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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Relationship Marketing and Service Quality Linda M. Delene PhD
a
a
Haworth College of Business , Western Michigan University , Kalamazoo, USA Published online: 09 Jul 2010.
To cite this article: Linda M. Delene PhD (1992) Relationship Marketing and Service Quality, Journal of American College Health, 40:6, 265-269, DOI: 10.1080/07448481.1992.9936291 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936291
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Relationship Marketing and Service Quality Linda M. Delene, PhD
Downloaded by [University of Glasgow] at 16:35 06 January 2015
Abstract. The delivery of services in college health centers is improved through the use of relationship marketing and service quality advancement. Relationship marketing works to attract, maintain, and enhance customer or client relationships with the healthcare provider. The facets of relationship marketing are explored, with the greatest emphasis placed on internal marketing. Higher quality health services come from continuous improvement, a focus on process, and intensive staff development and participation, which build a service culture. Key Words. college health centers, internal marketing, rela-
tionship marketing, service management, service quality
mong the groups targeted in the goals and objectives in Healthy People 2000, a report issued by the United States Department of Health and Human Services, are traditional college-aged students.’ Two dominant preventable health problems that face these adolescents and young adults are injuries and violence, which kill and disable many before they reach the age of 25, and emerging lifestyles that affect their health years later. Healthcare professionals recognize that some of the most important risk factors for chronic disease have roots in youthful behavior. That same report also underscores the central importance of preventive healthcare for risk reduction in young adults, including decreased alcohol consumption, cessation of smoking, weight reduction, and increased use of seat belts. The American College Health Association (ACHA) and some college and university health centers had already begun working on means of delivering the targeted health promotion objectives at the time that the federal report was issued. Topics under consideration for improving the delivery of services in college health include programs and discussions about quality assurance or service quality. This article presents a service quality framework within which positive, long-term relationships between the college health center and individual students can be achieved. ~~
Linda M. D e h e is a professor of marketing at the Haworth College of Business, Western Michigan University, Kalamazoo. VOL 40, MAY 1992
Moving from episodic clinical exchanges to a more comprehensive, continuing relationship with students will reinforce students’ development of healthier lifestyles. This reinforcement of positive lifestyle choices by students, in turn, will help move us toward the achievement of the objectives in the secretary’s report.
Service Management and Service Quality Before discussing relationship marketing and its possible use in college health, I should clarify the terminology of service and quality and provide some related background information. Quality m r a n c e is defined as a “planned, systematic way of finding and eliminating the root causes of quality problems.”2 The elimination of fundamental problems associated with quality encompasses more than sound management techniques. When managers identify problems with quality, they must define quality in healthcare. Although there is no agreedupon defdtion of healthcare quality, substantial research progress has been made toward a general defdtion of service quality that is applicable to such service industries as lodging, healthcare, and tran~portation.’.~ Service management and marketing scholars increasingly agree that service quality assessments occur when customers compare their service expectations with their perceptions of the service they receive.’ When customer or client expectations and perceptions of experienced service do not match, we have a service quality gap. As a consequence, service managers work to eliminate those discrepancies-to reduce or eliminate the quality gap between service expectations and service experiences. This gap elimination work is similar to other managerial and employee efforts in quality assurance programs in which the emphasis may also be on improving processes associated with service delivery. Many of these service quality improvements are accomplished through joint problem solving between employees and supervisors. In the management and marketing of health services, as with other service industries, an improvement in service design or processes should reduce or eliminate differences between expected and experienced service levels. Finally, when service design or delivery processes 265
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have been improved, customer satisfaction and higher quality ratings result; service providers continue to grow and prosper with satisfied customers or clients. Beyond quality assurance programs, managers of healthcare organizations most recently have been challenged by the concept of total quality management or TQM. This managerial concept “calls for continuous and relentless improvement in the total process that provides care.”qp7)Conflict will probably develop between this continuous improvement process of TQM and established professional norms, notably professional autonomy. The criterion for success with TQM is whether the user (customer) of the service is satisfied. The focus on customer satisfaction is most basic to marketing theory and practice, and many professionals in the healthcare industry bring this focus on customer or patient satisfaction to their work every day. These professionals include all in college health who work in this unique environment with a clear customer orientation. Barbara Driscoll, RNC, a past president of ACHA, characterized the nature of the college health environment as an “integrated holistic approach, an interdisciplinary collaborative practice, and one with an emphasis on prevention, education, empowerment, and consumer participation. ”7 This integrated, collaborative model, with its concern about the needs, attitudes, and behavior of the individual student healthcare consumer, reflects a strong marketing bias. Marketing bias or focus has been reflected in recently published general material