A STUDY ON INTER RELATIONSHIP BETWEEN CLINICAL

DEPARTMENT IN TREATING OUTPATIENT IN AACHI

HOSPITALS

ABSTRACT

To derive a conceptual framework of the factors that define patient–doctor relationships from the

perspective of patients. The purpose of this research is to establish the relationship between

individual level change factors that transpires into individual and organisational benefits This

paper deals with the distinctions between the contractual and tortious liability of the doctor

towards a patient. Firstly, an outline of the legal connotation of a doctor-patient relationship will

be discussed. Next, a distinction will be drawn out between the role of a contract and a tort in

such a relationship. This paper deals with the distinctions between the contractual and tortious

liability of the doctor towards a patient. Firstly, an outline of the legal connotation of a doctor-

patient relationship will be discussed. Next, a distinction will be drawn out between the role of a

contract and a tort in such a relationship. 

Page | 1
INTRODUCTION

Page | 2
 CHAPTER 1

INTRODUCTION

The doctor–out patient relationship has been and remains a keystone of care: the medium in
which data are gathered, diagnoses and plans are made, compliance is accomplished, and
healing, out patient activation, and support are provided.1 To managed care organizations, its
importance rests also on market savvy: satisfaction with the doctor–out patient relationship is a
critical factor in people's decisions to join and stay with a specific organization.2–5

The rapid penetration of managed care into the health care market raises concern for many
patients, practitioners, and scholars about the effects that different financial and organizational
features might have on the doctor–out patientrelationship.6–10 Some such concerns represent a
blatant backlash on the part of providers against the perceived or feared deleterious effects of the
corporatization of health care practices. But objective and theoretical bases for genuine concern
remain. This article examines the foundations and features of the doctor–out patient relationship,
and how it may be affected by managed care.

A doctor–out patient relationship (DPR) is considered to be the core element in the ethical
principles of medicine. DPR is usually developed when a physician tends to a patient’s medical
needs via check-up, diagnosis, and treatment in an agreeable manner. Due to the relationship, the
doctor owes a responsibility to the out patient to proceed toward the ailment or conclude the
relationship successfully. In particular, it is essential that primary care physicians develop a
satisfactory DPR in order to deliver prime health care to patients

Page | 3
A SPECIAL RELATIONSHIP:

The relationship between doctors and their patients has received philosophical, sociological, and
literary attention since Hippocrates, and is the subject of some 8,000 articles, monographs,
chapters, and books in the modern medical literature. A robust science of the doctor–out
patienten counter and relationship can guide decision making in health care plans. We know
much about the average doctor's skills and knowledge in this area, and how to teach doctors to
relate more effectively and efficiently.11, 12 We will first review data about the importance of
the doctor–out patient relationship and the medical encounter, then discuss moral features. We
describe problems that exist and are said to exist, we promulgate principles for safeguarding
what is good and improving that which requires remediation, and we finish with a brief
discussion of practical ways that the doctor–out patient relationship can be enhanced in managed
care.

Hypothesis:

This study used the revised SERVQUAL scale items to establish dimensions of hospital service
quality through reliability, responsiveness, trust and personalization. The relationship among the
hospital service quality dimensions, overall service quality and customer satisfaction is
hypothesized and discussed.

The medical interview is the major medium of health care. Most of the medical encounter is
spent in discussion between practitioner and patient. The interview has three functions and 14
structural elements (Table 1).13 The three functions are gathering information, developing and
maintaining a therapeutic relationship, and communicating information.14 These three functions
inextricably interact. For example, a out patient who does not trust or like the practitioner will
not disclose complete information efficiently. A out patient who is anxious will not comprehend
information clearly. The relationship therefore directly determines the quality and completeness
of information elicited and understood. It is the major influence on practitioner and out patient
satisfaction and thereby contributes to practice maintenance and prevention of practitioner
burnout and turnover, and is the major determinant of compliance.15 Increasing data suggest that
patients activated in the medical encounter to ask questions and to participate in their care do
better biologically, in quality of life, and have higher satisfaction.16

Page | 4
WHY IS THE DOCTOR-PATIENT RELATIONSHIP SO IMPORTANT?

The doctor-patient relationship involves vulnerability and trust. It is one of the most moving and
meaningful experiences shared by human beings. However, this relationship and the encounters
that flow from it are not always perfect.

The doctor-patient relationship has been defined as “a consensual relationship in which the
patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts
the person as a patient.”1(p6) At its core, the doctor-patient relationship represents a fiduciary
relationship in which, by entering into the relationship, the physician agrees to respect the
patient’s autonomy, maintain confidentiality, explain treatment options, obtain informed consent,
provide the highest standard of care, and commit not to abandon the patient without giving him
or her adequate time to find a new doctor. However, such a contractual definition fails to portray
the immense and profound nature of the doctor-patient relationship. Patients sometimes reveal
secrets, worries, and fears to physicians that they have not yet disclosed to friends or family
members. Placing trust in a doctor helps them maintain or regain their health and well-being.

This unique relationship encompasses 4 key elements: mutual knowledge, trust, loyalty, and
regard.2 Knowledge refers to the doctor’s knowledge of the patient as well as the patient’s
knowledge of the doctor. Trust involves the patient’s faith in the doctor’s competence and caring,
as well as the doctor’s trust in the patient and his or her beliefs and report of symptoms. Loyalty
refers to the patient’s willingness to forgive a doctor for any inconvenience or mistake and the
doctor’s commitment not to abandon a patient. Regard implies that the patients feel as though the
doctor likes them as individuals and is “on their side.” These 4 elements constitute the
foundation of the doctor-patient relationship.

Page | 5
WHAT IS THE STRUCTURE OF THE DOCTOR-PATIENT RELATIONSHIP?

In their seminal article from 1956, Szasz and Hollender3 outlined 3 basic models of the doctor-
patient relationship.

Active-Passive Model

The active-passive model is the oldest of the 3 models. It is based on the physician acting upon
the patient, who is treated as an inanimate object. This model may be appropriate during an
emergency when the patient may be unconscious or when a delay in treatment may cause
irreparable harm. In such situations, consent (and complicated conversations) is waived.

Guidance-Cooperation Model

In the guidance-cooperation model, a doctor is placed in a position of power due to having

medical knowledge that the patient lacks. The doctor is expected to decide what is in the
patient’s best interest and to make recommendations accordingly. The patient is then expected to
comply with these recommendations.

Mutual Participation Model

The mutual participation model is based on an equal partnership between the doctor and the
patient. The patient is viewed as an expert in his or her life experiences and goals, making patient
involvement essential for designing treatment. The physician’s role is to elicit a patient’s goals
and to help achieve these goals. This model requires that both parties have equal power, are
mutually interdependent, and engage in activities that are equally satisfying to both parties.

While each of these models may be appropriate in specific situations, over the last several
decades there has been increasing support for the mutual participation model whenever it is
medically feasible.

Page | 6
FUNDAMENTALS FOR DYNAMIC DPR

Several medical reviews have covered ways to form a relationship between a physician and a
patient. Some essential features are important for maintaining a healthy DPR are covered in more
detail below:

1. Communication: Good communication skills are essential to establish DPR. Studies

have revealed that effective communication between physician and out patient has
resulted in multiple impacts on various aspects of health consequences such as:

 improved medical, functional, and emotional condition of patients;

 better out patient compliance with medical treatment;
 enhanced fulfillment of out patient toward healthcare services;
 lesser risks of medical misconduct.

2. Doctor empathy: Empathy is vital to ensure the quality of DPR. This enables the
physician to understand the symptomatic experiences and needs of individual patients.
Studies have suggested that physician empathy improves the therapeutic effect and the
patient’s quality of life.

3. Trust: Trust in doctors allows patients to effectively discuss their health issues.

Development of trust enables the out patient to comply with the doctor’s guidance, which
consequently results in improvement of health.

