CALIFORNIA STATE UNIVERSITY, NORTHRIDGE CUSTOMER PREFERENCES TOWARD PEDIATRIC HEALTH CARE A project submitted in partial satisfaction of the requirements for the degree of Master of Science in Health Science Health Administration by Anne F. Shelley May' 1982 The Project of Anne F. Shelley is approved: California State University, Northridge ii ACKNO\vLEDG EMENTS I am grateful to my committee members, Mr. Allen G. Herkimer, Dr. Jerome Seliger and Dr. Donald M. Hufhines, for their guidance and assistance in enabling me to see this project through. A note Krishnamurty, of for sincere his appreciation generous to offering of Dr. G. time B. and expertise in the analyses of the project data. Special thanks to the cooperation of Fran Frey and the staff at Childrens Hospital of Los Angeles' Department of Planning and Public Affairs for their input to the development of the survey instrument and for putting aside precious time for consultation. Finally, a note of thanks to the respondents who participated in the interviews, attentiveness. iii for their cooperation and CONTENTS Page ..... APPROVAL PAGE ii ACKNOWLEDGEMENTS • iii LIST OF TABLES • • vi LIST OF FIGURES vii CHAPTER 1. 2. INTRODUCTION 1 Statement of Problems 4 Statement of the Problem 6 Signiticance of Problem • • 7 Description of Study Type . 8 Organization of Paper 10 BACKGROUND • ll Review of Literature ........ Setting of Project The Sponsoring Organization. 3. METHODOLOGY ll 17 • • • 18 20 Statement of Problem 20 Objectives . 21 Detinitions 23 Sources of Data and Their Measurement 24 Analysis 26 • • • • Limitations 27 lV 4. 5. RESULTS 28 Demographic Findings 28 Attitude Survey • • • 31 Knowledge Survey 47 CONCLUSIONS, RECOMMENDATIONS, AND SUMMARY • • . • • • • • 50 Conclusion 50 Recommendations • 52 Summary 54 BIBLIOGRAPHY 57 APPENDICES A. B. c. D. E. ............. ... ... lJ.l!:FINI'l'lONS .... POSITIVE COMMENTS ABOUT CHLA . . . . QUESTIONNAIRE 60 68 71 CONSUMER-PATIENT RECOMMENDATIONS TO CHLA ............ 73 AlJlJITIUNAL COMMENTS BY CONSUMERPATIENTS 75 .............. v TABLES Table 1. Page Respondent's Age, Marital Status, and Number of Children: Number and Percent . 29 2. Respondent's Race: 29 3. Respondent's Occupation and Education 30 4. Respondent's Source of Medical Coverage 31 5. Most Frequently Named Hospital in the Los Angeles Area • • • • • • • • • . • 32 Respondents Who Had Brought Child to Hospital • • • • • • • • • . . . . 33 Respondent's Preferred Hospital for Pediatric Care • • • • • • 34 Cross-Tabulation of Hospital by Geographic Area 35 Other Hospitals Selected as the Preferred Pediatric Hospital • . • • • . 36 6. 7. 8. 9. Number and Percent . .. ......... 10. Ranking Profile 11. Service Area UtJ.lized and Service Rating of CHLA 12. 13. 14. 15. 16. ........... Service (.;HLA Should Otter . Quiz 1 . . . . . . . . . . . . . Quiz 2 . . . . . . . . . . . . . Quiz 3 . . . . . ...... Quiz 4 . .......... Vi ... ... . . . ... ... ... ... ... ... 42 45 46 47 48 ... ... 48 49 FIGURES Figure 1. 2. 3. Page Variability and Ranking of Factors When Respondents Were Asked: If you had to Use a Hospital for your Child, which Factors would be Important, in order of Importance? • 38 Var1ab1lity and Ranking of Factors When Respondents were Asked: It your Child Had to be Admitted to the Hospital, Based on the Particular Hospital you Selected, Rank the tollowing Factors in order of Importance • • • • • • • • • • • • . 41 Variab1lity and Ranking of Factors Based on Respondents Ranking of the Factors Related to the Most Desirable Qualities of Any Hospital • • • • • • • • . • • . • • • • 44 vii CHAPTER 1 I. The goal of a INTRODUCTION hospital marketing program which wishes to be both successful and accepted, should be to eliminate barriers to people in obtaining needed health care services, without creating artificial needs or inap- proriate demands for those services. Marketing program objectives can include several options: unified, positive public image for the (1) creating a hospital~ (2) de- veloping a better understanding of the perceptions of, and demands on, the hospital by each of its constituent groups: and (3) appropriately designing and promoting the hospital's services. This project focused on item two above, specifi- cally, the patient-consumer attitudes toward acute care hospitals, with primary attention given to attitudes toward pediatric Angeles (CHLA). care and Childrens Hospital of Los It was felt that a project of this kind would be most helpful to an organization such as CHLA, whose future seemed uncertain as a result of historical, financial and organizational realities. A survey instrument was developed to test the attitudes and the level of knowledge of consumers about acute 1 2 care hospitals, and pediatric health care in an acute care setting. The questionnaire was developed with significant input from members of the CHLA's Department of Planning and Public Affairs, and from a review of the literature. Administration of the questionnaire was achieved through the selection of non-probablility samples based on geographic location. The survey yielded information about demographic, cultural and socioeconomic variables. Findings indicated most respondents to be white females aged 30-39, with at least one child. married, Most respondents owned their own home and had lived at their present address for 1-3 years. Respondents were primarily homemakers with some college education. A combined income of $25,000-$50,000 was re- ported for most respondents with almost half of all respondents covered by some form of commercial insurance. Interviews were conducted with 93 respondents during the months of July, August, and September, 1981. Cedars- Sinai Medical Center was the hospital named most often by respondents when asked to name a hospital in the Los Angeles Area. Doctor's recommendation was the most impor- tant factor in choosing the use of any hospital for children, whereas, reputation of the hospital was the most important factor when the choice of a particular hospital was justified by the respondent. Good doctors was chosen as the most desirable quality of any hospital. 3 One-fourth of all respondents interviewed had been a patient or had had a family member as a patient at CHLA. Most were inpatients at the Hospital and gave an overall service rating of excellent. of this The most unexpected finding survey indicated that 32% of the respondents favored walk-in treatment as the service they felt CHLA should offer the community. 