexes of qualty varetes equal each other, the one wth smaller satsfactory atttude, especally wth a negatve value, s the prorty mprovement object. The smaller the last dfference ndex s, the earler t becomes the ntal prorty, and further through the reverse sequence of ntal prorty becomes the ntal weght. The standardzed weght (SD) s therefore obtaned by summng up the ntal weght dvded by the ntal prorty. Step 3: Develop techncal specfcatons for medcal servces, whch are also called the servce elements n ths study. Located n the celng of the qualty house, and based on dscussons wth hosptal experts, fve medcal servce technologes are classfed as follows: overall envronment, hardware equpment, medcal servce, percepton attrbute, and admnstraton, from whch twenty medcal servce technque tems are desgned. Step 4: Develop the assocaton matrx of patent demand tems and medcal servce elements. Havng ntervewed and evaluated wth hosptal experts, the assocaton degrees are quantfed as nne hgh relaton ponts ( ), three medum relaton ponts (), or one low relaton pont ( ). The relatonshp degree between medcal servce technques and patent servce requrements s flled n by experts. Step 5: Calculate and determne the mprovement prorty. Wth the advantage of conformng to human Fuzzy judgments, the Fuzzy Integral approach s adopted to wegh the medcal servce technques n ths study. Wth regard to the calculaton and procedures, and usng the standardzed weght obtaned n step 2, the calculaton of medcal servce technque mportance through the Fuzzy Integral approach s as follows. (1) All relaton degrees of the requred qualtes and medcal servce technques are sequenced. (2) All relaton degrees of the requred qualtes and medcal servce technques are transformed nto [0,1] values, where x stands for the relaton strength of the relatve matrx. Relaton strength s dvded nto nne hgh relaton, three medum relaton, and one low relaton pont. Snce the hghest relaton degree s 9, t can be made h ( x ) = x 9. (3) Through standardzed weghts (SD) n the prorty sequence, all qualty requrements are transformed nto [0,1] values, as SDx10 as g makes the tems easer to compare. (4) Accordng to the Fuzzy Integral approach, λ = s obtaned. (5) Substtute λ, g and g λ ( H 1 ) for [ ] h and ( ) g λ ( H ) = g + g λ ( h ) + λ ( g ) g λ ( H 1 ) to get g λ ( H ) (6) Pck the smallest values of ( ) demand qualty tem. x g λ H from each

7 2540 Afr. J. Bus. Manage. (7) Fnd out medcal servce techncal tem from the bggest value of h( x ) g λ ( H ) as the relaton weght of the medcal servce techncal aspect. Get the weght of each medcal servce technque wth the Fuzzy Integral approach and the mportant weght number. The bgger the weght number s, the more prorty t has, and ths nformaton can be used by managers when plannng mprovements n hosptal servce qualty. DATA ANALYSIS Samplng and sample structure To nvestgate patent s expectatons and requrement wth regard to medcal servce qualty and ther correspondng weghts, the requrement tems were adopted from Carey and Sebert (1993). Accordng to respondents answers for satsfacton and the perceved mportance of servce requrements, the requrements can be classfed nto sx categores: attractve, reverse, ndfferent, nvald, one-dmensonal or must-be, based on the Kano Qualty Model. We can also classfy the servce demand nto crtcal, care-free, hghly attractve, low attractve, necessary or hgh-value added groups based on the Refned Kano Model. A statstcal analyss of basc statements shows that 74(54%) of the respondents were males, whle there were 63(46%) females of the respondents. 43 of the respondents were aged between 21 to 30 (31.4%), and 38 of respondents aged between 31 to 40 (27.7%). 