Influence of healthcare institution managers ’ proactive approach to communication activities on patient satisfaction

Background/Aim. Over the recent years customer satisfaction program as a tool for patient satisfaction has been recognized as an important issue in healthcare services. The aim of this preliminary study was to explore an influence of healthcare institution managers’ approach and attitudes to marketing and public relations activities (communication activities), in the context of implementation of customer satisfaction programs, on patient satisfaction. Methods. The study was conducted among managers from different state-owned healthcare institutions (healthcare centres, clinics, hospitals) in Serbia. The structured questionnaire form, comprising both open and closed questions, was used as a main research tool. The total number of sent questionnaires was 120; 56 questionnaires were sent back, while 49 of them were valid. Results. It was shown that 42.9% of healthcare institutions apply proactive media approach, and that 35.7% of the organizations have a person who, besides his/her basic engagements, performs activities connected with marketing and public relations. Using Chi-square likelihood ratio test it is confirmed that these activities have a significant role in supporting customer satisfaction program implementation (p < 0.05). The results showed that in 69.4% cases, positive attitude of healthcare institutions managers toward marketing and public relations activities had positive influence on patient satisfaction (p < 0.05). Conclusion. Managers in healthcare sector in Serbia who used proactive approach toward media and who had already institutionalized communication activities with external stakeholders have a positive attitude to implementation of customer satisfaction program. Furthermore, managers’ attitude toward communication activities has influence on patient satisfaction.


Introduction
Over the recent years customer satisfaction program as a tool for patient satisfaction has been recognized as an important issue in health services by many academics and practitioners.
Healthcare institutions are faced with new environmental changes and various challenges.Perception of environmental changes influences strategic response (efficiencyoriented or market-focused) of healthcare organization, which is related to appropriate measures of performance 1 .According to Avali and Yasin 2 factors that determine success in healthcare sector include: environmental change factors (customer and external environmental factors, innovation and competitive factors), healthcare industry, competitive responses (customer focus, service quality, strategic focus, efficiency and cost structure), implementation of quality improvement initiatives (Total Quality Management -TQM and other), and organizational benefits.
The healthcare market in Serbia is characterized by the rise of competition.The intensive growth of private sector, changing needs of customers, increase of health costs, development of knowledge and technologies are just some of the challenges that have brought a new perception of health care institution functioning.The relevance of market orientation, customer focus, service quality, quality improvements and other factors are recognized in the Serbian healthcare system.As the incumbent Minister of Health in the Serbian Government reported at the Fourth National Conference on Permanent Quality Improvement in Health Care (2008), important steps have already been made in this field: legislation for permanent quality improvement of healthcare has been developed; several projects related to healthcare quality have been implemented with international partners in recent years, national conferences on healthcare permanent quality improvement have been organized since 2005.Some outputs of these initiatives and activities are as follows: better understanding of healthcare quality and introduction of permanent quality improvements culture, training of employees on TQM, defining the indicators for quality and periodical examination of patients' satisfaction that started five years ago.
In the context of the presented initiatives and realized activities in healthcare sector in Serbia regarding quality improvements, the authors of the paper started to explore the correlation between management approach to external stakeholders and institutionalization of communication activities toward external stakeholders with attitudes toward introducing the quality improvement program.On the other side, the authors explored the correlation between managers' attitude to marketing and public relations activities (communication activities) and patient satisfaction.
Customer satisfaction is one of the fundamental concepts in marketing.Customer satisfaction could be defined as an overall assessment of the performance of various attributes that constitute a product or a service [3][4] .Concept of customer satisfaction is very important in the field of health care, because patients are not a usual category of customers.Patient satisfaction could be used as an instrument for meas-uring the success of quality improvement effort 5 .More comprehensive patient satisfaction is a tool for overall performance improvement 6 , and way to business excellence 7 .
Antecedents to satisfaction have been investigated by different authors.In main antecedents to customer satisfaction identified by consumers are expectations, perceived quality (product and service) and disconfirmation 8 .Other antecedents besides mentioned are image, perceived quality of hardware and human ware and perceived value 9 .Outcomes could be connected with consumers, employees, efficiency and overall performances [10][11][12][13][14] .A more detailed classification was presented in the study of Luo and Homburg 15 .
In the healthcare literature authors show a positive correlation between nursing care and overall patient satisfaction [16][17][18][19] .Main characteristics that have impact on patient satisfaction are: how seriously institution viewed a patient's problem, how courteously staff treated a patient and how well institutions paid attention to a patient's needs 20 .
In order to achieve a higher customer satisfaction, organizations must develop appropriate customer satisfaction programs.Success of a customer satisfaction program is not secured by a simple procedure for obtaining a customer feedback.A customer satisfaction program requires turning the obtained information into action plans and then effective implementation for the purpose of business results improvement.
Customer satisfaction program [21][22][23] is a process that consists of several stages and begins with an understanding of customer satisfaction drivers.Successful implementation of any customer satisfaction program requires paying attention to influential factors.The factors associated with all successful programs are: top management support and guidance, satisfaction that is incorporated into the strategic focus, function integration and multifunctional team formation, first line employees are responsible for satisfaction program execution and questionnaires, satisfaction measurements must involve combination of qualitative and quantitative research methods, evaluation must include companies and competitors' satisfaction performance, good communication and implementation plan, feasible and achievable action planning and implementation that should be in line with short and long-term objectives 23,24 .
The aim of this preliminary research of the was to explore approach and attitudes of healthcare institutions managers toward marketing and public relations activities (communication activities) in the context of implementation of customer satisfaction programs and their influence on patient satisfaction.