4 II. Historically, STATEMENT OF PROBLEMS hospitals developed their services to suit the physician and the hospital rather than the community and the patient. health care system, The impetus for changes in the from a management orientation with a product concept toward a management orientation with a marketing concept, movement. can be traced back to the consumerism The decade of the sixties was one of extreme social criticism for all institutions including the hospital. The central criticism was that the hospital was not responsive to the community. There was much truth to this as the hospital had been too busy keeping in step with medical and technological advances - the product concept. The system had given greater priority to the search for medical solutions than to the quest for community health problems. The consumer movement continued to remain in the forefront during the early and middle 1970's. But now consumerism seems to have been set aside given the nation's political and financial ever, conservative trend. How- some authors believe that consumerism will continue to have a significant impact, especially, in the field of 5 marketing. Bloom and Greyserl believe consumerism has moved through the stages of its life cycle in much the same way consumer packaged goods or consumer durables do. They believe consumerism has experienced a large degree of market fragmentation and now offers a wide variety of brands of consumerism to different segments of society. Within these brands of consumerism, porters exists. competition for sup- For these reasons, hospital management must change its orientation, shifting its emphasis from the services and the products produced to the people. Most hospitals that have initiated a marketing program have focused on the physician. The Physician Support Program at Childrens Hospital of Los Angeles includes the creation of a physician liaison function to provide immediate, effective response to physician needs, mechanisms to improve the Hospital's ability to communicate effectively with the referring physician, efforts to reform the Hospital's admitting procedures, the distribution of ap- propriate publications, and the expansion of courtesies provided to Attending Staff. The Physician Support Program at CHLA is an understandable response since physicians are the Hospital's primary source of patients. However, the consumer-patient 1 Paul N. Bloom and Stephen A. Greyser, "The Maturing of Consumerism," Harvard Business Review, NovemberDecember, 1981, p. 130. ------ 6 must be targeted for marketing as well. The hospital industry must realize that it is in the health care business, not the medical care business. It is important that the hospitals target the physician for marketing, but to forget about the consumer-patient, is to forget about a vital segment of the market. Statement of the Problem The Marketing Concept is a management orientation that holds that the key to achieving organizational goals consists of the organization's determining the needs and wants of target markets and adapting itself to delivering the desired satisfactions more effectively and efficiently than its competitors.2 The marketing concept begins with existing or potential consumer needs and wants, plans a coordinated set of programs and services to serve those needs and wants, and in return satisfies its goals through creating consumer satisfaction. The specific problem of this project is to identify shifts in customer preferences and attitudes, and demon- strate through the employment of a survey instrument, the usefulness of receiving input from the consumer-patient in the design of goals and objectives for the hospital organization. 2 Philip Kotler, Principles of Marketing (Englewood Cliffs, N.J.: Prentice-Hall, Inc.-,-1980), p. 22. 7 Significance of Problem The prelude to all planning is investigation. This is certainly the case for the planning of marketing strategies. Information is a requisite required. Information about potential target markets and their reactions various marketing mixes, to and the collection and analysis of this information is the function of marketing research. This activity is concluded to some degree in health care institutions in the form of questionnaires and surveys of patients and physicians. Marketing research may also be used by health care executives prior to introducing a new service. Analysis of market data provide valuable insights as to whether a potential market exists and its size. It aids in esti- mating the probable success and reduces the element of risk. Although a certain amount of marketing research is conducted in health care organizations, it has not at- tained the needed comprehensiveness by studying the whowhat-where-when-why-how of actual and potential markets.3 This project is a marketing research effort aimed at separating the problems from the symptoms. For instance, CHLA's lower census figures may be a symptom of a more 3 Roberta N. Clarke and Linda Shyavitz, "Marketing Information and Market REsearch - Valuable Tools for Managers," Health Car~ Management Review, Winter, 1981, pp. 73-77. 8 basic problem: lack of a marketing orientation. This project is directed at increasing CHLA's management knowledge of the Hospital's external environment, specifically its customer market. Description of Study Type A survey instrument was developed to assess consumer attitudes toward acute care hospitals. A review of the literature in addition to input from the sponsoring organization were used in its construction. The survey in- strument, a questionniare, consisted of a three part document. Items were designed to identify information in the following three areas: 1. Demographic: Cultural and Socioeconomic 2. Attitudinal: Opinions and Preferences 3. Knowledge: Respondents understanding of the health care industry. The questionnaire was designed with the intention of conducting personal interviews, with the interviewer completing the survey form. It was felt that this would remove some of the barriers that might exist between the respondent and the interviewer. A review of the questionnaire contained in Appendix A will reveal extensive inquiries regarding the respondent's demographic, cultural and socioeconomic status. A total of eleven questions made up the demographic profile for each respondent. The second part of the survey con- 9 cerned the attitudes and preferences of respondents and included 20 