on health services marketing and college health. For example, at ACHA Annual Meetings and articles in this journal, I have outlined a framework for the application of marketing in the field of college health and a discussion of the issues of market segmentation, target marketing, and marketing research.a” Others have described collaborative work between student affairs staff and marketing students,’* with positive results for both groups. In the last 2 years, specific services marketing and management texts and casebooks have appeared.13-” These provide generalized assistance to managers in a wide variety of service industries. For some time, it has been recognized that healthcare services are difficult for consumers to evaluate.16 This difficulty, as well as the intangible nature of healthcare services, results in services being classified as high in credence qualities, that is, services that are impossible to evaluate after purchase and consumption. Because few patients who receive healthcare services have the medical knowledge to ratify the care they received, they rely, as consumers, on other cues and processes when they evaluate healthcare. Thus, everything and everyone surrounding the core medical service provide cues, symbols, and processes that connote good (or poor) service quality to the healthcare consumer. Every resource, person, activity, and process should enhance the relationship with healthcare service users and, thus, have a positive impact on the service exchange. This interactive system of service delivery has been delineated in detailI7
and supports the development of strong and durable relationships between providers and their customers. If healthcare customers, including college students, have difficulty evaluating health services, what, then, constitutes good service quality? Significant service quality has led to the empirical verification’* of five dimensions of service quality: (1) tangibles, (2) reliability, (3) responsiveness, (4) assurance (includes communication, credibility, security, competence, and courtesy), and ( 5 ) empathy (understanding and knowing the customer). Tangibles involve collateral materials, facilities, or advertisements about the service. Reliability accounts for four fifths of customer-perceived service quality and means providing the correct service the first time. This dimension of reliability overshadows all other dimensions in importance. Being responsive and empathetic are also important, but those dimensions of service quality do not compensate for an incorrect procedure or poor medical treatment. Thus, a superior level of professional competence or reliability is critical for the achievement of high service quality. In this consideration, we must remember, however, that customers (or healthcare patients) have difficulty in evaluating health services. We expect that the topical areas of communication and courtesy, under the dimension “assurance,” will receive adequate consideration in most healthcare quality assurance programs. Another scholar has suggested six criteria of service quality” that are somewhat different from those previously cited. These are (1) professionalism and skills, (2) behavior and attitudes, (3) accessibility and flexibility, (4) reliability and trustworthiness, ( 5 ) recovery (when something goes wrong or happens unpredictably, it will be made right immediately), and (6) reputation and credibility. Four of these (2, 3, 4, and 5 ) are classified as process skills and usually fall under scrutiny in both quality assurance and relationship marketing programs. Whether all six criteria are necessary in every healthcare quality assurance program bears further research in specific situations. The aforementioned definitions of quality assurance and service quality, as well as the collaborative college health model and recent college health marketing and service management publications, direct our attention to the field of relationship marketing. The consideration of relationship marketing in the practice of college health centers may further improve services and their quality. Relationship Marketing
Relationship marketing has been defined as attracting, maintaining, and enhancing customer relationships.20 Among those elements of relationship marketing, the major emphasis is placed on maintaining and enhancing the relationships an organization has with its customers. For many organizations, including college health tenters, competition for the customer or client is increasingly severe. Thus, it is important (and usually less costly) for organizations such as health centers to concenJACH
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trate on customer retention rather than on customer attraction. Furthermore, the demographic trends in higher education for the next several years indicate a shrinking pool of high school students from which to recruit new undergraduates. With a smaller pool of students and more competition for college health center customers, using relationship marketing in the college health environment is both logical and appropriate. College health centers satisfy the three basic conditions that make relationship marketing appropriate: (1) customers have an ongoing need for the service; (2) alternative suppliers of the same service are available; and (3) the customer is free to select a particular supplier. Clearly, students need healthcare regularly during their college careers, and they have many options in selecting a healthcare provider. Managers must make it clear to all college health professionals that students’ repeated visits to the health center provide another basis for assessing quality and delivering healthcare services. This involves the use of strategies associated with relationship marketing. Several strategies are associated with the practice of relationship marketing. These include (1) the design of a core service, (2) customizing the relationship between the service provider and the organization, (3) enhancing the core service with value-added extras to differentiate service from competition, (4) relationship pricing, and ( 5 ) internal marketing.” Although I can discuss these five strategies only briefly here, all merit in-depth exploration for possible use by college health centers and their management teams. Because the core or primary service design of most college health centers is predetermined as ambulatory outpatient care, this examination of relationship marketing turns to the second strategic element-how health centers can customize the relationship between the center and the students it serves. To customize this relationship, health