Methods
The research was designed to define and investigate the relevance of marketing and public relations activities of healthcare institutions and their influence on implementing customer satisfaction program and customer satisfaction.The respondents were managers from different state-owned healthcare institutions (health centers, clinics, hospitals) in Serbia.The structured questionnaire form, comprising both Strana 269 open and closed questions, has been used as a main research tool.The total number of sent questionnaires was 120.During the research, we received 56 filled-in questionnaires, but 49 out of them were valid.
The problems of research of managerial implementation of customer satisfaction program and patient satisfaction are based on internal analysis of health institutions, through managers' attitude on marketing and public relations activity, institutionalization of these activities within healthcare institutions and relations with media, one of the important external groups from business environment.The media approach was researched in our study through a 3-stage scale, where a response 2 describes proactive approach (health care institution communicates with media on a regular basis), while responses 1 and 3 represent other possible approaches to media (1-reactive approach, 3 -occasionally).
The starting hypotheses were the following: H1: healthcare institutions managers who apply proactive media approach have positive attitude toward implementation of customer satisfaction program; H2: healthcare institutions which have institutionalized marketing or public relations activities have positive toward implementation of customer satisfaction program; H3 positive attitude of healthcare institutions managers to marketing and public relations activities has positive influence on customer satisfaction.
In data analysis, the SPSS statistical computer analysis package was used to analyze research findings.

Results
The results showed that 42.9% healthcare institutions apply proactive media approach, meaning that they communicate with media on a regular basis, 22.4% apply reactive approach, and 34.7% of them communicate with media occasionally.Moreover, 35.7% organizations have a person who, besides his/her basic engagements, performs activities connected with marketing and public relations, 26.5% have a person whose only activity is communication, while 28.6% of institutions do not have anyone engaged in such activities although there is a need for that.Only 4.6% of institutions do not have a need for communication activities and the same number of institutions hire consultants and marketing and public relations agencies.
Based on cross tab analysis using Chi-square likelihood ratio test we found support for hypothesis 1 (p < 0.05).Hypothesis 2 can also be accepted.The existence of a person or department responsible for marketing and public relations activities in the healthcare institutions has a significant role in supporting the change related to customer satisfaction program implementation (p < 0.05).The results about relationship between managers' positive attitude toward implementation of customer satisfaction program and patient satisfaction, are presented in Table 1.As a multiply response in hypothesis 3, we can accept that positive attitude of healthcare institutions managers to marketing and public relations activities has positive influence on patient satisfaction (69.4%).Furthermore, negative attitude of healthcare institutions managers on marketing and public relations activities has negative influence on patient satisfaction almost in the same percent (69.2%).The odds ratio was OR = 3.833 (95%CI = 1.093-13.450)and relative risk for negative attitude to generate negative influence on patient satisfaction is RR = 2.063 (95%CI = 1.086-3.918).Mantel-Haenszel Common Odds Ratio Estimate statistics revealed a statistically significant relationship (p = 0.036).