questions. It focused primarily on factors the respondent considered most important in choosing a hospital for pediatric care. section was concerned The last third of this with attitudes toward CHLA, and was completed only by those who had previous experience with the Hospital. The third part of the survey contained four questions designed to give an indication of the respondent's understanding of the health care industry. p • 10 III. ORGANIZATION OF PAPER The presentation of this project begins with a review of the literature. As will be discussed, most mar- keting research programs in the health care industry were first initiated by Health Maintenance Organizations. This form of health care delivery relies heavily on a reliable estimate of potential enrollees, since revenue is based on number of members and not acuity of disease. A chapter on methodology will follow and include a review of the objectives of the project as well as a discussion of the sources of data and their measurement, the analysis of the data, and the limitations of the study. Next, the find- ings will be presented from the questionnaire and discussed relative to the objectives of the project. A concluding chapter will provide recommendations specific to the future of CHLA and applicable to all acute care facilities. Finally, areas in health care marketing need- ing further research and study will be discussed. CHAPTER 2 - BACKGROUND I. REVIE~l OF LITERATURE The example of health care marketing research most cited in the literature is the enrollment process for Health Maintenance Organizations (HMO's). Studies re- lating the characteristics of individuals and plans to the decision to findings. as: join a HMO have produced some interesting Acito4 summarizes the results of such studies (1) Persons with greater risk of sickness and greater frequency of hospital use were found to be members of HMO's; (2) there was found to be no relationship between utilization and expenditures and tendency to join HMO's~ (3) larger family sizes with older heads of households, greater income and higher educational attainment were found to be among the joiners of HMO's; and (4) married persons with children aged 6 to 18 and a greater proportion of blacks tended to choose HMO' s. Studies reporting results of opinion, preference, and attitude surveys were also examined by Acito.s These 4 Franklin Acito, "Consumer Decision Making and Health Maintenance Organizations: A Review," Hedical Care, January, 1978, pp. 3-4. 5Ibid., pp. 6-7. 11 12 studies described respondents from the general population who were not actually confronted with the decision to join a HMO. One study examined the interest in health in- surance of the sample. It was found the persons who felt their income was well below average for their geographic areas indicated the highest demand for health insurance. However, when the added cost of insurance was mentioned, this group showed the greatest decline in reported demand. In addition, they found that older persons and married persons with children tended to have high demand insurance. for As far as overall consumer preference for group practice, some evidence has been found the younger, better-educated individuals tended to prefer group practice as did blacks and persons in middle income groups. In a study by Luft,6 factors affecting the use of physician services were examined. The results are compar- able to those of other studies which find that health status is the primary determinant of utilization. is not at all a factor in utilization. found to correlate with education, primary determinant of check-up. the Income However, income is and education is a likelihood of obtaining a In addition, it was found that the lower utili- zation of people with no usual source of care was only 6 Harold s. Luft, John D. Hershey, and Joan Morrell, "Factors Affecting the Use of Physician Services in a Rural Community," Health Care Management Review, Winter, 1981, P• 70. 13 partly attributable to the different socioeconomic characteristics of the group who responded. These studies suggest the relative unimportance of price and the critical role of need in the choice of provider. In recent years increasing importance has placed on the evaluation of medical care. been Upon discharge, patients are sometimes asked to fill out a hospital patient questionnaire in which the patient is given the opportunity to express hisjher attitudes toward his/her hospital stay. One such study found several patient char- acteristics to influence perception of medical care.7 It was found that patients previously admitted to the particular hospital rated the hospital higher than first-time patients. This suggests that some learning takes place during hospitalization. tant variable. Length of stay was also an impor- Patients staying in the hospital less than two weeks rated the hospital higher than patient hospitalized more than two weeks. Race and social class vari- ables also had a significant effect on perception of care. However, the authors were unable to offer any explanation for this result. 7 Eleanor Nelson-Wernick, Hal s. Currey, Paul w. Taylor, Mar ion \Joodbury and Alan Cantor, "Patient Perception of Medical Care," Health Care Management Review, Winter, 1981, p. 70. 14 A review article by Lebow8 focuses on studies using consumers evaluation of quality of medical care. cusses the studies in light of Donabedian' s preaches to quality of care: come, and impact. four ap- structural, process, out- However, he suggests a fifth approach to the evaluation of medical care: care. He dis- patient perception of Lebow does not feel comfortable grouping patient perception of care with process or outcome of care. He believes that the mood of the questioned individual and the time of assessment are two factors which affect the patient's perceptions but are not accounted for in process or outcome quality assurance programs. Lebow9 summarizes the results of one study using patient opinions. The most desirable qualities sought in a medical center were, first, good doctors, followed by well-trained staff, information from doctors, personal interest in patient, pleasant staff, and privacy, of importance. Satisfaction was found to be related to improvement in condition, in the patient, ditions. in order personal interest of the staff and explanation received about their con- Also, patients who rated the medical facility negatively on one item tended to do so on other items as well. 8 Jay L. Lebow, "Consumer Assessments of the Quality of Medical Care," Medical Care, April, 1974, p. 328. 