52 of the respondents only had senor hgh school educaton (38%), whle the next degree s college educaton (29.9%). There were 72 respondents marred (52.6%), and 65 sngle ones (47.4%). 118 of the respondents had a monthly salary of sxty thousand NTD or below (86%), and 19 (14%) more than ths. 19 (14%) respondents were surgcal outpatents, wth 16 each beng ophthalmology and rehabltaton outpatents (11.7% each). Relablty and valdty analyses Relablty, related to the accuracy and precson of a measurng tool, ndcates the concdence and stablty of fndngs. Ths study adopts the coeffcent value presented by Cueford (1965) to stand for relablty, wth a Cronbach s value of 0.7 or above representng hgh relablty. The results show that the relablty of the overall Kano qualty attrbutes s 0.924, and non-possessed 0.926, and the relablty of overall mportance and overall satsfacton are and 0.923, respectvely, showng that ths research has hgh relablty. Valdty assesses whether the questonnare examnes what t s ntended to. When q questonnare s based on theory and refers to questonnare tems used n smlar studes, t s consdered as havng acceptable content valdty. In ths case, ths study refers to the questonnare dmensons desgned by Carey and Sebert (1993) amed at examnng the medcal servce qualty dmensons, wth some approprate changes made before the questonnares were dstrbuted. These were based on focus groups, ntervews and evaluatons by fve hosptal experts who are n charge of daly hosptal operatons. The valdty of ths questonnare should therefore be above the necessary standard. Analyss of Kano model The questonnares collected n ths study were categorzed wth data codes representng the 26 topcs n Kano Model for the dfferent servce qualtes to obtan the classfed attrbute analyss. Wthn the 26 qualty tems n ths study, nne are attractve qualtes, 12 must-be qualtes, three one-dmensonal qualtes and two ndfferent qualtes, as shown n Table 2. (1) Attractve qualtes, whch patents are satsfed wth when hosptals provde the servce, but ther satsfacton s not affected f not provded, contan nne servce qualty attrbutes whch are as follows: Clear drectons for each department n a hosptal, Hosptal provdes computerzed servce, Hosptal provdes obstacle-free facltes, Empathetc servce atttude of nursng staff, Empathetc servce atttude of hosptal volunteers, Doctors can explan the dsease and ts treatment n detal, Hosptal provdes a complete complant channel, Hosptal provdes detaled nformaton about hygene educaton, and Sde effects do not occur when patents take medcne ; (2) Must-be qualtes, whch patents consder as natural and rght when the hosptal provdes the servce, but are dssatsfed f not provded, nclude 12 servce qualty attrbutes, as follows: Hosptal provdes perfect medcal equpment, Hosptal provdes perfect escape equpment, Good hosptal santaton, Hosptal washrooms properly cleaned, Approprate temperature from ar condtonng system, Empathetc servce atttude of hosptal admnstrators, Nursng staff are concerned wth and lsten to patents demands, Skllful technques of nursng staff, Nursng staff can handle and react to emergences, Patents recover after treatment, Convenent hosptal parkng, and Hosptal can quckly make mprovements based on patents suggestons. (3) One-dmensonal qualtes, for whch customers are satsfed when the hosptal provdes the servce whle dssatsfed f not provded, contan three servce qualty attrbutes, as follows: Empathetc atttude of doctors, Doctors can patently lsten to detals of patents condtons, and Hosptal guarantees the confdentalty of patents personal nformaton. (4) Indfferent qualtes, whch do not affect patents satsfacton whether or not hosptal provdes the servces, nclude two tems, namely Convenent hosptal transportaton and whether the hosptal can promptly reply to patents complants.