4. Informed consent: This is based on the moral and legal arguments of the patient’s
autonomy (independence in decision making). In relation to trust, the physician needs to
be honest with the out patient and his family to provide a genuine assessment of
favorable and unfavorable outcome probabilities, along with the suggested therapy.

5. Professional boundaries: This deals with any behavior on the part of the doctor that
transgresses the limits of the professional relationship, or boundary violations. For
example, the following behaviors should be avoided to respect professional boundaries
between the doctor and patient:

Page | 7
Michael and Enid Baling together pioneered the study of the physician out patient relationship in
the UK. Michael Balint's "The Doctor, His Out patient and the Illness" (1957) outlined several
case histories in detail and became a seminal text. [4] Their work is continued by the Balint
Society, The International Balint Federation[5] and other national Balint societies in other
countries. It is one of the most influential works on the topic of doctor-out patient relationships.
In addition, a Canadian physician known as Sir William Osler was known as one of the "Big
Four" professors at the time that the Johns Hopkins Hospital was first founded. [6] At the Johns
Hopkins Hospital, Osler had invented the world's first medical residency system.[7] In terms
of efficacy (i.e. the outcome of treatment), the doctor–out patient relationship seems to have a
"small, but statistically significant impact on healthcare outcomes".[8] However, due to a
relatively small sample size and a minimally effective test, researchers concluded additional
research on this topic is necessary.[8] Recognizing that patients receive the best care when they
work in partnership with doctors, the UK General Medical Council issued guidance for both of
doctors named "Ethical guidance for doctors" and for patients "What to expect from your doctor"
in April 2013

A government estimate puts the figure of foreign exchange spent for treatment abroad at Tk 3000
crore, with such initiatives as United Hospital Ltd., Apollo Hospital and Square Hospital have
undergone, people of Bangladesh can now rely on these hospitals.

United Group, the founders of United Hospital, was established about three decades ago in 1977.
From its humble beginnings the group has emerged today as one of the major player in the
development of the economy of Bangladesh. Its areas of activities cover power generation,
property and land development, weaving, spinning and textiles, pharmaceuticals, land port
services, travel & tourism and educational institutions.

United Hospital is one of the leading health service providers in the country with a massive 450
beds capacity. As United Hospital Ltd is a multi disciplinary Hospital, it is committed to provide
best health service; it’s always tried to develop themselves with the best doctors and equipments.
At present it does have world class equipments and bringing all the new equipments. As we can

Page | 8
see the Hospital has most of the major departments and many of them will open soon, its target is
to provide all the health care services in the world.

United Hospital Ltd is a long cherished dream of world-class health service provider in
Bangladesh has come true. We believe in building a healthy nation by healthy people. United
Hospital Limited is enriched with a dedicated team of competent medical professionals, trained
nurses and staffs to provide a complete health solution. We strongly desire to be the trendsetter
in providing quality and complete treatment and are committed to rendering medical services
better than the best. As such the latest medical equipments with the state of the art technology are
in place to facilitate the complete treatment. United hospital is one of the largest private hospitals
in Bangladesh with over 450 beds capacity spread across a total covered area of approximately
45,000 sft. Currently United Hospital is planning to establish a nurse hostel.

Tele health
With the extensive use of technology in healthcare, a new dynamic has risen in this relationship.
Telehealth is the use of telecommunications and/or electronic information to support a patient. [2This
applies to clinical care, health-related education, and health administration. [ An important fact about
telehealth is that it increases the quality of the doctor-out patient relationship by making health
resources more easily available, affordable, and more convenient for both parties. Challenges with
using telehealth are that it is harder to get reimbursements, to acquire cross-state licensure, to have

Page | 9
common standards, maintain privacy, and have proper guiding principles. The types of care that can
be provided via telehealth include general health care (wellness visits), prescriptions for medicine,
dermatology, eye exams, nutrition counseling, and mental health counseling. Just like with an in-
person visit, it is important to prepare for a telehealth consultation beforehand and have good
communication with the healthcare provider.

An interesting outcome of telehealth is that doctors have started to play a different role in the
relationship. With patients having more access to information, medical knowledge, and their health
data; doctors play the role of a translator between technical data and the patients. This has caused a
shift in the way that the doctors see themselves concerning the doctor-out patientrelationship.
Doctors who are engaged in telehealth see themselves as a guide to the out patientand undertake the
role of a guardian and information manager in the description, collection, and sharing of their
patient's data. This is the new dynamic that has risen in this ancient relationship and one which will
continue to evolve.

Effective use of the structural elements of the interview also affect the therapeutic relationship
and important outcomes such as biological and psychosocial quality of life, compliance, and
satisfaction. Effective use gives patients a sense that they have been heard and allowed to express
their major concerns,17 as well as respect,18 caring,19 empathy, self-disclosure, positive regard,
congruence, and understanding,20 and allows patients to express and reflect their feelings21 and
relate their stories in their own words.22 Interestingly, actual time spent together is less critical
than the perception by patients that they are the focus of the time and that they are accurately
heard. Other aspects important to the relationship include eliciting patients' own explanations of
their illness,23, 24 giving patients information,25, 26 and involving patients in developing a
treatment plan.27 (For an overview of this area of research, see Putnam and Lipkin, 1995.28)

A series of organizational or system factors also affect the doctor–out patientrelationship. The
accessibility of personnel, both administrative and clinical, and their courtesy level, provide a
sense that patients are important and respected, as do reasonable waiting times and attention to
personal comfort. The availability of covering nurses and doctors contributes to a sense of
security. Reminders and user-friendly educational materials create an atmosphere of caring and

Page | 10
concern. Organizations can promote a patient-centered culture,29 or one that is profit- or
physician-centered, with consequences for individual doctor–out patientrelationships.
Organizations (as well as whole health care systems) can promote continuity in clinical
relationships, which in turn affects the strength of in those relationships. For instance, a market-
based system with health insurance linked to employers' whims, with competitive provider
networks and frequent mergers and acquisitions, thwarts long-term relationships. A health plan
that includes the spectrum of outout patientand inpatient, acute and chronic services has an
opportunity to promote continuity across care settings.

The competition to enroll patients is often characterized by a combination of exaggerated

promises and efforts to deliver less. Patients may arrive at the doctor's office expecting all their
needs to be met in the way they themselves expect and define. They discover instead that the
employer's negotiator defines their needs and the managed care company has communicated
them in very fine or incomprehensible print. Primary care doctors thus become the bearers of the
bad news, and are seen as closing gates to the patient's wishes and needs. When this happens, an
immediate and enduring barrier to a trust-based patient-doctor relationship is created.

The doctor–out patient relationship is critical for vulnerable patients as they experience a
heightened reliance on the physician's competence, skills, and good will. The relationship need
not involve a difference in power but usually does,30 especially to the degree the out patient is
vulnerable or the physician is autocratic. United States law considers the relationship fiduciary;
i.e., physicians are expected and required to act in their patient's interests, even when those
interests may conflict with their own.9 In addition, the doctor–out patient relationship is
remarkable for its centrality during life-altering and meaningful times in persons' lives, times of
birth, death, severe illness, and healing. Thus, providing health care, and being a doctor, is a
moral enterprise. An incompetent doctor is judged not merely to be a poor businessperson, but
also morally blameworthy, as having not lived up to the expectations of patients, and having
violated the trust that is an essential and moral feature of the doctor–out patientrelationship.31

Page | 11
Trust is a fragile state. Deception or other, even minor, betrayals are given weight
disproportional to their occurrence, probably because of the vulnerability of the trusting party.

EFFECTS OF MANAGED CARE

A managed care organization serves a defined population with limited resources in an integrated
system of care. Thus, a single organization may both provide and pay for care. Organizations as
providers have duties such as competence, skill, and fidelity to sick members. Organizations as
payers have duties of stewardship and justice that can conflict with provider duties. Managed
care organizations thus have conflicting roles and conflicting accountability.