center personnel must understand that all aspects of the student’s experience with the center are important and cumulative. Each visit or service contact adds to the student’s view of credibility and satisfaction (or dissatisfaction) with health center personnel and services. Thus, the management and evaluation of these periodic visits over time evolves into a relationship that becomes the major framework for service delivery by college health personnel. Nonetheless, the initial health center contact with the student is also crucial-whether that contact is through printed material, other media, by telephone, or in person-in establishing the visibility and credibility of the health center. Are materials (including brochures and pamphlets) selected and used to promote an image of credibility and quality? Are materials attractive and contemporary? Does the attire of personnel reflect a consistent organizational standard or an expected norm? Should conversations be personalized? Do staff at the health center understand that such a policy sets an intentional tone and style with students? Is the initial inforVOL 40, MAY 1992
mation solicited from the student in a confidential space or can questions and responses be overheard by others? May students, after their initial visit, routinely visit the same physician or clinician of their choice? Do billing systems accommodate individual student financial circumstances, or is the payment policy a perceived barrier to services? Finally, do centers adjust the service schedule or program mix in terms of satisfaction data from reliable survey instruments? The service management and marketing task is to build a strong, ongoing relationship with students during their entire college career at each institution. How each health center proceeds to do this will vary substantially among different colleges and universities. The managerial requirement is to set an organization style and culture that builds customized relationships with students over time as a matter of intentional policy and consistent practice. As continuing relationships with students develop, there is natural progression to the third relationship marketing strategy of service augmentation. The established relationships between the health center and student often require augmentation with value enhancement. This augmentation of health services works best when the “extras,” or value-added components, are both meaningful and useful to the student. For example, providing a free laminated card with the center pharmacy’s telephone number (perhaps an 800 number for large universities) and student allergy prescription information would provide added value to a student’s regular visit for allergy shots. This laminated card also could be given to students who receive regular shots and medication from the health center, more than six times, for example. Another ambitious augmentation or enhancement strategy of student health services would be a “competition for life” fitness and academic excellence program in which students could enroll as freshmen and strive for individualized goals of personal fitness and academic excellence during their collegiate years. In any case, managerial time and staff resources should be directed at designing service augmentation elements as a continuing part of their relationship with students during their entire matriculation period. The fourth relationship marketing strategy, perhaps more important than any other, is internal marketing. Every person at the health center must understand that work attitudes and behavior affect student perceptions of quality and satisfaction with the healthcare services provided and, in turn, determine whether repeat visits will occur. An across-the-board understanding of this perception-quality-service relationship can occur only with appropriate and consistent internal marketing education and supportive supervision. This internal marketing will involve “discovery contributions”U from each employee, regardless of rank, credentials, or employment status. Discovery contributions involve the identification of factors that affect individual client satisfaction and the later communication of these important factors to colleagues. In other words, health center staff are encouraged to en267
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vision part of their role as a service researcher and a teacher of quality. The staffs identification and discovery of factors that affect the credibility, performance, and satisfaction of students should be used as guides for service improvement. This requires management’s support and reward of teamwork throughout the health center and the entire academic enterprise. The cornerstone of internal marketing is the premise that external marketing to targeted customers cannot succeed if the internal market of employees is not able and ready. Only health center staff who are service minded and have positive attitudes toward service can ensure the success of programs and activities. Clearly, staff members who are service minded need to be retained and rewarded for superior service delivery and sensitivity. If management does not add the internal marketing of programs to staff to its already long list of work, the results of external marketing to customers may be wasted. Internal marketing is much more than a short announcement at a staff meeting. It entails motivating employees, through professional development and education, to adopt an appropriate service profile in the conduct of all their work and, then, rewarding their performance accordingly. Relationship pricing, the fifth strategic element of relationship marketing, simply means pricing services to attract all, or most of, a customer’s specific business. Relationship pricing encourages more and more service transactions between, in this instance, the college health center and its student customers. It can involve such customary pricing incentives as quantity and frequencyof-use discounts. This strategy is more dependent upon the availability of staff and facility and may not be reasonable or feasible at some institutions. The complexity of institutional payment systems and financial aid programs may also preclude serious consideration of this strategy. Relationship marketing, with most of its managerial strategies, provides the framework for improving college health services. College health managers and directors need to use relationship marketing to build longterm relationships that focus on students’ needs and development over time and have a foundation of strong quality in healthcare objectives, service design, and delivery.