8 Yeh 2541 Refned Kano model analyss Ths study further analyzed the data wth the Refned Kano Model, as shown n Table 2. The analyss shows three hgh value-added qualty tems, ncludng Doctors can patently lsten to detals of the patents condton, Hosptal guarantees the confdentalty of patents personal nformaton, and Empathetc atttude of doctors. In addton, there are seven crtcal qualtes, ncludng: Hosptal provdes perfect medcal equpment, Hosptal provdes perfect escape equpment, Convenent hosptal parkng, Nursng staff are concerned wth and lsten to patents demands, Skllful technque of nursng staff, Nursng staff can handle and react to emergences, Patents recover after treatment. There are also fve necessary qualtes, as follows: Good hosptal santaton, Hosptal washrooms properly cleaned, Approprate temperature from ar condtonng system, Empathetc servce atttude of hosptal admnstrators, and Hosptal can quckly make mprovements based on the patents suggestons. In addton, there are fve hghly attractve qualtes, whch are: Clear drectons for each department n the hosptal, Empathetc servce atttude of nursng staff, Empathetc servce atttude of hosptal volunteers, Doctors can explan the dsease and ts treatment n detal, and Sde effects do not occur when patents take medcne. Fnally, there are four low attractve qualtes, as follows: Hosptal provdes computerzed servce, Hosptal provdes obstacle-free facltes, Hosptal provdes a complete complant channel, and Hosptal provdes detaled nformaton about hygene educaton, as well as two care-free qualtes, Convenent hosptal transportaton and Hosptal can promptly reply to patents complants. Qualty house deployment of medcal servce element tems Ths study uses a qualty house model, calculates the weghts of patent servce demands, and uses the Fuzzy Integral method to assess the mportance of each medcal servce element by takng the 20 medcal servce elements obtaned from ntervews wth experts. Table 3 shows Qualty Functon Deployment of the medcal servce elements. Havng ntroduced Qualty Functon Deployment nto the calculatons of each medcal servce element s mportance, the top ten mprovement elements are sequenced, as follows: staff tranng wth the hghest mportance of 0.841, safety of hosptal desgn (0.803), convenence of hosptal (0.785), empathetc servce (0.734), equpment mantenance and medcal-used equpment (both 0.714), cleanness of hosptal (0.7), coordnated servce and emphaszng patents rghts (both 0.629), and professonal servce (0.584). Accordng to the above fndngs, patents are concerned that the hosptal envronment should be well cleaned and mantaned, such as keepng washroom clean, to avod the rsk of elderly patents sldng and fallng due to a wet or slppery floor. Moreover, servce staff should be more actvely concerned about patents to see f they are n need of any assstance, so that the overall level of satsfacton wth the hosptal can be effectvely ncreased. DISCUSSION AND CONCLUSIONS Wth rsng patents s conscousness wth regard to health, hosptals now need to pay more attenton to satsfyng the demands of patents. For ths reason, the promoton of qualty s an mportant compettve strategy n the medcal ndustry. How to advance servce qualty and patents satsfacton s thus not only the ultmate goal of the collectve efforts of medcal organzatons, but t s also the prmary management polcy. It s therefore mportant for the medcal ndustry to realze the actual demands (requrements) of patents so as to be better able to focus resources on the most mportant tems. Ths study used data codes and the 26 topcs n Kano Model to fnd 12 must-be qualtes, three one-dmensonal qualtes, nne attractve qualtes, and two ndfferent qualtes. Must-be qualtes are the prorty attrbutes for hosptals, as patents consder that hosptals should essentally possess a safe envronment or provde hghqualty medcal care. One-dmensonal qualtes are the second most mportant tems, showng that patents perceptons when dscussng ther problems wth doctors wll affect ther satsfacton, and hosptals should protect patents personal nformaton to mantan trust n the organzaton. Attractve qualtes, the most compettve attrbutes for hosptals, can enhance patent satsfacton, but do not ncrease dssatsfacton f they are absent, as patents do not consder them mportant. Fnally, applyng the Refned Kano Model combned wth the average of mportance for re-modfcaton, medcal servce qualty s subdvded to acheve more accurate results, and thus the hgh value-added qualty tems nduced from the research fndngs that have a hgh contrbuton to hosptals are consdered as the most mportant qualty tems that hosptals should provde. Crtcal qualty refers to the mportant qualty tems that hosptals should provde. Necessary qualty should be mantaned on certan servces to prevent patents from beng dssatsfed. Hghly attractve qualty tems should also be a focus. Low attractve qualty tems can be neglected when consderng the numerous other tems and the lmted resources n hosptals. Care-free qualty tems, whch can be effectvely handled wth lmted resources, are not taken n to consderaton because of the relatvely low costs nvolved. Ths study adopts Qualty Functon Deployment Integrated wth the Fuzzy Integral approach to obtan the prorty mprovement sequence as follows: staff tranng, safety of hosptal desgn, convenence of hosptal, empathetc servce, equpment mantenance, and medcal-used equpment. Therefore, ths study suggests