An organization's accountability to its member population and to individual members has a series
of inherent conflicts. Is the organization's primary accountability to its owners, to employer
purchasers, to its population of members, or to individual, sick members? If these constituents
somehow share the accountability, how are conflicting interests resolved or balanced? For
example, the use of the primary care clinician to coordinate or restrain access to other services
involves the primary care clinician in accountability for resource use as well as for care of
individual patients. Although unrestricted advocacy for all patients is never really achievable, the
proper balance and the principles of balancing between accountability to individual patients, a
population of patients, or an organization need to be made explicit and to be negotiated in new
ways.32–34

Does paying physicians by salary, capitation, risk withholds, or bonuses, with a variety of
incentives to withhold (more or less) needed care from patients, represent a conflict of interest
for physicians and violate the fiduciary nature of the relationship? All mechanisms for paying
physicians, including fee-for-service reimbursement, create financial incentives to practice
medicine in certain ways. We still lack a calculus to minimize or even describe in fine detail how
such conflicts affect our ability to justify trusting relationships. Even-handed social attention
seems appropriate to all the different mechanisms of payment. Balanced assessment of how the
details of remuneration systems influence doctor's willingness to act on behalf of patients will
best protect both the health of the public and the health of doctor–out patientrelationships. This is
a priority for a new form of empirical, ethical research.

Page | 12
“Whose doctor is it anyway?” expresses one of the most critical problems inherent in managed
care for the doctor–out patient relationship. Patients correctly wonder if doctors are caring for
them, the plan, or their own jobs or incomes (the latter is equally problematic in fee-for-service
care). This ambiguity erodes trust, promotes adversarial relationships, and inhibits patient–
centered care. The recent controversy over gag rules has only confirmed this set of fears in the
mind of the public which is now seeking regulation of the managed care industry through the
political process. As illustrated in Figure 1, the interests of patients, plans, and doctors can
overlap to a greater or lesser extent. Professional ethics dictate that physicians attempt, as
individuals and as a profession, to ensure that their interests and those of their patients are
congruent in clinical practice. Plan interests, however, can pull physicians away from this goal,
as the organization's values and their implementation inevitably influence attitudes, behavior,
and experiences. Alternatively, plans could promote patient-centered care by trying to maximize
the extent to which patient, doctor, and plan interests overlap. For example, promoting
continuity, communication, and prevention can further all three interests so long as value (and
not cost alone) is seen as the plan's product. Similarly, resource stewardship can be honestly
promoted as a way to ensure that quality care is available for future patients.

Page | 13
Another feature of managed care organizations is their emphasis, in principle, on primary care.
They often rely on primary care clinicians to manage, coordinate, or restrain access to other
services. Members are required to choose or are assigned a primary care physician. With the
primary care emphasis comes an opportunity for the development of strong relationships
between primary care doctors and their patients. In addition, new relationships with patients who
in the past never sought care and seldom entered into a doctor–out patientrelationship may be
more likely in a system that emphasizes wellness and primary care, although this may be more
apparent than real. It is unclear at present how a “relationship” between a primary care physician
and a member of the physician's panel, who have never met, should be characterized, or what
responsibilities are associated with it. It is not yet demonstrated that an emphasis, in principle, on
primary care leads to stronger relationships, and to what extent countervailing forces such as lack
of continuity counter this.

Page | 14
Integrated systems, characteristic of most managed care plans, introduce opportunities for
improvement in continuity across the spectrum of care. For example, opportunities arise for case
management or for coordinating care between doctors' offices, hospitals, nursing homes, and
home care so that individuals do not fall through the cracks of a fragmented system. With
integration come new responsibilities for doctors and other health care practitioners for
communication, teamwork, and a more longitudinal approach to out patientcare. This continuity
may be thwarted, however, by turnover in Doctorsor members.

Standardization of practice, sometimes relying on “evidence–based medicine,” is often used by

managed care to minimize costs or maximize or ensure quality of care. Standardization is often
touted as promoting fairness by treating like individuals in like manner. Both standardization and
the application of evidence-based principles in choosing care standards, however, rely on value
judgments about what counts as good evidence and how that evidence should be interpreted and
applied. The danger to the doctor–out patientrelationship in these movements is that individual
patients with their individual needs and preferences may be considered secondary to following
practice guidelines, adherence to which may form part of an evaluation measure of physician's
performance. Using practice guidelines and the “standard of care” to determine which benefits
are covered, and for whom, ignores the incredible variation in out patientpreferences and
characteristics. This approach treats the disease without reference to the illness. 35 Rather than
treating individuals with similar illnesses in like manner, the result is that individuals who
merely have the same disease are treated in like manner. Fairness is sacrificed to
uniformity.36 Reliance on “data” may discount the patient's own story, thus discounting specific
evidence about personal aspects of disease and its meaning and value. Obviously, discounting
the person depreciates the relationship.

Continuous quality improvement and total quality management are industrial strategies37 lately
applied in the health care arena. Although quality improvement efforts are by no means unique to
managed care organizations (MCOs) in the health care industry, a few individual MCOs and the
American Association of Health Plans have been leaders in promoting quality initiatives and
include them in the accreditation process. Implementing continuous quality improvement may
work for the doctor–out patientrelationship by enhancing competence and the perception of
competence, or it may work against the doctor–out patientrelationship if it diminishes

Page | 15
practitioner flexibility or accountability, or if it is perceived by practitioners as a manifestation of
distrust by the organization.

The effort to cut costs to increase competitiveness or profit means having doctors be more
“productive” by seeing patients faster. The first thing dropped as visit length shortens is
psychosocial discussion.38 So far, the average length of visits in the United States does not seem
to have dropped significantly, probably because of inherent inefficiencies in scheduling and
doctors' abilities to finagle time to fit the needs of patients. 39 Yet both patients and doctors feel a
heightened sense of time pressure, and patients worry about being on a conveyor belt with a
production-line-oriented doctor. As companies attempt to increase providers' efficiency, these
fears will be realized unless thwarted by consumers, professionals, or more visionary
organizations. Less time, otherwise, will mean less relating time and damage to care: less-
accurate and incomplete data; difficulty in identifying the real problems; less efficiency in test
and treatment choices based on knowledge of the individual patient; less trust; less healing; more
errors and more waste.39 A penny of good communication time may avert a pound of unnecessary
or even harmful spending used to reassure an anxious out patientor substitute for a sketchy
history.

FUNCTIONS OF OUT PATIENT

Out patient Department is one of the department of the hospital which cares for the
ambulatory out patient who come for diagnosis, treatment and follow up.

The role and functions of out out patient services include:

1. To provide for the community a major source of specialist diagnostic medical opinion by
mixing the knowledge, skills and ability of the specialist and supported by the resources
of the hospital.
2. These include not only the physical resources but also the materials and machines, which
facilitates early diagnosis with support of paramedical Doctors and other allied health
profession

Page | 16
 3. To treat on ambulatory and domiciliary basis all cases which can be treated in
the Out out patient Department.
4. To refer patients for admission to the hospital of those who need it. About 80% of total
admissions are through OUT PATIENT.
5. To carry out after care and medical rehabilitation, when necessary, after discharge from
hospital.
6. To promote health of the individuals under care in the Out out patient Department by
means of health education.
7. To train medical students, house physicians and other professional Doctors such as
nurses and technicians with valuable and diversified clinical experiences.
8. To carry out preventive and primitive services through provision of immunization,
screening, antenatal, counseling, family welfare clinics etc.
9. To compile, collate and analyze records of patients using outout patient services for
epidemiological, social clinical research and for periodic assessment of clinical outcomes
etc.

STRATEGIES FOR MANAGED CARE PLANS

A number of strategies that MCOs can use to strengthen doctor–out patient relationships are
listed in Often, plans do not know how to detect and remediate problems in doctor–out patient
relationships, how to train their practitioners and their Doctors to relate effectively and
efficiently, or how to train their enrollees to be effective in their own care. As we now know how
to do all of these things, there is no longer justification for poor performance in the encounters
between providers and patients. Doctors need training in dealing with difficult patients, about
common aspects of life adjustment such as reaction to illness, in recognizing the underlying
psychological problems that remain a leading cause of seeking medical care, in negotiating, and
in handling tough situations like breaking bad news. Courses such as those of the American
Academy on Physician and Out patient(AAPP) can provide such skill. Patients need to be taught
to organize their approach to care, to ask questions, to negotiate, and to discuss feelings. The
AAPP, the Northwest Institute, the Bager Institute, and others can provide such training.