9 rbid., P. 330. 15 In another study examined by LebowlO, it was found that the overall level of patient satisfaction with care was related to the amount of information received by the patient. The researchers employed a patient satisfaction questionnaire with patients recently discharged after at least a two-day stay at a large hospital. cular study, In this parti- 17% of the respondents felt they would be reluctant to return to this hospital again if they had to. Additional studies evaluated by Lebowll found that patients rated technical accuracy, staff, personal interest of and accessibility as the most important characterIn another study, personal interest of istics in care. the physician, accessibility of the service, and convenience for the pat1ent were important factors in judging care. In a study conducted by Hulka,l2 the attitude of the public toward physicians and medical services was examined. sions: The survey instrument consisted of three dimenprofessional competence, Overall, cost/convenience. 10 Ibid., p. personal qualities, attitudes were and favorable 331. llibid., p. 331. 1 2Barbara s. Hulka, Lawrence L. Kupper, Mary B. Daly, John c. Cassel, and Frederic Schoen, "Correlates with Satisfaction and Dissatisfaction with Medical Care: A Community Perspective," Medical Care, August, 1975, PP• 648-658. 16 toward the professional competency and the personal qualities of physicians. Accessibility, including costs and convenience, were less highly regarded. satisfied than Whites. women and Blacks less Men were less satisfied then Particularly negative attitudes were expressed toward the personal qualities of physicians by young Blacks, whereas among Blacks over 60 the negative effect It was also found that was toward costs and convenience. having a regular physician and long attendance with that physician were correlated with positive attitudes. The most negative feeling was expressed by women without a regular source of care. It seems as though the hospital must be sensitive to what people perceive they are getting (caring, relief from pain and anxiety, knowledge about their condition, re- storation of function) in return for its costs to them (out-of-pocket payment, nity). discomfort, inconvenience, indig- The perceptions of current and prospective pa- tients are what will affect their behavior, perceptions are accurate or not. whether such The hospital by identi- fying and analyzing factors influencing consumer choice can change consumer behavior. By utilizing specific mar- keting techniques one can alter the nature of the exchange relationship underlying that behavior. 17 II. SETTING OF PROJECT Childrens Hospital of Los Angeles (CHLA) served as the sponsoring organization for this project. CHLA is a tertiary care center primarily serving the southwestern United States. The primary market area includes the area from San Francisco in the north to the Mexican border in the south to Las Vegas in the east. However, the Hospital sees patients from every state and all over the world. The population served includes children from birth through 18 years of age. In some cases, patients are seen up to 21 years of age. Six geographic areas in the Los Angeles Area were selected for this project, and these areas represented a major source of patients for the Hospital. Sites where the survey was conducted consisted primarily of shopping centers, parks and recreation centers. The following indicates the geographic areas where the survey was conducted and the number of respondents interviewed from each target area: Geographic Area Los Angeles San Fernando Valley Basin San Gabriel Valley "604" Corridor Conejo Valley Number of Respondents 6 25 17 19 9 17 18 Interviews were obtained from 100 respondents during the months of July, August and September, 1981. Of these 100 interviews, 93 questionnaires were completed; seven surveys were incomplete and so were eliminated. The Sponsoring Organization Childrens Hospital of Los Angeles was founded as a private, charitable hospital April 1, 1901, by a small group of women from the King's Daughters, anthopic organization in Los Angeles. the first phil- In 1932, the Hospi- tal became affiliated with the University of Southern California School of Medicine as a pediatric teaching hospital. The Hospital contains a long history of firsts ·and continues to maintain its reputation as one of the world's leading pediatric tertiary care centers. Hospital Yet, the lags far behind other major teaching facilities in terms of its management capabilities. The inadequate performance of the management team is no match for the excellence demonstrated by the professional staff. It is not so much the members of the man- agement team, but rather, the resources available to management to make effective decisions. agement team are well-qualified, l1embers of the man- having extensive exper- ience and credentials to match the demands of their positions. Unfortunately, the lack of resources, taken for granted in other organizations, retards management effec- 19 tiveness. This lack of resources is most evident in the area of marketing. decisions (MIS).l3 without a The Hospital seems to make pertinent formal marketing information system The investment of the Hospital into a MIS would provide the management team with timely and accurate information to improve planning, execution, and control. The lack of resources is further compounded by a particular Board member who yields considerable power and authority due to her generous donations to the Hospital. Add to these problems the erosion of the Hospital's reputation and referral network and you have an anti-marketing philosophy in the Hospital's planning and developmental efforts. The much publicized budget cuts of 1980, some long standing systems problems, the geographic location, and increasingly aggressive competitors have forced CHLA to reevaluate their interpal and external environments. The Hospital has begun to take a marketing approach in order to survive. Hopefully, the Hospital will face the reality of the situation and will take the time to make the drastic changes necessary to save the vital community interests it serves and maintain its high quality standards in pediatrics. l3Philip Kotler, Principles of Marketing (Englewood Cliffs, N.J.: Prentice-Hall, Inc.,-r980), p. 136. CHAPTER 3 - METHODOLOGY I. STATEMENT OF PROBLEM Marketing involves the pr'actical application of an understanding of human motivation in terms of exchanges of values. Through exchanges, various social units attain the inputs they need. By giving up something, acquire something else in return. they This something else is normally valued more than that which is given up, which explains the motivation for the exchange.l4 Health care has a cost to the consumer in time spent, travel, risk, perceived loss of dignity, dependency, etc. The hospital employees may receive the gratitude and improved functioning of the patients as a benefit in addition to their salaries and titles. When services are considered in reciprocal benefit terms, the need for the provider to understand the consumer becomes as important as the need for the consumer to understand what the provider has to offer. 