Managerial Implications The directors and staff of college health services have a long history of active concern with the quality of delivered care and student satisfaction with their services. Many health centers regularly conduct patient satisfaction surveys, and others use anecdotal means of verifying service quality or determining service quality gaps. In performing these managerial tasks and others that relate to the growing drive toward high-quality healthcare services, the area of relationship marketing and service quality research offers contributions for further improvements in college health services. Such improve268
ments have several managerial implications for college health providers. First, relationship marketing (as is also true for TQM) focuses on continuous improvement rather than the achievement of some predetermined standard. This drive toward constant improvement will shift some areas of decision making down the hierarchical structure that is typically found in healthcare organizations. As improvements in programs and processes continue to be made, and with discovery contributions possible from each employee involved in service delivery, more and better decision making should occur at middle-management and direct-service levels. This, of course, assumes that the health center staff are appropriately trained and able to make decisions for their respective domains. Directors, from necessity, will become more focused on building a service culture and allocating resources to support different processes and programs. Increasingly, healthcare managers and directors face the reality that “service is not an event; it is the process of creating a customer environment of information, assurance, and c ~ m f o r t . ” ~ ~ ~ ~ ) A second major managerial implication from relationship marketing and service quality research will be additional emphasis on process-related objectives rather than performance-related objectives. How a service is delivered will dominate customers’ perceptions of quality-not whether the service was delivered. More managerial time, attention, and knowledge will be dedicated to improving the human relations skills and the communication abilities of everyone. The service arena for relationship marketing is individually intensive and demanding in every instance. The third managerial implication stems from employee participation in internal marketing programs. Because internal marketing is a central strategy for successful relationship marketing and service quality improvements, policy conflicts and inconsistent information will quickly surface. Unless health center leadership makes the necessary policy changes, the internal marketing activities will not be perceived as genuine. As employer knowledge and information expand and the center staffs work changes, any inconsistency between announced objectives and actual service programs will become more obvious. Everyone’s participation will be needed to develop procedures, processes, and policies that are consistent and sound. Then, as individuals increasingly contribute to improved service design and delivery, their personal sense of value and commitment will also improve. Furthermore, the use of strategies associated with relationship marketing will build a more loyal student clientele, one that perceives the importance of receiving health services from a high-quality provider-the college health center. The demand and scope of services may change somewhat, but the managerial objective must be to provide services within an intentional service culture. If relationship marketing is taken seriously, a JACH
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service orientation to students will dominate all operations and processes within the health center. Conclusion The collaborative, interdisciplinary college health model will facilitate the incorporation of findings from marketing and service quality research. This can best be accomplished when college health center directors assume central leadershuip and responsibility for developing a service culture climate that is reflected in all internal operations. Those in leadership positions cannot engage in marginal marketing and service quality research activities and expect a service strategy to grow and flourish. If service, manifested through relationship marketing and with a focus on quality, is to become an organizational precept, then service management and marketing need the same attention that is usually given to the fwal and personnel areas of management within the organization. The costs of relationship marketing, including costs associated with service augmentation, need to be determined. Over time, if college health centers are similar to other service organizations, the resulting reductions in staff turnover, employee absenteeism, and improved client satisfaction will exceed the costs of the internal marketing programs, service development time, and quality improvement programs. Among other changes, employee recruitment and retention programs will shift to focus on service-sensitive personnel who recognize that the service culture dominates all their work, programs, and activities. These same service-minded individuals will adopt the relationship marketing framework, which can provide a high-quality continuum of care for the student’s healthcare needs during the course of the student’s enrollment at the college or university. Many elements of relationship marketing may now exist in some college health centers. Now we need to recognize that the various activities undertaken constitute health services management that can be defined, discussed, and developed for each health center. The foundation for this service management rests upon the framework of relationship marketing and its drive toward improved service quality. REFERENCES 1. Guyton R, Corbin S, Zimmer C, et al. College students and National Health Objectives for the Year 2000: A summary report. J A m Coil Health. 1989;38:9-14. 2. DiPrimio A. Quality assurance: Improving quality, productivity, and cost effectiveness of operating departments. Review of Business. 1988;9(3):%22. 3. Bowen DE, Chase RB, Cummings TG, and Associates.
VOL 40, MAY 1992
Service Management Effectiveness. San Francisco: JosseyBass; 1990. 4. Berry LL. Marketing Services: Competing Through Quality. New York: Free Press; 1991. 5. Brogowicz AA, Delene LM, Lyth DM. A synthesized service quality model with managerial implications. Intern J Service Zndustty Management. 1990,1(1):27-45. 6. McLaughlin CP, Kaluzny AD. Total quality management in health: Making it work. Health Care Management Review. 1990,15(3):7- 14. 7. Drikoll CB. The College Health Model. President’s address. Annual Meeting, American College Health Association. San Antonio, TX, May 31, 1990. 8. Delene LM. Realistic health services marketing: A research report. Presented at the Sixty-fourth Annual Meeting, American College Health Association, New Orleans, LA, May 29, 1986. 9. Delene LM, Brogowicz AA. Marketing implications from the empirical study of student healthcare needs and attitudes. Presented at the Sixty-sixth Annual Meeting, American College Health Association, Denver, CO, May 30, 1988. 10. Delene LM. Strategy and targets for relationship
marketing-Institutional commitment to health. Presented at the Sixty-eighth Annual Meeting, American College Health Association, San Antonio, TX, May 29, 1990. 11. Delene LM. Marketing postsecondary health services. J A m Coil Health. 1988;36:229-234. 12. Dod GA, Earwood-Smith G. Marketing a wellness program: A case study in bridging the gap between academic and student affairs. NASPA Journal. 1988;26(2): 105-109. 13. Bateson JEG. Managing Services Marketing. Hinsdale, IL: Dryden Press; 1989. 14. Zemke R, Schaaf D. The Service Edge: 101 Companies That Profit From Customer Care. New York: New American Library; 1989. 15. Gronroos C. Service Management and Marketing. Lexington, MA: Lexington Books; 1990. 16. Zeithaml VA. How consumer evaluation processes differ between goods and services. In: Donnelly JH, George WR, eds. Marketing of Services. Chicago: American Marketing Association; 1981: 186-190. 17. Gronroos C. Relationship approach to marketing in service contexts: The marketing and organizational behavior interface. J Business Research. 1990;20:3-11. 18. Parasuraman A, Zeithaml VA, Berry LL. SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality. J Retailing. 1988;W 12-40. 19. Gronroos C. Service quality: The six criteria of good perceived service quality. Rev Business. 1988;9: 1-9. 20. Berry L. Relationship marketing. In: Berry LL, Shostack GL, Upah GD, eds. Emerging Perspectives on Services Marketing. Chicago: American Marketing Association; 1983:25-28. 21. Dwyer FR, Schurr PH, Oh S. Developing buyer-seller relationships. J Marketing 1987;51(2): 11-27.