Page | 17
Plans can promote a culture that is patient- and member-centered. This variation on “put the
customer first” acknowledges the vulnerability of patients as ill persons needing care,
compassion, and special attention. It also implicitly and explicitly makes care, not profit, the
center of attention for those doing the daily work of providing health care. Physicians and other
clinicians are encouraged to put their patients' good first, ahead of profit (their own or the
organization's), politics (e.g., reluctance to whistle blow or disclose mistakes), or personnel (e.g.,
the convenience of the other staff). Conserving resources for future patients or to expand services
becomes an important part of serving the member population. Although creating a culture that is
patient-centered is not a quick or easy task, there are resources available.44

It is useful for plans to separate out patient care from administrative rules communication. Too
often, the practitioner is the person who has the difficult task of saying “no” to a patient.45 Plans
can be purposefully deceptive or vague in communicating what they will not do for a member,
when they are trying to enroll new members.46 It would ease the situation between doctor and
out patient if the out patient clearly understood when the doctor said no that (when applicable)
this is not the doctor's decision but the plan's. This approach is likely to require regulatory
change.

Plans can structure contracts with employers that encourage accountability to the membership
rather than the employer. It is hard to balance the competing interests of sick and well members,
those who need resources now and those who may need them later, Doctors and the community.
Employers' standing in decisions that affect primarily their employee members adds more
complexity, and is fraught with conflict. The illusion remains that employers pay for health
insurance. This illusion, however, affects how health insurers view their accountability. Managed
care plans do what it takes to please employers, because employees are their customers. The
member, sick or well, has little voice. One way to alleviate this situation is to ensure that
members have a voice, either through their employer or union, or in the health plan itself, for
example, through representation on guideline development initiatives or benefits committees. If
policies can be said to be self-imposed by the membership, physicians making judgments about
resource use are acting for their patients, current and future, and not for employers.47, 48
Another strategy is to require management to use the same plans their employees do.

Page | 18
OBJECTIVES OF THE STUDY

The objectives of this study are:

1. To investigate the influence of Interrelationship between towards the doctor and out patient.
2. To explore at what extent out patient out patient staffs acts a meaning indicator to measure out
out patient Inter relationship.
3. To treat on ambulatory and domiciliary basis all cases which can be treated in the Out
out patient Department.
4. To refer patients for admission to the hospital of those who need it. About 80% of total
admissions are through Out Patient.
5. To carry out after care and medical rehabilitation, when necessary, after discharge from
hospital.

6. to study the Inter of the out patient communication

SCOPE OF THE STUDY

 To consolidate core areas of relationship in-patient, out-out patient and community based
health services delivery
 To consolidate and introduce a select number of specialized services directly expected to
improve patients care, physiotherapy, clinical pastoral care, etc
 To secure, train and retain a sufficient number of qualified satisfied and committed
personnel through development of comprehensive human resources strategic plan
 To sensitize the relationship management of the facility and the health providers to the
needs of their patients
 To demonstrate an improvement in out out patient relationship through the use of this
tool.

Page | 19
Significance of the study:

From the company’s perspective this study will help AACHI HOSPITALto understand its
position in terms of satisfying its customers. It will help them to know which service attributes
are most important for the customers. They will be able to understand in which area of services
AACHI HOSPITALlack most and thus improve the quality of their service. They will
understand which customer groups are more potential. They will also be able to know which
treatment’s sector of AACHI HOSPITALare mostly preferred by the customers. This study will
also help other hospitals and service organizations to understand the factors that affect the inter
relationship between doctors and outout patient level of the patients and thus they will be able to
improve their services.

Limitations:

 Most of the time patients are not that friendly to fill up questionnaire or to talk for a little
while.
 To measure the visibility, a sample survey is conducted which may not represent the
entire population.
 Every organization has their own secretary that is not revealed to others. While collecting
data, sometimes they might not disclose much information for the sake of confidentiality
of the organization.

Page | 20
REVIEW OF LITERATURE

Page | 21
 CHAPTER 2

REVIEW OF LITERATURE

The patient–doctor relationship is thought to be important, but research demonstrating its value has been
hampered by a lack of clarity about what is meant by the term. Drawing on published qualitative studies with
patients, two key aspects are identified: factors that develop or maintain the relationship (longitudinal care and
patients' consultation experiences), and factors that characterise an ongoing depth of relationship (knowledge,
trust, loyalty, and regard). Further work is required to substantiate the distinctiveness of these elements, how
they influence one another, and their significance for out patientcare.

The first researcher was a GP with prior experience of conducting research on continuity and interpersonal
care. The researcher approached the studies with a particular interest in identifying how the patient–doctor
relationship was described in terms of communication skills, continuity, and ongoing relationship
characteristics such as trust. Atlas.ti (version 5.0, Scientific Software) was used to aid the analysis, using
electronic copies of the articles as primary documents. After reading and re-reading each document codes were
attached to sections of text relating to different aspects of patient–doctor relationships. A detailed indexing
system was employed, which meant applying multiple codes to sections of text, even if it was suspected that
any differences were minor. All codes were given a working definition to ensure that they were used
consistently. It was an iterative process, so the codes evolved over repeated readings of the articles.

Hall, Bobinski & Orentliche It was decided to perform a thematic synthesis,12 which allows clear
identification of prominent themes, and provides an organized, structured, and yet flexible, way of dealing with
the articles under these themes. Where studies interviewed patients and healthcare team members, only
sections on patients' views were included. Two researchers independently read the selected papers, focusing on
the findings and discussion sections, and identified themes. However, they were from different professional
backgrounds and undertook the analysis in alternative ways.

Creating a good inter-personal relationship between doctors and patients can be seen as an important
purpose of communication [20, 35-37]. Roter and Hall [20] state that "...talk is the main ingredient in
medical care and it is the fundamental instrument by which the doctor-out patient relationship is crafted

Page | 22
and by which therapeutic goals are achieved". From this viewpoint, a good interpersonal relationship can
be regarded as a prerequisite for optimal medical care. Communication researchers have different
opinions on how to define a good interrelationship. Some authors refer to this relationship mainly as a
social relationship where 'good manners' are most important. Necessary 'ingredients' are: laughing or
making jokes, making personal remarks, giving the outpatient compliments, conveying interest,
friendliness, honesty, a desire to help, devotion, a non judgmental attitude and a social orientation [9, 10,
36, 38, 39]

Other authors with a more clinical/psychotherapeutically background claim that the importance of a good
doctor-out patient relationship is determined by its therapeutic qualities. Irwin et al. [40] see clinical
medicine as communication between two people aiming to establish or sustain an effective working
relationship in which mutual trust exists. Many of the concepts used by these psychotherapeutically
oriented researchers are based on Carl Rogers' 'client centered' theory. He distinguished basic 'core
conditions' which are crucial to the efficacy of the therapy: empathy, respect, genuineness, unconditional
acceptance, and warmth [41,42]. Even though different authors define empathy in different ways, they
agree that this core condition must be considered very important [17, 43]. Empathic doctor-out patient
relations consist of: eliciting feelings, paraphrasing and reflecting, using silence, listening to what the out
patient is saying, but also to what he is unable to say, encouragements and non-verbal behavior

The Patient-Centered Method can be seen as an example of a more care oriented system. Many medical
problems, however, cannot be solved by either instrumental or affective behavior. An interaction analysis
system which attempts to capture both types of behavior, such as the Roter Interaction Analysis System,
seems most realistic. Besides the cure-care distinction, observation instruments differ from each other
with regard to their clinical relevance (is the system specifically designed for analyzing communication in
the medical setting?), observational strategy (coding from video-, audiotape, direct observation or literal
transcripts?), reliability/validity, and channels of communicative behavior (applicable to verbal, non-
verbal behavior or both). Table 1 shows the differences between twelve interaction analysis systems.