15 14 Philip Kotler, Marketing for Non.:...profit Organizations, (Englewood c1T£fi-;-"New Jersey:--J?rent.:lc::e= Hall, 1975), P• 5. 15 william A. Flexner, Curtis p. McLaughlin, and James E. Littlefield, "Discovering What the Health Consumer Really Wants," Health Care Management Review, Fall, 1977, P• 44. 20 21 The purpose of this project was to assess the needs, wants, and values of a specific service area in order to evaluate existing acute care hospitals from the consumerpatient perspective. The specific purpose is to undertake a marketing research of a particular service area. The problem is to demonstrate through the employment of a survey instrument the need to elicit information from the consumer-patient regarding his/her opinions, attitudes, and preferences toward acute care hospitals, generally pediatric acute care and CHLA. The tasks pertinent to the problem: (1) development of a survey instrument to test the level of knowledge of consumer-patients about the hospital industry, and to measure their attitudes and preferences, and to provide demographic, cultural and socioeconomic data on the con- sumer-patient; (2) administration of the survey instrument to the target markets based on geographic location; and (3) assessment of the needs, wants, and values of the respondents. Objectives Marketing is the distinguishing, any hospital. unique function of A hospital is set apart from all other providers of health care by the fact that it markets a program or service. Since it is the job of hospital marketing to produce what the market needs, marketing 22 should be the foundation area in objective setting for the Furthermore, hospital. marketing demands prior decisions of high risk which requires a need for objectives in respect to all resources. The goal of this project was to establish the need for input from the consumer-patient, and to recognize the importance of monitoring shifts in consumer preferences regarding the creation and elimination of programs and services. At the same time, it was hoped that this pro- ject would incrase the knowledge and understanding of CHLA 1 s management staff about consumer-patient attitudes and preferences toward pediatric acute care. The follow- ing objectives provided the direction toward attainment of the goal: 1. To obtain a demographic respondent interviewed. profile of each 2. To determine the most frequently named hospital(s) in the Los Angeles Area. 3. To determine the accessibility respondents had to a regular source of health care. 4. To determine the respondent•s favored choice of hospital when utilizing a hospital for pediatric care. s. To ascertain the importance of various factors in choosing a hospital for pediatric care. 6. To ascertain the most desirable qualities of any hospital. 7. To ascertain the respondent•s satisfaction with the services provided at CHLA. 23 a. To determine the service respondent's believe CHLA should provide to the community. 9. To obtain the consumer's understanding of the health care industry. A review of the survey instrument utilized for this project will reveal a variety of responses required by each respondent. questions, There are ranking questions, multiple choice, yes-no and open-ended questions (see Appendix A). Definitions In this project, marketing is defined as human activities directed at satisfying needs and wants through exchange processes.l6 of life. Its goal is to maximize the quality This project is a marketing research effort, which is only one function involved in the set of marketing activities. For the purposes of this project, the reader may wish to acquaint himself/herself with some of the marketing terminology (see Appendix B). l6Philip Kotler, Principles of Marketing (Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1980). pp. GlG9. 24 II. SOURCES OF DATA AND THEIR MEASUREMENT In this project, the primary market of Childrens Hospital of Los Angeles (CHLA} was divided into different geographic regions, based on the notion that consumerpatient needs or responses vary geographically. Geo- graphic segmentation allows the hospital to distinguish their geographic markets according to market potential. In this way, the Hospital can allocate different resources and use different marketing strategies in each of the ~eographical regions. As already discussed, six geographic areas in Los Angeles were selected for this project. Sites where the survey was conducted consisted primarily of shopping centers, parks and recreation centers. The data were col- lected over a three month period beginning in July and ending in September, 1981. The questionnaire was com- pleted via personal interview, with the interviewer nor- mally writing the responses to each question. The method of conducting the survey proved effective in obtaining respondents' cooperation in finishing the interview as it usually generated conversation. Each respondent was approached ·and asked, "Would you 25 mind taking a survey on your attitudes towards children's health care? It's for a project of mine in school." Each respondent willing to take the survey was assured that the responses would be kept confidential and that responses could not be traced to them. obtained from 100 respondents, individual Interviews were but seven surveys were incomplete and so were eliminated. The collected data were coded and keypunched for processing with the Statistical Package for the Social Sciences. Market characteristics were examined through the use of frequency distributions and crosstabulations. 