22. Paul T. Relationship marketing for health care providers. J Health Care Marketing. 1988;8(3):%25. 23. MacStravic RES. Relationship marketing for health care supervisors. The Health Care Supervkor. 1986;5(1): 71-80.
24. McKenna R. Marketing is everything. Harvard Business Rev. 1991;69(1):65-79.
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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Relationship Marketing and Service Quality Linda M. Delene PhD
a
a
Haworth College of Business , Western Michigan University , Kalamazoo, USA Published online: 09 Jul 2010.
To cite this article: Linda M. Delene PhD (1992) Relationship Marketing and Service Quality, Journal of American College Health, 40:6, 265-269, DOI: 10.1080/07448481.1992.9936291 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936291
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Relationship Marketing and Service Quality Linda M. Delene, PhD
Downloaded by [University of Glasgow] at 16:35 06 January 2015
Abstract. The delivery of services in college health centers is improved through the use of relationship marketing and service quality advancement. Relationship marketing works to attract, maintain, and enhance customer or client relationships with the healthcare provider. The facets of relationship marketing are explored, with the greatest emphasis placed on internal marketing. Higher quality health services come from continuous improvement, a focus on process, and intensive staff development and participation, which build a service culture. Key Words. college health centers, internal marketing, rela-
tionship marketing, service management, service quality
mong the groups targeted in the goals and objectives in Healthy People 2000, a report issued by the United States Department of Health and Human Services, are traditional college-aged students.’ Two dominant preventable health problems that face these adolescents and young adults are injuries and violence, which kill and disable many before they reach the age of 25, and emerging lifestyles that affect their health years later. Healthcare professionals recognize that some of the most important risk factors for chronic disease have roots in youthful behavior. That same report also underscores the central importance of preventive healthcare for risk reduction in young adults, including decreased alcohol consumption, cessation of smoking, weight reduction, and increased use of seat belts. The American College Health Association (ACHA) and some college and university health centers had already begun working on means of delivering the targeted health promotion objectives at the time that the federal report was issued. Topics under consideration for improving the delivery of services in college health include programs and discussions about quality assurance or service quality. This article presents a service quality framework within which positive, long-term relationships between the college health center and individual students can be achieved. ~~
Linda M. D e h e is a professor of marketing at the Haworth College of Business, Western Michigan University, Kalamazoo. VOL 40, MAY 1992
Moving from episodic clinical exchanges to a more comprehensive, continuing relationship with students will reinforce students’ development of healthier lifestyles. This reinforcement of positive lifestyle choices by students, in turn, will help move us toward the achievement of the objectives in the secretary’s report.
Service Management and Service Quality Before discussing relationship marketing and its possible use in college health, I should clarify the terminology of service and quality and provide some related background information. Quality m r a n c e is defined as a “planned, systematic way of finding and eliminating the root causes of quality problems.”2 The elimination of fundamental problems associated with quality encompasses more than sound management techniques. When managers identify problems with quality, they must define quality in healthcare. Although there is no agreedupon defdtion of healthcare quality, substantial research progress has been made toward a general defdtion of service quality that is applicable to such service industries as lodging, healthcare, and tran~portation.’.~ Service management and marketing scholars increasingly agree that service quality assessments occur when customers compare their service expectations with their perceptions of the service they receive.’ When customer or client expectations and perceptions of experienced service do not match, we have a service quality gap. As a consequence, service managers work to eliminate those discrepancies-to reduce or eliminate the quality gap between service expectations and service experiences. This gap elimination work is similar to other managerial and employee efforts in quality assurance programs in which the emphasis may also be on improving processes associated with service delivery. Many of these service quality improvements are accomplished through joint problem solving between employees and supervisors. In the management and marketing of health services, as with other service industries, an improvement in service design or processes should reduce or eliminate differences between expected and experienced service levels. Finally, when service design or delivery processes 265
Downloaded by [University of Glasgow] at 16:35 06 January 2015
COLLEGE HEALTH
have been improved, customer satisfaction and higher quality ratings result; service providers continue to grow and prosper with satisfied customers or clients. Beyond quality assurance programs, managers of healthcare organizations most recently have been challenged by the concept of total quality management or TQM. This managerial concept “calls for continuous and relentless improvement in the total process that provides care.”qp7)Conflict will probably develop between this continuous improvement process of TQM and established professional norms, notably professional autonomy. The criterion for success with TQM is whether the user (customer) of the service is satisfied. The focus on customer satisfaction is most basic to marketing theory and practice, and many professionals in the healthcare industry bring this focus on customer or patient satisfaction to their work every day. These professionals include all in college health who work in this unique environment with a clear customer orientation. Barbara Driscoll, RNC, a past president of ACHA, characterized the nature of the college health environment as an “integrated holistic approach, an interdisciplinary collaborative practice, and one with an emphasis on prevention, education, empowerment, and consumer participation. ”7 This integrated, collaborative model, with