Platt and McMath [88] use the term "high control style" as an example of "clinical hypo competence" in
internal medicine. It involves behaviors such as asking many questions and interrupting frequently. This
way the doctor keeps tight control over the interaction and does not let the out patient speak at any length.

Page | 23
'Control' was used by Kaplan et al. [13] as one of three categories for classifying doctor-out patient
communication. An utterance is classified in the control category when it is aimed at controlling the
behavior of the other party. They distinguish three patterns which describe all conversation during the
consultation, including 'physician direction' (questions, interruptions, etc. by the doctor), 'out patient
direction' (questions, interruptions by the patient) and 'affect/opinion exchange'. The first two patterns
include controlling behaviors

Buller and Buller [10] state that there are two general styles displayed by physicians during medical
visits: affiliation (affective behavior) and control. Control "includes behaviors that establish and maintain
the physicians control in the medical interaction": dominating conversations, verbally exaggerating to
emphasize a point, dramatizing, being very argumentative, constantly making gestures when
communicating

Hadlow and Pitts examined the understanding of common health terms by doctors, nurses and patients.
The results of this survey showed that clear differences of understanding of common medical and
psychological terms exist between doctors, nurses, other health care professionals and patients. The level
of correct understanding was highest for physicians (70%) and lowest for patients (36%). The widest gap
in physician-out patient understanding was with respect to common psychological terms, e.g. depression,
migraine, eating disorders. Terms like these are often used in doctor-out patient interactions.

Carter et al. found a positive relationship between 'sharing opinions' and 'out patient knowledge about
illness', and subsequent adherence to medical recommendations. In an overview of Roter's met analysis
[78] it was shown that compliance was weakly related to physician behavior. Compliance was only
associated with more information-giving and positive talk. Compliance was negatively related to doctors'
question asking and negative talk.

Stewart examined physicians' patient-centered behaviors, namely those in which the patients' points of
view are actively sought by the physician. Results demonstrated that a high frequency of patient centered
behavior was related to higher reported compliance. It did not however have an effect on objectively
measured compliance, namely better pill counts

Larsen and Smith studied the relationship between doctors' non-verbal activities and out
patientsatisfaction. A higher non-verbal score in overall doctors' 'immediacy' (degree of closeness in
interactions) was associated with higher out patient satisfaction. An interesting finding was that
physicians' touch was associated with lower satisfaction. It is possible that touch was perceived by the
patients as a violation of their physical privacy. In Scarpaci's study [87] however, being touched by the

Page | 24
physician was frequently cited by Chilean patients as a reason why they believed that the care they
received was good. Apparently, cultural differences play a role

Young, Gary J. JD, Meterko, Mark, Desai, Kamal R , 2000.

There are a growing number of efforts to compare the service quality of health care organizations
on the basis of out patients satisfaction data. Such efforts inevitably raise questions about the
fairness of the comparisons. Fair comparisons presumably should not penalize (or reward) health
care organizations for factors that influence satisfaction scores but are not within the control of
managers or clinicians. On the basis of previous research, these factors might include the
demographic characteristics of patients (e.g.-age) and the institutional characteristics (e.g.-size)
of the health care organizations where care was received. The goal of this study was to examine
the extent to which a patient's satisfaction scores are related to both his/her demographic
characteristics and the institutional characteristics of the health care organization where care was
received. Conducted an analysis of secondary data from the Veterans Health Administration
(VHA), US Department of Veterans Affairs. The database contained out patientresponses to self-
administered satisfaction questionnaires and information about demographic institutional
characteristics of the hospitals where patients received their care. Among demographic
characteristics, age, health status, and race consistently had a statistically significant effect on
satisfaction scores. Among the institutional characteristics, hospital size consistently had a
significant effect on out patientsatisfaction scores. Study results can be interpreted as justifying
the need to adjust out patientsatisfaction scores for differences in out patientpopulation among
health care organizations. However, from a policy perspective, such adjustments may ultimately
create a disincentive for health care organizations to customize their care.

Service quality has become an important research topic in view of its significant relationship to
costs (Crosby, 1979), profitability (Rust and Zahorik, 1993), customer satisfaction (Boulding et
al., 1993), customer retention (Reichheld and Sasser, 1990), service guarantees (Kandampuly
and Butler, 2001), and financial performance (Buttle, 1996). Wan Edura Wan Rashid, Hj.
Kamaruzaman Jusoff,1 (2009) attempted to explore the concept of service quality in a health
care setting. This paper probes the definition of service quality from technical and functional
aspects for a better understanding on how consumers evaluate the quality of health care. It adopts
the conceptual model of service quality frequently used by the most researchers in the health care

Page | 25
sector. Daniel Butler, Sharon L. Oswald, Douglas E. Turner (1996) investigated the effects of
demographic factors on users and observers of perceived hospital quality and noted that previous
research suggests the components of perceived service quality are industry specific, and that calls
have been made for academics to integrate their theory into practice. At the end the researcher
found that perceived quality is industry specific, users and observers differ in their perceptions of
hospital quality and demographic factors do make a difference in perceived hospital quality.

Page | 26
PROFILE OF THE HOSPITAL
ACHI

Page | 27
 CHAPTER -3

PROFILE OF THE HOSPITAL

A Health Care Provider of Western Approach with an Indian Touch. AACHI HOSPITAL is the
most trusted Multispecialty Hospital in the Southern Indian City of karur .The relentless service
of AACHI HOSPITAL in the past 12 years, taken health care to the most modern levels in the
region catering to urban and rural population. Aachi Maternity & Eye Hospital in Namakkal.
Hospitals with Address, Contact Number, Photos, Maps. View Aachi Maternity & Eye Hospital,
Namakkal on Justdial.

A Commitment:
The AACHI HOSPITAL over the years has been playing an active role in nation building in
many ways.
The Group is known for its philanthropic works as well. Innumerable charities and trusts for the
uplift of the underprivileged have been set up. Technology museums, planetary, educational
institutions and hospitals testified”
Among the finest Hospitals in the city, Aachi Maternity & Eye Hospital in Paramathi Velur,
Namakkal is known for offering excellent patient care. The clinic is located centrally in
Paramathi Velur, a prominent locality in the city. It stands close to Opposite Lions Club, Kandar

Page | 28
Nagar which not only makes it convenient for people from the vicinity to consult the doctor but
also for those from other neighbourhoods to seek medical guidance. There is no dearth of public
modes of transport to reach the clinic from all major areas of the city. A landmark medical
institution with more than 400 beds, CMRI has tie up with Cleveland Clinic Foundation, the No.
1 Heart Hospital in America for 10 years in a row, to provide international healthcare.

VISION, MISSION & COMMITMENT OF CMRI

VISSION: To be the leading multispecialty healthcare & research institute in eastern India with
world class standards of quality & service.

MISSION: To offer the highest standards of medical treatments with utmost care compassion &
commitment to all sections of the society at best value-for-money costs.

COMMITMENT: To constantly upgrade our human & technological resources in order to keep
pace with best global development in medical science.

OBJECTIVES OF HOSPITALS

Top management has established the following objectives, which are measureable and consistent
with the quality policy. The objectives are as follows:

 To provide efficient, effective, timely care with a human touch to our patients.
 To provide effective quality systems through feedback mechanism for continual
improvement.
 To create a congenial work environment, provide can the job training and quality
concepts or systems to all concerned.
 To provide facilities for proper disposal of waste as per the prevailing statutory and
regulatory requirements.

Our departments of cardiology, cardiac surgery, oncology, gynecology, orthopedic and

pediatrics are staffed by the most esteemed doctors in their respective fields. As an example, a
glimpse at our cardiology department would reveal that till date we have conducted over 5440
open heart surgeries and over 22169 angiograms and angioplasty operations. That’s over 4-6
heart related surgeries per day alone since our inception.