26 III. ANALYSIS The data collected during the project were analyzed by use of descriptive statistics. For the most part, descriptive statistics include frequencies, and ranges. lations. Selected statistics means, include cross modes, tabu- A complete review of the data may be found in the chapter on results. In addition, the data are ana- lyzed by the use of the open-ended responses given in the questionnaire {see Appendix C, D & E). While this is qualitative and limited in representation {consumer-patient response was low), it is reflective of the project's worthwhileness and appeal. 27 IV. LIMITATIONS The project was intended to provide a descriptive profile of factors, identified by the consumer, associated with acute care hospitals, Los Angeles. and generally Childrens Hospital of One could hardly say that the 93 respondents are representatives of the Greater Los Angeles Area. project used non-probability sampling; determined who would be interviewed. are no confidence intervals, determined, The the interviewer As a result, there the reliability cannot be and the validity is open to question. strengthen the research, To if true quota samples were drawn, a much larger sample size would be required to meet the demands of representativeness. Chapter 4 - Results A survey instrument was developed to assess consumer attitudes and preferences toward pediatric health care in acute care hospitals. graphics, Information was obtained on demo- attitudes and preferences, and understan,ding of the health care industry from respondents within the designated geographic areas. The findings are reported below with reference to each of the objectives of this project. Demographic Findings Objective 1: To obtain a demographic profile of each respondent. Of the 73% of the sample who were married, 87% reported at least one child. The single group consisted of 14% of the sample and corresponds with those 13% having no children. Of the respondents, 41% had two children. Of the respondents, 74% were female and 26% were male (see Table 1). 28 29 Table 1 Respondent's Age, Marital Status, and Number of Children: Number and Percent Age >19 20-29 30-39 40-49 50-59 ~60 # 0 27 34 16 11 5 Only % Marital Stat. 0 29.0 36.6 17-2 11.8 5.4 Single Married Widowed Divorced Separated one cultural % # 13 68 2 6 4 # of Children 14.0 73.1 2-2 6.5 4.3 variable was 0 l 2 3 4 # 12.9 23.7 40.9 9.7 12.9 12 22 38 9 12 obtained % - race. White and Black constituted over 86% of the total sample; 80% of the sample were Caucasian. A religious variable was not part of the survey (see Table 2). Table 2 Respondent's Race: Race White Black Hispanic Asian Indian Other Number and Percent # 74 6 6 4 0 3 % 79.6 6.5 6.5 4.3 0 3-2 Socioeconomic variables included occupation, cation and income. edu- Of the 93 respondents interviewed, 34% described their occupation as homemakers with 14%, 15%, and 16% of the respondents describing themselves as office workers, managerial, and professionals, respectively. Of 30 the sample, 39% reported some college education, while 28% reported college graduation. $25,000 - A middle income range of $50,000 was reported by 37% of the respondents (see Table 3). Table 3 Respondent's Occupation and Education Occupation Homemakers Management Professional Office Worker Technical Trade· Retired Student # % 32 15 14 13 8 5 3 3 34.4 16. 1 15.1 14.0 8.6 5.4 3.2 3.2 Other variables reported Education # Professional College Graduate Some College High School Tech/Voc School Less Than 12 6 6.5 28.0 38.7 21.5 2.2 3.2 in the demographic profile included data on horne ownership, and type of medical coverage. 26 36 20 2 3 % time at present address Of the sample, 67% of the respondents reported owning their horne with 32% reported renting their living quarters. Of the 93 respondents interviewed, 30% had lived at their present address for 13 years. Those individuals reporting living at their present address less than one year or more than 25 years made up 12% of the sample. Of the sample, insurance. 44% had some form of group or private Another 25% claimed Blue Cross as their major form of medical coverage. Health Maintenance Organization ~ 31 enrollees accounted for 16% of the respondents (see Table 4) • Table 4 Respondent•s Source of Medical Coverage Paying Agent Self Private/Group MediCare MediCal Blue Cross HMO # 9 41 2 3 23 15 % 9.7 44.1 2.2 3.2 24.7 16.1 Attitude Survey Objective 2: To determine the most frequently named hospital(s) in the Los Angeles Area. The first question required respondents to name a hospital in the Los Angeles Area. fined: Some respondents wanted the Los Angeles Area deDid Los Angeles mean the city or the county? Respondents were informed that this meant the total Los Angeles County Area. Cedars-Sinai Medical Center was named most often by 15 respondents of the total 34 different hospitals named, with Kaiser named second most often by 8 respondents (see Table 5). 32 Table 5 Most Frequently Named Hospital(s) In The Los Angeles Area Hospital Number of Respondents Named lst No. of Respondents Named 2nd & 3rd 15 15 Cedars-Sinai Kaiser USC County Northridge Holly Presby UCLA Huntington Los Robles CHLA 7 8 7 5 5 4 15 6 6 15 4 4 0 2 7 0 Respondents were then asked to name two or more hospitals in the Los Angeles area. were named. About 60 different hospitals This time Cedars-Sinai, UCLA and USC County Hospitals were named 15 times each with Kaiser and Childrens named second most often by 7 respondents (see Table 5) • Next, respondents were asked if they ever had to bring their child to a hospital. If the respondent had no children, they were asked if they ever had to bring any child to the hospital. 70% of the sample reported bring- ing their child to the hospital. were named as the hospital 31 different hospitals their child was brought. Kaiser was named most often by 7 of the respondents with Northridge Hospital Foundation and Cedars-Sinai Medical Center named second most often by 5 respondents each (see Table 6). 