its concern about the needs, attitudes, and behavior of the individual student healthcare consumer, reflects a strong marketing bias. Marketing bias or focus has been reflected in recently published general material on health services marketing and college health. For example, at ACHA Annual Meetings and articles in this journal, I have outlined a framework for the application of marketing in the field of college health and a discussion of the issues of market segmentation, target marketing, and marketing research.a” Others have described collaborative work between student affairs staff and marketing students,’* with positive results for both groups. In the last 2 years, specific services marketing and management texts and casebooks have appeared.13-” These provide generalized assistance to managers in a wide variety of service industries. For some time, it has been recognized that healthcare services are difficult for consumers to evaluate.16 This difficulty, as well as the intangible nature of healthcare services, results in services being classified as high in credence qualities, that is, services that are impossible to evaluate after purchase and consumption. Because few patients who receive healthcare services have the medical knowledge to ratify the care they received, they rely, as consumers, on other cues and processes when they evaluate healthcare. Thus, everything and everyone surrounding the core medical service provide cues, symbols, and processes that connote good (or poor) service quality to the healthcare consumer. Every resource, person, activity, and process should enhance the relationship with healthcare service users and, thus, have a positive impact on the service exchange. This interactive system of service delivery has been delineated in detailI7
and supports the development of strong and durable relationships between providers and their customers. If healthcare customers, including college students, have difficulty evaluating health services, what, then, constitutes good service quality? Significant service quality has led to the empirical verification’* of five dimensions of service quality: (1) tangibles, (2) reliability, (3) responsiveness, (4) assurance (includes communication, credibility, security, competence, and courtesy), and ( 5 ) empathy (understanding and knowing the customer). Tangibles involve collateral materials, facilities, or advertisements about the service. Reliability accounts for four fifths of customer-perceived service quality and means providing the correct service the first time. This dimension of reliability overshadows all other dimensions in importance. Being responsive and empathetic are also important, but those dimensions of service quality do not compensate for an incorrect procedure or poor medical treatment. Thus, a superior level of professional competence or reliability is critical for the achievement of high service quality. In this consideration, we must remember, however, that customers (or healthcare patients) have difficulty in evaluating health services. We expect that the topical areas of communication and courtesy, under the dimension “assurance,” will receive adequate consideration in most healthcare quality assurance programs. Another scholar has suggested six criteria of service quality” that are somewhat different from those previously cited. These are (1) professionalism and skills, (2) behavior and attitudes, (3) accessibility and flexibility, (4) reliability and trustworthiness, ( 5 ) recovery (when something goes wrong or happens unpredictably, it will be made right immediately), and (6) reputation and credibility. Four of these (2, 3, 4, and 5 ) are classified as process skills and usually fall under scrutiny in both quality assurance and relationship marketing programs. Whether all six criteria are necessary in every healthcare quality assurance program bears further research in specific situations. The aforementioned definitions of quality assurance and service quality, as well as the collaborative college health model and recent college health marketing and service management publications, direct our attention to the field of relationship marketing. The consideration of relationship marketing in the practice of college health centers may further improve services and their quality. Relationship Marketing
Relationship marketing has been defined as attracting, maintaining, and enhancing customer relationships.20 Among those elements of relationship marketing, the major emphasis is placed on maintaining and enhancing the relationships an organization has with its customers. For many organizations, including college health tenters, competition for the customer or client is increasingly severe. Thus, it is important (and usually less costly) for organizations such as health centers to concenJACH
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trate on customer retention rather than on customer attraction. Furthermore, the demographic trends in higher education for the next several years indicate a shrinking pool of high school students from which to recruit new undergraduates. With a smaller pool of students and more competition for college health center customers, using relationship marketing in the college health environment is both logical and appropriate. College health centers satisfy the three basic conditions that make relationship marketing appropriate: (1) customers have an ongoing need for the service; (2) alternative suppliers of the same service are available; and (3) the customer is free to select a particular supplier. Clearly, students need healthcare regularly during their college careers, and they have many options in selecting a healthcare provider. Managers must make it clear to all college health professionals that students’ repeated visits to the health center provide another basis for assessing quality and delivering healthcare services. This involves the use of strategies associated with relationship marketing. Several strategies are associated with the practice of relationship marketing. These include (1) the design of a core service, (2) customizing the relationship between the service provider and the organization, (3) enhancing the core service with value-added extras to differentiate service from competition, (4) relationship pricing, and ( 5 ) internal marketing.” Although I can discuss these five strategies only briefly here, all merit in-depth exploration for possible use by college health centers and their management teams. Because the core or primary service design of most college health centers is predetermined as ambulatory outpatient care, this examination of relationship marketing turns to the second strategic element-how health centers can