Page | 29
With their technology and their expertise, and with the support of their friendly staff, they strive
each day to be the number one health care provider, not only within Bangladesh but within the
Asia-Pacific region.

Quality

Operating at the highest standards of safe and ethical practices and demonstrating continuous
improvement.

Effectiveness

Selecting the most appropriate services to produce the desired health outcomes.

Integration

Providing clear pathways by ensuring collaboration, consultation, effective communication with

health service providers.

Caring for the Community

Promoting health and providing care based on a commitment to well being of the patients.

Caring for our staff

Caring for the health of our Doctorsand developing a culture of trust, and training for personal
growth.

Research and Training

Providing an environment that promotes personal development, learning and research.

Vision

Page | 30
  To be the hospital of choice for patients, physicians and employees in Bangladesh
because of our preeminent out patientcare and teaching programs.
 To be well recognized as a technology leader in Dhaka.
 To be a prominent community member known for meeting the healthcare needs of the
entire community through incomparable out patientcare and wellness programs.

Intensive Care Unit:

They provide state of the art specialized personal care for every critical out patienton 1:1 basis
nursing service supervised by trained ICU doctors 24 hours a day, 7 days a week.

Their ICU Services & Facilities are:

 24 hours supervision under-guidance of highly trained consultant with 10 year overseas

experience in ICU.
 24 hours trained nursing Doctorsfor each individual patient.
 Central monitoring system.
 Portable X-ray machine within ICU
 Facility to implant temporary pacemaker
 Hi-tech vital sign monitor for every patient

Supporting Facilities

 We have 4 Ambulances, 2 are equipped with all types of support required for cardiac
patients.
 Ambulance support is provided countrywide.
 Emergency department has instant access to our Consultants and other departments.
 AACHI HOSPITALhas its own Radiology and Pathological departments for instant
diagnosis, including a licensed Blood Bank.
 We have our own power generation capacity of 2.4 MW.
 In-house F&B facility to cater 1500 meals per day.
 In house laundry and housekeeping services to satisfy patients.

Page | 31
Medical and Professional services

Blood Bank

Many patients are eligible to donate blood for their own use (antilogous donor) (antilogous =
Derived or transferred from the same individual's body). We can ask our physician for
information about whether or not we can be an antilogous Dona

Cardiac Rehabilitation

The Cardiac Rehabilitation program will assist us in achieving and maintaining a healthy life-
style. We will have the opportunity to learn more about our own cardiac disease. To become
more aware of our risk factors and we will be educated in the most beneficial way to exercise
after having a cardiac event.

Cardiopulmonary

Certified therapists and technicians identify and treat breathing and lung problems, administering
breathing and oxygen treatments and monitoring patients requiring mechanical ventilation. The
department also provides ECG testing and EEG testing as well as a pulmonary rehabilitation
program.

Intensive Care Unit

Our Intensive Care Unit is designed to provide a concentration of skills, state-of-art equipment
and facilities. Highly skilled and specially trained critical care nurses directed by physicians and
supported by other members of our healthcare team are dedicated to delivering the highest level
of medical care possible.

Emergency Services

The Emergency Services Department is a 24-hour, full service emergency department,

responding promptly with the highest degree of commitment to delivering quality emergency
care. Specialty rooms are maintained to handle cases of cardiovascular illness, trauma,
orthopedic injuries and pediatric patients. Specially trained emergency nurses trained in Advance
Cardiac Life Support (PALS) support our physician.

Page | 32
Laboratory

The hospital offers a full service laboratory that is staffed 24 hours a day, seven days a week for
in out patient services. On Fridays and holidays, the laboratory is closed for out out patient
services except for the Emergency Department.

Page | 33
RESEARCH METHODOLOGY

CHAPTER 4

RESEARCH METHODOLOGY
Page | 34
Research Methodology covers the following: 
1.Data Collection Method 
2.Source of Data
3.Tools for data Collection  
4.Sampling size
5. Compiling of Data

1. Data Collection Method: 

The researcher used scheduled interview method using questionnaire for   primary data, 
secondary data are collected from different sources. 

2. Sources of Data: 

Primary data  were  collected  through  questionnaire  from  employees. Secondary data 

were  collected  from  company  profile,  brochures  and  past reports. 

3. Tools for Data Collection: 

The data collection method adopted for the project is prepared through a set of
questionnaire. Their responses and feedback is noted down in the questionnaire. 

4. Sampling size 

100 employees of  the foundries

5. Compiling of Data 

The primary data and secondary data collected from different sources are made intabular
form.  They are arranged according to different factors for easy inference and analysis.

 Simple average method

 Chi square test

Research model:

Page | 35
This study proposed that hospital service quality dimensions include reliability, responsiveness,
trust and personalization, and moreover developed a research model for understanding the
perceptions of rational customers regarding hospital services. The model proposed that hospital
service quality dimensions are casually linked to the level of customer satisfaction and in turn
influence customer purchase decision. The Hospital Service Quality Dimension is as follows:

Page | 36
DATA ANALYSIS & INTERPRETATION

CHAPTER 5
Page | 37
 DATA ANALYSIS & INTERPRETATION

Frequency Test:

1. Age

TABLE 5.1: Age

Frequency Percent Valid Percent Cumulative Percent
Valid 1-15yrs 7 5.8 5.8 5.8
16-30yrs 23 19.2 19.2 25.0
31-45yrs 34 28.3 28.3 53.3
46-60yrs 34 28.3 28.3 81.7
61+yrs 22 18.3 18.3 100.0
Total 120 100.0 100.0

LAY OF CHART 5.1.1

Interpretation:

The table and bar chart illustrated above shows frequency distribution of gender of the
respondents. Out of total 120 respondents, 7 respondents were between the age group 1-15 years,

Page | 38
23 were between 16 to 30, 34 were between the age group 31 to 45, 34 were between 46 to 60
and 22 were above 61 years.

2. Gender

TABLE 5.2 : Gender

Cumulative
Frequency Percent Valid Percent Percent
Valid male 75 62.5 62.5 62.5
female 45 37.5 37.5 100.0
Total 120 100.0 100.0

Interpretation:

The table and bar chart illustrated above shows frequency distribution of gender of the
respondents. Out of total 120 respondents, 75 respondents were male and 45 respondents were
female. If we convert it to percentage figure, male respondents constitute 62.5% and on the other
hand, female respondents constitute 37.5% of the total respondents.

3. When I have a problem, the hospital show a sincere interest in solving with doctors

Page | 39
 TABLE 5.3: Hospital shows a sincere interest in solving it
Frequency Percent Valid Percent Cumulative Percent
Vali dissatisfied 8 6.7 6.7 6.7
d somewhat satisfied 28 23.3 23.3 30.0
satisfied 54 45.0 45.0 75.0
strongly satisfied 30 25.0 25.0 100.0
Total 120 100.0 100.0

LAY OF CHART:3

Interpretation:

As per the variable “When I have a problem, the hospital shows a sincere interest in solving
it” and the factors were classified into four prime categories and those were dissatisfied,
somewhat satisfied, satisfied and strongly satisfied. Out of 120 respondents a majority went for
satisfied. The factors like Satisfied had taken 45%, Strongly satisfied 25%, Somewhat satisfied
had 23% and Dissatisfied had taken 6.7%. So, when patients have a problem, the hospital shows
a sincere interest in solving it has been proved.

4. The facilities are clean, comfortable and attractive

Page | 40
 TABLE 5.4: The facilities are clean, comfortable and attractive
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 5 4.2 4.2 4.2
somewhat satisfied 27 22.5 22.5 26.7
satisfied 50 41.7 41.7 68.3
strongly satisfied 38 31.7 31.7 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “The facilities are clean, comfortable and attractive” and the factors were
classified into four prime categories and those were dissatisfied, somewhat satisfied, satisfied
and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors like
Satisfied had taken 41.7%, Strongly satisfied 31.7%, Somewhat satisfied had 22.5% and
Dissatisfied had taken 4.2%. So, the facilities are clean, comfortable and attractive has been
proved.