9 2542 Afr. J. Bus. Manage. Table 2. Classfcaton of servce requrements n Kano and Refned Kano models. Servce requrements Importance average Satsfacton average Kano qualty classfcaton Refned Kano model Hosptal provdes perfect medcal equpment Must-be qualty Crtcal qualty Convenent hosptal transportaton Indfferent qualty Care-free qualty Convenent hosptal parkng Must-be qualty Crtcal qualty Hosptal provdes perfect escape equpment Must-be qualty Crtcal qualty Clear drectons for each department n the hosptal Attractve qualty Hgh attractve qualty Hosptal provdes computerzed servce Attractve qualty Low attractve qualty Hosptal provdes obstacle-free facltes Attractve qualty Low attractve qualty Good hosptal santaton Must-be qualty Necessary qualty Hosptal washrooms properly cleaned Must-be qualty Necessary qualty Approprate temperature from ar condtonng system Must-be qualty Necessary qualty Empathetc atttude of doctors One-dmensonal qualty Hgh value-added qualty Empathetc servce atttude of nursng staff Attractve qualty Hgh attractve qualty Empathetc servce atttude of hosptal admnstrators Must-be qualty Necessary qualty Empathetc servce atttude of hosptal volunteers Attractve qualty Hgh attractve qualty Nursng staff are concerned wth and lsten to patents demands Must-be qualty Crtcal qualty Skllful technques of nursng staff Must-be qualty Crtcal qualty Nursng staff can handle and react to emergences Must-be qualty Crtcal qualty Doctors can explan the dsease and ts treatment n detal Attractve qualty Hgh attractve qualty Doctors can patently lsten to detals of the patents condtons One-dmensonal qualty Hgh value-added qualty Hosptal provdes a complete complant channel Attractve qualty Low attractve qualty Hosptal can promptly reply to patents complants Indfferent qualty Care-free qualty Hosptal can quckly make mprovements based on patents suggestons Must-be qualty Necessary qualty Hosptal provdes detaled nformaton about hygene educaton Attractve qualty Low attractve qualty Hosptal guarantees the confdentalty of patents personal nformaton One-dmensonal qualty Hgh value-added qualty Patents recover after treatment Must-be qualty Crtcal qualty Sde effects do not occur when patents take medcne Attractve qualty Hgh attractve qualty Overall average

10 Yeh 2543 Table 3. Qualty functon deployment. Demand qualty weght Closeness of hosptal Medcal servce technques Convenence of hosptal Safety of hosptal desgn Cleanness of hosptal Medcal-used equpment Publc faclty n hosptal Equpment mantenance Coordnatve servce Empathetc servce Servce reacton ablty Professonal servce Effcency of medcal servce Envronmental comfort Emphasze patents rghts Effectveness of medcaton Suffcent personnel Patent complant handlng Personnel admnstraton Staff tranng Instant nformaton Hosptal provdes perfect medcal equpment Convenence of hosptal transportaton 0.06 Convenence of hosptal parkng Hosptal provdes perfect escape equpment Clear marks of drectons to each department n hosptal Hosptal provdes computerzed servce Hosptal provdes obstacle-free faclty Hosptal santaton Hosptal washroom duly cleaned Approprate temperature form ar condtoner n hosptal Empathetc atttude of hosptal doctors Empathetc servce atttude of hosptal nursng staff Empathetc servce atttude of hosptal admnstrators 0.02 Empathetc servce atttude of hosptal volunteers 0.04 Nursng staff beng able to concern and lsten to patents demands 0.029

11 2544 Afr. J. Bus. Manage. Table 3. Cont d. Skllful technques of nursng staff Nursng staff wth emergency handlng and reactng ablty Doctors can explan the dsease and ts treatment n detals Doctors can patently lsten to patents sckness condton Hosptal provdes complete complant channel Hosptal can promptly reply to patents complants Hosptal can quckly make mprovements to patents suggestons Hosptal provdes detaled nformaton of Hygene educaton Hosptal guarantees the prvacy of patents personal nformaton Patents sck condton mproved after doctor s treatment Sde effect does not happen durng patents takng medcne Medcal servce technque weghts Medcal servce technque mportance Relaton symbols: 9 Hghly relatve, 3 Medum relatve, 1 Lowly relatve.

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