customize the relationship between the center and the students it serves. To customize this relationship, health center personnel must understand that all aspects of the student’s experience with the center are important and cumulative. Each visit or service contact adds to the student’s view of credibility and satisfaction (or dissatisfaction) with health center personnel and services. Thus, the management and evaluation of these periodic visits over time evolves into a relationship that becomes the major framework for service delivery by college health personnel. Nonetheless, the initial health center contact with the student is also crucial-whether that contact is through printed material, other media, by telephone, or in person-in establishing the visibility and credibility of the health center. Are materials (including brochures and pamphlets) selected and used to promote an image of credibility and quality? Are materials attractive and contemporary? Does the attire of personnel reflect a consistent organizational standard or an expected norm? Should conversations be personalized? Do staff at the health center understand that such a policy sets an intentional tone and style with students? Is the initial inforVOL 40, MAY 1992
mation solicited from the student in a confidential space or can questions and responses be overheard by others? May students, after their initial visit, routinely visit the same physician or clinician of their choice? Do billing systems accommodate individual student financial circumstances, or is the payment policy a perceived barrier to services? Finally, do centers adjust the service schedule or program mix in terms of satisfaction data from reliable survey instruments? The service management and marketing task is to build a strong, ongoing relationship with students during their entire college career at each institution. How each health center proceeds to do this will vary substantially among different colleges and universities. The managerial requirement is to set an organization style and culture that builds customized relationships with students over time as a matter of intentional policy and consistent practice. As continuing relationships with students develop, there is natural progression to the third relationship marketing strategy of service augmentation. The established relationships between the health center and student often require augmentation with value enhancement. This augmentation of health services works best when the “extras,” or value-added components, are both meaningful and useful to the student. For example, providing a free laminated card with the center pharmacy’s telephone number (perhaps an 800 number for large universities) and student allergy prescription information would provide added value to a student’s regular visit for allergy shots. This laminated card also could be given to students who receive regular shots and medication from the health center, more than six times, for example. Another ambitious augmentation or enhancement strategy of student health services would be a “competition for life” fitness and academic excellence program in which students could enroll as freshmen and strive for individualized goals of personal fitness and academic excellence during their collegiate years. In any case, managerial time and staff resources should be directed at designing service augmentation elements as a continuing part of their relationship with students during their entire matriculation period. The fourth relationship marketing strategy, perhaps more important than any other, is internal marketing. Every person at the health center must understand that work attitudes and behavior affect student perceptions of quality and satisfaction with the healthcare services provided and, in turn, determine whether repeat visits will occur. An across-the-board understanding of this perception-quality-service relationship can occur only with appropriate and consistent internal marketing education and supportive supervision. This internal marketing will involve “discovery contributions”U from each employee, regardless of rank, credentials, or employment status. Discovery contributions involve the identification of factors that affect individual client satisfaction and the later communication of these important factors to colleagues. In other words, health center staff are encouraged to en267
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vision part of their role as a service researcher and a teacher of quality. The staffs identification and discovery of factors that affect the credibility, performance, and satisfaction of students should be used as guides for service improvement. This requires management’s support and reward of teamwork throughout the health center and the entire academic enterprise. The cornerstone of internal marketing is the premise that external marketing to targeted customers cannot succeed if the internal market of employees is not able and ready. Only health center staff who are service minded and have positive attitudes toward service can ensure the success of programs and activities. Clearly, staff members who are service minded need to be retained and rewarded for superior service delivery and sensitivity. If management does not add the internal marketing of programs to staff to its already long list of work, the results of external marketing to customers may be wasted. Internal marketing is much more than a short announcement at a staff meeting. It entails motivating employees, through professional development and education, to adopt an appropriate service profile in the conduct of all their work and, then, rewarding their performance accordingly. Relationship pricing, the fifth strategic element of relationship marketing, simply means pricing services to attract all, or most of, a customer’s specific business. Relationship pricing encourages more and more service transactions between, in this instance, the college health center and its student customers. It can involve such customary pricing incentives as quantity and frequencyof-use discounts. This strategy is more dependent upon the availability of staff and facility and may not be reasonable or feasible at some institutions. The complexity of institutional payment systems and financial aid programs may also preclude serious consideration of this strategy. Relationship marketing, with most of its managerial strategies, provides the framework for improving college health services. College health managers and directors need to use relationship marketing to build longterm relationships that focus on students’ needs and development over time and have a foundation of strong quality in healthcare objectives, service design, and delivery.