5. We feel safe in getting treated by the doctors

Page | 41
 TABLE 5.5: We feel safe in getting treated by the doctors
Frequency Percent Valid Percent Cumulative Percent
Valid dissatisfied 9 7.5 7.5 7.5
somewhat satisfied 19 15.8 15.8 23.3
satisfied 57 47.5 47.5 70.8
strongly satisfied 35 29.2 29.2 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “We feel safe in getting treated by the doctors” and the factors were
classified into four prime categories and those were dissatisfied, somewhat satisfied, satisfied
and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors like
Satisfied had taken 47.5%, Strongly satisfied 29.2%, Somewhat satisfied had 15.8% and
Dissatisfied had taken 7.5%. So, we feel safe in getting treated by the doctors has been proved.

6. The hospital has adequate security system

Page | 42
 TABLE 5.6: The hospital has adequate security system
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 4 3.3 3.3 3.3
somewhat satisfied 28 23.3 23.3 26.7
satisfied 56 46.7 46.7 73.3
strongly satisfied 32 26.7 26.7 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “The hospital has adequate security system” and the factors were
classified into four prime categories and those were dissatisfied, somewhat satisfied, satisfied
and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors like
Satisfied had taken 46.7%, Strongly satisfied 26.7%, Somewhat satisfied had 23.3% and
Dissatisfied had taken 3.3%. So, The hospital has adequate security system has been proved.

7. Hospital staffs give prompt attention

Page | 43
 TABLE 5.7 Hospital staffs give prompt attention
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 11 9.2 9.2 9.2
somewhat satisfied 24 20.0 20.0 29.2
satisfied 46 38.3 38.3 67.5
strongly satisfied 39 32.5 32.5 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “Hospital staffs give prompt attention” and the factors were classified into
four prime categories and those were dissatisfied, somewhat satisfied, satisfied and strongly
satisfied. Out of 120 respondents a majority went for satisfied. The factors like Satisfied had
taken 38.3%, Strongly satisfied 32.5%, Somewhat satisfied had 20% and Dissatisfied had taken
9.2%. So, hospital staffs give prompt attention to the patients has been proved.

8. Hospital staffs treat me with respect

Page | 44
 TABLE 5.8: Hospital Doctors treat me with respect
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 7 5.8 5.8 5.8
somewhat satisfied 29 24.2 24.2 30.0
satisfied 52 43.3 43.3 73.3
strongly satisfied 32 26.7 26.7 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “Hospital Doctorstreat me with respect” and the factors were classified
into four prime categories and those were dissatisfied, somewhat satisfied, satisfied and strongly
satisfied. Out of 120 respondents a majority went for satisfied. The factors like Satisfied had
taken 43.3%, Strongly satisfied 26.7%, Somewhat satisfied had 24.2% and Dissatisfied had taken
5.8%. So, hospital staffs treat their patients with respect has been proved.

9. Hospital doctor are Doctorshelps according to my need out out patient

Page | 45
 TABLE 5.9: Hospital Doctorshelps according to my need
Valid Cumulative
Frequency Percent Percent Percent
Valid dissatisfied 7 5.8 5.8 5.8
somewhat 28 23.3 23.3 29.2
satisfied
satisfied 45 37.5 37.5 66.7
strongly satisfied 40 33.3 33.3 100.0

Total 120 100.0 100.0

Interpretation:

As per the variable “Hospital Doctorshelps according to my need” and the factors were
classified into four prime categories and those were dissatisfied, somewhat satisfied, satisfied
and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors like
Satisfied had taken 37.5%, Strongly satisfied 33.3%, Somewhat satisfied had 23.3% and
Dissatisfied had taken 5.8%. So, hospital staffs help their patients according to their need has
been proved.

10. Doctors and out out patientare available to me when I need

Page | 46
 TABLE 5.10: Doctors are available to me when I need
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 6 5.0 5.0 5.0
somewhat satisfied 22 18.3 18.3 23.3
satisfied 52 43.3 43.3 66.7
strongly satisfied 40 33.3 33.3 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “Doctors are available to me when I need” and the factors were classified
into four prime categories and those were dissatisfied, somewhat satisfied, satisfied and strongly
satisfied. Out of 120 respondents a majority went for satisfied. The factors like Satisfied had
taken 43.3%, Strongly satisfied 33.3%, Somewhat satisfied had 18.3% and Dissatisfied had taken
5.0%. So, doctors are available to the patients according to their need has been proved.

11. The services I need are completely available

Page | 47
 TABLE 5.11: The services I need are completely available
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 10 8.3 8.3 8.3
somewhat satisfied 26 21.7 21.7 30.0
satisfied 50 41.7 41.7 71.7
strongly satisfied 34 28.3 28.3 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “The services I need are completely available” and the factors were
classified into four prime categories and those were dissatisfied, somewhat satisfied, satisfied
and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors like
Satisfied had taken 41.7%, Strongly satisfied 28.3%, Somewhat satisfied had 21.7% and
Dissatisfied had taken 8.3%. So, The services the patients need are completely available has been
proved.

12. Any complaints I have about the bill are handled well

Page | 48
 TABLE 5.12: Any complaints I have about the bill are handled well
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 6 5.0 5.0 5.0
somewhat satisfied 30 25.0 25.0 30.0
satisfied 52 43.3 43.3 73.3
strongly satisfied 32 26.7 26.7 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “Any complaints I have about the bill are handled well” and the factors
were classified into four prime categories and those were dissatisfied, somewhat satisfied,
satisfied and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors
like Satisfied had taken 43.3%, Strongly satisfied 26.7%, Somewhat satisfied had 25% and
Dissatisfied had taken 5%. So, any complaints the patients have about the bill are handled well
has been proved.

13. Hospital staffs are caring and pleasant to deal with out out patie

Page | 49
 TABLE 5.13: Hospital Doctorsare caring and pleasant to deal with
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 8 6.7 6.7 6.7
somewhat satisfied 27 22.5 22.5 29.2
satisfied 48 40.0 40.0 69.2
strongly satisfied 37 30.8 30.8 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “Hospital staffs are caring and pleasant to deal with” and the factors were
classified into four prime categories and those were dissatisfied, somewhat satisfied, satisfied
and strongly satisfied. Out of 120 respondents a majority went for satisfied. The factors like
Satisfied had taken 40%, Strongly satisfied 30.8%, Somewhat satisfied had 22.5% and
Dissatisfied had taken 6.7%. So, Hospital staffs are caring and pleasant to deal with the patients
has been proved.

14. The support activities (counter dealing, communication etc) are excellent relationship

Page | 50
 TABLE 5.14: The support activities (counter dealing, communication etc) are
excellent
Frequency Percent Valid Percent Cumulative Percent
Valid dissatisfied 4 3.3 3.3 3.3
somewhat satisfied 27 22.5 22.5 25.8
satisfied 57 47.5 47.5 73.3
strongly satisfied 32 26.7 26.7 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “The support activities (counter dealing, communication etc) are
excellent” and the factors were classified into four prime categories and those were dissatisfied,
somewhat satisfied, satisfied and strongly satisfied. Out of 120 respondents a majority went for
satisfied. The factors like Satisfied had taken 47.5%, Strongly satisfied 26.7%, Somewhat
satisfied had 22.5% and Dissatisfied had taken 3.3%. So, the support activities are excellent to
the patients has been proved.