Discussion
A successful implementation of various programs and business changes implicates various management skills and recognition of various tasks 25 .The role of managers, especially their leadership style is proven as very important in implementation of decisions within any organization 26 , which also refers to healthcare organization 27,28 .
In the TQM literature, top management support is crucial for successful implementation of quality programs 29,30 .As customer satisfaction program roots are in TQM, management support is crucial for its implementation 23,24 .The role of managers in implementation of programs within healthcare organizations is usually explored in the domain of quality programs, which leads to service excellence.Management support, commitment and leadership have significant relevance for implementation of TQM program in the service sector 31 , in quality improvement program 32 , in the success or failure of any customer satisfaction program 23 , and belong to external factors that affect quality assurance program success 33 .
As we determined the significance of managers in quality program implementation, the key considerations are to determine the domain of their influence, their main tasks, attitudes and behaviour toward stakeholders and correlation with the successful program implementation, etc. Homes 25 reported tasks of managers for successful implementation of any business change, such as establishing change program terms of reference, setting up steering committee, establishing finances, establishing change control procedures, defining change program standards, conducting risk management study, determination of methodology and determination of resource requirements.Den Hartog and Verburg 34 identified main tasks of higher level managers in order to contribute attainment of high service quality, as first communicating norms and values of high quality service, and then creating rules and procedures that should be applied.
As marketing is a process of creating, communicating and delivering values to customers 35 and public relations activities imply managing communication between organization and its stakeholders 36 the authors of this study explored greater influence of marketing and public relations activities (communication activities) on customer satisfaction in health care sector.
As previously mentioned, one of the antecedents to customer satisfaction is organization image 9 .On the other hand, it is known that organization image depends on relations with external stakeholders.In this study, the authors explored the relevance of external target stakeholders of healthcare organization, especially media, and managers' behavior toward them, in order to find if there is the correlation with managers' attitude regarding implementation of quality programs, especially customer satisfaction program.
Media, as mediators in communication between any organization and its target groups, are considered as very important in healthcare sector.At general level, they have influence on healthcare system and public trust in health care 37 .The main goal of activities directed to media is to generate publicity, as specific way of communication with all other stakeholders, and the advantages of good relations with media are numerous 38 .For healthcare organizations media have significant role in creating a positive image as an important part of attaining service quality 39 .
In planning and organizing activities towards media, healthcare institution could apply one of the following approaches: defensive (reactive) -after the expressed interest of media; strategic (proactive) -active effort to create and maintain professional relationship with media; and only in an event of crisis 40 .The extreme situation is the case that activities towards media do not exist at all, but even in this case, media will find the information on healthcare issue and/or organization from other sources, if they need it.That is the reason why healthcare organization should use the media in the best way, as a tool in providing service quality 39 .
Communication between a patient and healthcare organizations can be improved by institutionalization of marketing or public relations activities, meaning planning and applying of communication strategy.Following our research, we can state that regarding media (one of the most important external stakeholders) it is preferable to use proactive communication strategy.
The study also showed media as important stakeholders in implementation of customer satisfaction program.This implies that both national healthcare institutions and media should cooperate, promote and actively participate in the process of quality improvement in healthcare institutions.
For the healthcare service marketer, proactive approach toward media influences to effective implementation of customer satisfaction program.
This preliminary study was based upon the results obtained in healthcare institutions in Serbia and was just a part of a longitudinal research project.It is necessary to perform further research in other countries in the region in order to compare various outcomes.We also need to investigate other important external stakeholders that have relevant influence on customer satisfaction program.The broader framework should also include patient perception in healthcare sector in the context of customer satisfaction.

Conclusion
Positive attitude of healthcare institutions managers towards marketing and public relations activities generates patient satisfaction in 70% of cases, and negative attitude generates negative patient satisfaction also in about 70% of cases.Negative attitude is two times higher in risk to generate negative patient satisfaction.
Healthcare institutions should apply a proactive approach to communication activities because it will positively influence better implementing and managing customer satisfaction program and patient satisfaction.By managing customer experience, healthcare institutions will be able to drive positive image, secure patient loyalty and ultimately increase profit.

Healthcare institutions managers who apply proactive media approach have positive attitude toward implementation of customer satisfac- tion program, H2 -Healthcare institutions which have institutionalized marketing or public relations activities have positive attitude toward implementation of customer satisfaction program, H3 -Positive attitude of healthcare institutions managers to marketing and public relations activities has positive influence on customer satisfac- tion, LR -likelihood ratio
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