Managerial Implications The directors and staff of college health services have a long history of active concern with the quality of delivered care and student satisfaction with their services. Many health centers regularly conduct patient satisfaction surveys, and others use anecdotal means of verifying service quality or determining service quality gaps. In performing these managerial tasks and others that relate to the growing drive toward high-quality healthcare services, the area of relationship marketing and service quality research offers contributions for further improvements in college health services. Such improve268
ments have several managerial implications for college health providers. First, relationship marketing (as is also true for TQM) focuses on continuous improvement rather than the achievement of some predetermined standard. This drive toward constant improvement will shift some areas of decision making down the hierarchical structure that is typically found in healthcare organizations. As improvements in programs and processes continue to be made, and with discovery contributions possible from each employee involved in service delivery, more and better decision making should occur at middle-management and direct-service levels. This, of course, assumes that the health center staff are appropriately trained and able to make decisions for their respective domains. Directors, from necessity, will become more focused on building a service culture and allocating resources to support different processes and programs. Increasingly, healthcare managers and directors face the reality that “service is not an event; it is the process of creating a customer environment of information, assurance, and c ~ m f o r t . ” ~ ~ ~ ~ ) A second major managerial implication from relationship marketing and service quality research will be additional emphasis on process-related objectives rather than performance-related objectives. How a service is delivered will dominate customers’ perceptions of quality-not whether the service was delivered. More managerial time, attention, and knowledge will be dedicated to improving the human relations skills and the communication abilities of everyone. The service arena for relationship marketing is individually intensive and demanding in every instance. The third managerial implication stems from employee participation in internal marketing programs. Because internal marketing is a central strategy for successful relationship marketing and service quality improvements, policy conflicts and inconsistent information will quickly surface. Unless health center leadership makes the necessary policy changes, the internal marketing activities will not be perceived as genuine. As employer knowledge and information expand and the center staffs work changes, any inconsistency between announced objectives and actual service programs will become more obvious. Everyone’s participation will be needed to develop procedures, processes, and policies that are consistent and sound. Then, as individuals increasingly contribute to improved service design and delivery, their personal sense of value and commitment will also improve. Furthermore, the use of strategies associated with relationship marketing will build a more loyal student clientele, one that perceives the importance of receiving health services from a high-quality provider-the college health center. The demand and scope of services may change somewhat, but the managerial objective must be to provide services within an intentional service culture. If relationship marketing is taken seriously, a JACH
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service orientation to students will dominate all operations and processes within the health center. Conclusion The collaborative, interdisciplinary college health model will facilitate the incorporation of findings from marketing and service quality research. This can best be accomplished when college health center directors assume central leadershuip and responsibility for developing a service culture climate that is reflected in all internal operations. Those in leadership positions cannot engage in marginal marketing and service quality research activities and expect a service strategy to grow and flourish. If service, manifested through relationship marketing and with a focus on quality, is to become an organizational precept, then service management and marketing need the same attention that is usually given to the fwal and personnel areas of management within the organization. The costs of relationship marketing, including costs associated with service augmentation, need to be determined. Over time, if college health centers are similar to other service organizations, the resulting reductions in staff turnover, employee absenteeism, and improved client satisfaction will exceed the costs of the internal marketing programs, service development time, and quality improvement programs. Among other changes, employee recruitment and retention programs will shift to focus on service-sensitive personnel who recognize that the service culture dominates all their work, programs, and activities. These same service-minded individuals will adopt the relationship marketing framework, which can provide a high-quality continuum of care for the student’s healthcare needs during the course of the student’s enrollment at the college or university. Many elements of relationship marketing may now exist in some college health centers. Now we need to recognize that the various activities undertaken constitute health services management that can be defined, discussed, and developed for each health center. The foundation for this service management rests upon the framework of relationship marketing and its drive toward improved service quality. REFERENCES 1. Guyton R, Corbin S, Zimmer C, et al. College students and National Health Objectives for the Year 2000: A summary report. J A m Coil Health. 1989;38:9-14. 2. DiPrimio A. Quality assurance: Improving quality, productivity, and cost effectiveness of operating departments. Review of Business. 1988;9(3):%22. 3. Bowen DE, Chase RB, Cummings TG, and Associates.
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Service Management Effectiveness. San Francisco: JosseyBass; 1990. 4. Berry LL. Marketing Services: Competing Through Quality. New York: Free Press; 1991. 5. Brogowicz AA, Delene LM, Lyth DM. A synthesized service quality model with managerial implications. Intern J Service Zndustty Management. 1990,1(1):27-45. 6. McLaughlin CP, Kaluzny AD. Total quality management in health: Making it work. Health Care Management Review. 1990,15(3):7- 14. 7. Drikoll CB. The College Health Model. President’s address. Annual Meeting, American College Health Association. San Antonio, TX, May 31, 1990. 8. Delene LM. Realistic health services marketing: A research report. Presented at the Sixty-fourth Annual Meeting, American College Health Association, New Orleans, LA, May 29, 1986. 9. Delene LM, Brogowicz AA. Marketing implications from the empirical study of student healthcare needs and attitudes. Presented at the Sixty-sixth Annual Meeting, American College Health Association, Denver, CO, May 30, 1988. 10. Delene LM. Strategy and targets for relationship
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