15. After being discharged, I am able to stay in contact with the hospital easily with doctor

Page | 51
 TABLE 5.15: After being discharged, I am able to stay in contact with the
hospital easily
Cumulative
Frequency Percent Valid Percent Percent
Valid dissatisfied 6 5.0 5.0 5.0
somewhat satisfied 26 21.7 21.7 26.7
satisfied 52 43.3 43.3 70.0
strongly satisfied 36 30.0 30.0 100.0
Total 120 100.0 100.0

Interpretation:

As per the variable “After being discharged, I am able to stay in contact with the hospital
easily” and the factors were classified into four prime categories and those were dissatisfied,
somewhat satisfied, satisfied and strongly satisfied. Out of 120 respondents a majority went for
satisfied. The factors like Satisfied had taken 43.3%, Strongly satisfied 30%, Somewhat satisfied
had 21.7% and Dissatisfied had taken 5.0%. So, after being discharged, the patients are able to
stay in contact with the hospital easily has been proved.

CHAPTER 5
CONCLUSION

The current study illustrates the importance of trust and communication in a doctor-patient
relationship for a better and effective treatment given to the patients. As our vignettes intended to

Page | 52
illustrate, the doctor-patient relationship is a powerful part of a doctor’s visit and can alter health
outcomes for patients. Therefore, it is important for physicians to recognize when the relationship is
challenged or failing. If the relationship is challenged or failing, physicians should be able to recognize
the causes for the disruption in the relationship and implement solutions to improve care Trust is
something that must be built and gained and having good communication skills, assists in
building this trust between a doctor and patient. The evidence shows that trust and
communication with a patient - centered approach has contributed to improved patient outcomes
with patients being satisfied with the services they were offered at the health facility. This is
associated with better adherence to the treatment and better perceived quality of health care
services. The importance of trust and communication in a doctor -patient relationship carry the
same importance for both developed and developing countries in terms of patient satisfaction and
quality of health care services, though the determinants may differ slightly. Conducting regular
patient satisfaction surveys and further research on this topic will help health facilities to
evaluate their services and help with strategic planning to better their service

SUGGESTIONS

Through a thematic analysis of primary qualitative studies this study has drawn together
the data from 11 studies of patients' perspectives to derive a conceptual framework that helps us
to understand the complex topic of patient–doctor relationships (Figure 2). Two major elements
have been identified (longitudinal care and consultation experiences) that contribute to the
development and maintenance of patient–doctor relationships. As a consequence of these
dynamic processes, an ongoing depth of relationship may be established. This is characterised by
four main elements: knowledge, trust, loyalty, and regard. Each of these elements has two sides:
the patient's opinion about the doctor, and the patient's perception of the doctor's opinion about
them, which may be reciprocal.Hospital should provide some extra vehicles for the easy and fast
movement of the employees for their purpose of the official works.

FINDING

Page | 53
Viewing the patient–doctor relationship in terms of longitudinal care, consultation experiences,
and depth of relationship represents one unifying framework by which to investigate questions
about its value for patient care. It is a framework grounded in empirically-derived data from
several qualitative studies, which provides an explicit conceptual underpinning for future
research in this complex field.

Out Patient Staffs: Comparing with the visitors and out patient staffs ratio , there is lack of
manpower. in order have a smooth workflow in the out patient more staffs should be posted to
the out patient of the hospital.

Perceptions of patients’ about the attributes of factor services/facilities provided by the

hospitals are almost good.

The largest difference between expectations and perceptions is 1.91 for attribute handling of
queries and lowest for individual consideration 0.88 under factor behaviour of doctors.
Relational aspects of continuity are often referred to as interpersonal continuity,5
which is potentially confusing because it combines notions of length and depth of
relationship. Additionally, patient–doctor relationship research has sometimes confused
knowledge between doctor and patient with the presence of a relationship.6 The present model
identifies knowledge as one aspect of the depth of the patient–doctor relationship that has both
factual and affective components..

Page | 54
REFERENCES

ANNEXURE- I

REFERENCES

Page | 55
1. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor–patient communication: a review of the
literature. Soc Sci Med.  1995;40(7):903–918.

2. Stewart MA. Effective physician–patient communication and health outcomes: a

review. CMAJ. 1995;152(9):1423–1433. 

3. Williams S, Weinman J, Dale J. Doctor–patient communication and patient satisfaction: a

review. Fam Pract. 1998;15(5):480–492. 

4. Beck RS, Daughtridge R, Sloane PD. Physician–patient communication in the primary care
office: a systematic review. J Am Board Fam Pract. 2002;15(1):25–38. [

5. Freeman G, Shepperd S, Robinson I, et al. Continuity of care: report of a scoping exercise for

the SDO programme of NHS R&D. London: NHS Service Delivery and Organisation National
Research and Development Programme; 2000

6 6. Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med. 2003;

7. Haggerty JL, Reid RJ, Freeman GK, et al. Continuity of care: a multidisciplinary
review. BMJ. 2003;327(7425):1219–1221.

8. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is
it, can it be measured, and does it matter? Milbank Q. 2001;79(4):613–639

9. Duck S. Human relationships. 3rd edn. London: Sage; 1998. 

10. Dowrick C. Rethinking the doctor–patient relationship in general practice. Health Social

Care Comm. 1997;5:11–14. 

BIBLIOGRAPHY

WEBSITES:

Page | 56
https://ABShospitals.com/

https://en.wikipedia.org/wiki/Wikipedia

https://www.ncbi.nlm.nih.gov/

https://books.google.co.in/

ANNEXURE- II

Page | 57
QUESTIONNAIRE

Name (optional): _____________________________________

Age: _______________________

Gender: ▫ Male ▫ Female

1. Have you ever visited this Outpatients Department before for the same condition?

a.) YES

b.)No

2. From The Time You Were First Told You Needed An Appointment To The Time You
Went To The Outpatients Department, How Long Did You Wait For Your Appointment?

a.) Up to 1 month

b.) 1 month to 6 weeks

c.) More than 6 weeks but no more than 3 month.

3.Did you have enough time to discuss our health or medical problem with the doctor?
a.)Yes, definitely

b.)Yes,tosomeextent

c.)No

4.Did The Doctor Explain The Reasons For Any Treatment Or Action In A Way That
You Could Understand?
a.) Yes, definitely

Page | 58
 b.)Yes, to some extent No
c.) I did not need an explanation.

THINKING ABOUT YOUR MOST RECENT VISIT TO THE OUTPATIENT

DEPARTMENT.

5. Were you given a choice of appointment times?

a.)Yes

b.)No, but I did not need/want a choice .

c.) No, but I would have liked a choice Don't know / Can't remember.

6. Before your appointment, were you given any printed information about the hospital?

a.) Yes
b.) No, but I would have liked this information

c.) No, but I did not need this information Don't know / Can't remember

7. Before your appointment, were you given any printed information about your condition
or treatment?

a.)Yes.
b.)No, but I would have liked this information No.

c.)but I did not need this information.

Page | 59
8. Before your appointment, were you given the name of the person that the appointment
was with?

a.) Yes.
b.) No.
c.) Yes/No.

9. When you arrived, was your appointment with the person you were told it would be
with?

a.) Yes

b.) No, and I was not happy about it No, but I did not mind

c.) Don't know / Can't remember.

10. Was your appointment changed to a later date by the hospital?

a.) Yes

b.) No, and I was not happy about it No, but I did not mind

c.) Don't know / Can't remember.

ARRIVAL AT THE HOSPITAL

11. When you arrived at the Outpatients Department, how would you rate the courtesy of the
receptionist?

a.)Excellent Very good Good.

b.)Fair Poor.

c.)Very poor.

Page | 60
12.)Once you arrived at the hospital, was it easy to find your way to the Outpatients Department?

a.)Yes, definitely
b.)Yes, but it could be improved No
c.)Don't know / Can't remember

13.)In the reception area, could other patients overhear what you talked about with the
receptionist?

a.)Yes, and I was not happy about it

b.)Yes, but I did not mind

c.)No, others could not overhear Don't know / Can't say

14.) How did you travel to the hospital for your most recent out patient

appointment?

a.)By Patient Transport Services (Hospital transport / Non urgent

ambulance transport

b.)By car

c.)By taxi

15.) when i have a problem, the hospital show a sincere interest in solving it .

a.) Yes.
b.) No.
c.) Yes/No.

Page | 61
Page | 62
Page | 63