33 Table 6 Number of Respondents Who Brought Child to a Particular Hospital Number of Respondents Who Brought Child to a Particular Hospital Hospital Kaiser Northridge Cedars-Sinai Westlake Comm. Los Robles Childrens Objective 3: 7 5 5 4 4 3 To determine the accessibility respondents had to a regular source of health care. asked if they Respondents were had a regular family phisician. only one aspect of accessibility. This is Of the sample, 73% indicated that they had a regular family physician and 27% indicated that they did not have a regular family physician. Objective 4: To determine the respondent's favored choice of hospital when utilizing a hospital for pediatric care. This question required the respondent to choose a hospital in the event they had to admit their child to the hospital. Eight hospitals were listed and respondents were informed that they should specify another hospital if the one they were to choose was not listed. All hospitals given are considered key competitors of CHLA and are major acute care facilities located in one of the six geographic areas of the county of Los Angeles. It is important to 34 note that respondents were not aware of CHLA as the sponsoring organization. The results shown in Table 7 indicate that of the given hospitals CHLA was chosen by 19 respondents. ever, How- the majority of respondents indicated other hospi- tals as their choice in the event their child had to be admitted to the hospital. Kaiser was named most often by 5 respondents with Los Robles Hospital named second most often by 3 respondents. A total of 23 hospitals were named by 32 respondents. Table 7 Respondent's Preferred Hospital for Pediatric Care Hospital Other CHLA UCLA Cedars-Sinai Northridge Huntington Tarzana Glendale Adventist Long Beach Memorial Number of Respondents Percent of Respondents 32 19 12 10 34.4 20.4 12.9 10.8 7.5 7.5 3.2 2·2 7 7 3 2 1 1.1 Crosstabulation of geographic area by hospital indicates that in most cases the geographic area determined the choice of hospital. As can be seen from Table 8, of 25 San Fernando Valley residents interviewed, six selected 35 Table 8 Cross Tabulation of Hospital by Geographic Area "604" HOSPITAL L.A. Northridge Hospital Foundation SFV 6 Basin Corridor 1 Tarzana Medical Center 2 Conejo Valley 1 Glendale Adventist Hosptial 1 1 Long Beach Memorial Hospital Childrens Hospital of Los Angeles SGV 1 3 4 4 Huntington Memorial Hospital 3 5 7 Cedars-Sinai Medical Center 1 6 2 1 2 UCLA Hospital 2 2 4 2 Other Hospitals 1 10 5 2 6 8 36 Northridge Hospital, Center. In short, and two selected Tarzana Medical it seems as though the geographic residence of the respondent is a factor effecting choice of hospital. It is interesting to note the number of respondents who indicated some other hospital. Of the 23 other hospital specified, 15 would be considered small community hospitals (see Table 9). Table 9 Other Hospitals Selected as the Preferred Pediatric Hospital Objective 5: Other Hospitals # Kaiser Los Robles Hospital St. Joseph Med Cntr Holy Cross Hospital Downey Cornm. Hospital 5 3 2 2 2 To ascertain the importance of various fac- tors in choosing a hospital for pediatric care. The survey instrument contains three questions that require the respondent to rank factors from most important to least important regarding (1} the use of any hospital for children, children, (2) the choice of a particular hospital for and (3} the most desirable quality of any hospital. The first ranking concerns itself with the general: If you had to use a hospital for your child, which factor 37 would be most important? Nine factors are given and the respondent may specify other factors that are not listed. Figure 1 shows the factors ranking for each factor. the factor doctor's and the varabili ty of the For example, recommenda~ion factor distance from home. the variability of is less than for the This indicates that respon- dent's choice of the factor doctor's recommendation is generally agreed upon, whereas the factor distance from home is more spread out and less decisive. RANKED FACTORS 4th 5th 6th 7th 8th 9th 20 6 3 3 1 0 0 2 8 24 15 12 12 14 6 18 29 23 14 4 1 2 1 1 Distance from home 7 12 14 12 11 12 11 11 3 Cost of Medical Services 1 5 3 9 18 21 17 13 6 Type of Payment Required 0 1 1 6 11 13 26 27 ~mployees 1 1 3 11 24 22 13 14 4 29 19 21 11 6 4 1 2 0 0 1 0 0 1 5 10 11 65 FACTORS 1st Doctor's Recommendation 37 Peer's Recommendation Reputation of the Hospital are Friendly & Understanding Quality of Care Ease of Parking Figure 1. 2nd 3rd 23 0 1 2 3 4 5 6 7 8 8 9 Variability and ranking of factors are shown based on respondents ranking of the factors when asked: If you had to use a hospital for your child, which factors would be important, in order of importance? PROFILE RANKING 1. 2. 3. 4. 5. Doctor's Recommendation Quality of Care Reputation of the Hospital Distance from home Peer's Recommendation 6. 7. 8. 9. Employees are Friendly & Understanding Cost of Medical Services Type of Payment Required Ease of Parking w 00 39 With a total of 9 factors to rank, there are 9J0 or 387,420,489 possible ranked combinations. 92 different rankings were obtained from a sample of 93. A ranking profile using the mode was compiled based on cumulative choice. Doctor's recommendation was chosen by 37 respondents as the most important factor in use of a hospital for children. Quality of care and reputation of the hospital were ranked second and third, respectively. However, one could argue a tie between these two factors for second most important factor in use of a hospital. ranked that in the middle, is, factors through eighth were more variable. ranked fourth Perhaps if a much larger sample size were obtained these factors ordered differently. Factors would be Parking was clearly considered the least important factor with 65 respondents placing this factor last in their individual rankings. In short, rank- ings seem to indicate very strong preferences for most and least important factors as reflected in the varability of the factors doctor's recommendations and ease of parking. The second ranking question gives additional insight into the respondent's choice of hospital in the event their child had to be admitted to the hospital. It asks: Which factors determined your choice of hospital in the event your child had to be admitted to the hospital? This 40 question complements the first ranking which was concerned with general factors related to the choice of any hospital. The respondent is asked to rank the factors in order of importance based on what factors determined their choice of a particular hospital. spondent is asked: Specifically, the re- Which of the following factors deter- mined your choice of hospital the most? Figure 2 shows the factors and the variability of the ranking for each factor. Eight factors are given with the respondent free to specify other factors not listed that he/she feels are important. Peer's recommendation and type of payment required are two factors dropped from the first ranking and the factor, have been there before, is added to the second ranking. Some of the factors are reworded but mean the same, i.e., personal physician selected hospital means the same as doctor's recommendation. RANKED FACTORS FACTORS 1st Distance from home 14 Reputation of the Hospital 28 1 2nd 3rd 4th 5th 5 6th 7th 8th 15 14 6 1 9 10 8 17 27 19 8 5 3 2 31 26 22 6 12 3 7 11 Cost of Medical Services 1 1 7 8 8 Employees are Friendly & Understanding 0 2 3 17 34 Parking Convenience 0 0 1 1 1 13 26 49 Personal Physician Selected Hospital 16 23 14 19 9 3 4 5 Have Been There Before 20 12 16 10 6 4 7 18 Quality of Care 14 19 22 13 2 2 0 Figure 2. 2 3 4 21 8 Variability and ranking of factors are shown based on respondents ranking of the factors when asked: If your child had to be admitted to the hospital, based on the particular choice of hospital you selected, rank the following factors in order of importance. PROFILE RANKING 1. 2. 3. 4. Reputation of the hospital Personal Physician Selected Hospital Quality of Care Have Been There Before 5. 6. 7. 8. Distance from home Employees are Friendly & Understanding Cost of Medical Services Parking Convenience "'I-'" 42 With a total of eight factors to rank, there are sB or 16,777,216 possible ranked combinations. 89 different rankings were obtained from a sample of 93. A ranking profile using the mode was compiled based on cumulative choice. Reputation of the hospital was ranked first fol- lowed by personal physician selected hospital and quality of care. Parking was again, clearly considered the least important factor in determining the respondent's choice of hospital (See Table 10). Table 10 Ranking Profile Any Hospital Profile Particular Hospital Profile Doctor's recommendation Quality of Care Reputation of the Hospital Personal Physician Selected Hospital Quality of Care Have Been There Before Distance from Home Employees are Friendly & Understanding Cost of Medical Services Parking Convenience Reputation of the Hospital Distance from Home Peer's Recommendation Employees are Friendly & Understanding Cost of Medical Services Ease of Parking 43 Objective 6: To ascertain the most desirable quali ti tes of any hospital. The third and final ranking concerns the most desirable quality of any hospital. Respondents are given six factors and can specify other factors if not indicated. There are 46,656 possible ranked combinations. Fifty- seven different ranked combinations were obtained from the sample of 93 respondents. A ranked profile using the mode was compiled based on cumulative choice. Good doctors was ranked the most desirable quality of any hospital. The personal interest shown in the patient's medical condition was ranked second followed closely by explanations given about medical/ surgical condition/treatment. Privacy was ranked sixth. (See Figure 3). Results from the rankings seem to elicit a strong indication of likes and dislikes. Generally speaking, the factors that respondents were not sure of or had a neutral feeling about were placed in the middle. Objective 7: To ascertain the respondent's satisfaction with the services provided at CHLA. This next question was the first indication the respondents received that the survey was a joint venture with CHLA. question was asked of all respondents: in your family ever been a The following Have you or anyone patient at CHLA? 23 re- spondents replied positively and went on to answer the RANKED FACTORS FACTORS 1st 2nd The personal interest shown in the patient's medical condition 18 32 Friendly and helpful staff 1 Privacy 1 1 3rd 4th 27 10 2 15 33 0 6 21 13 2 Good doctors 52 Explanations given about medical/surgical condition/treatment 12 32 22 7 6 10 Accessibility and convenience of services Figure 3. 3 5th 6th 3 3 35 7 10 25 49 5 2 0 12 9 6 23 19 5 28 4 6 variability and ranking of factors are shown:based ci>.n respondents ranking of the factors related to the most desirable qualities of any hospital. PROFILE RANKING 1. 2. 3. 4. 5. 6. Good Doc tors The personal interest in the patient's medical condition Explanations given about medical/surgical condition/treatment Friendly and helpful staff Accessibility and convenience of services Privacy .r:::. .p. 45 next three questions. The 70 respondents who had had no experience with CHLA skipped these three questions. The first question in the 3-question series con- cerning CHLA asked respondents to rate the service area utilized. the second question asked respondents to rate the service received at CHLA overall. The third question was an open-ended question which asked respondents to indicate their reasons for their rating of the service at CHLA (see Table ll). Table 11 Service Area Utilized Inpatient Outpatient Clinic Emergency Room A Special Unit (#) 9 5 5 4 Service Rating of CHLA ill Excellent Satisfactory Poor No Opinion 14 7 1 l Following the 3-question series about CHLA, two questions were asked of all respondents. The first question asked the respondent to indicate something positive about the Hospital, while the second question asked the re- spondent for changes or recommendations that would help improve the services at the Hospital. Those who had had experience with CHLA found these questions to be redundant~ some felt they could not answer or make any recom- mendations. Appendix C and Appendix D list the responses to these two questions. 46 Objective 8: To determine the service respondent's be- lieve CHLA should provide to the community. One of the more fascinating results of the survey was this next question: Which one of the following outpatient services do you feel CHLA should provide to children in the community? It required respondents to indicate outpatient service. ~e Some respondents wanted to know which services listed CHLA presently provided. These respon- dents were informed that it really did not matter which services were currently offered as the Hospital wanted to know which one service they preferred as consumers. The results of this question are shown in Table 12. Walk-in treatment was chosen by 32% of the sample. eight respondents who specified other, Hospital The indicated that the should offer nutritional services or they indi- cated their preference for all of the series listed, after they were informed a even second time that only one service was requested. Table 12 Service CHLA Should Offer Outpatient Service Walk-in Treatment Trauma Center Poison Center Community Health Education Other (Nutrition) Mobile Clinic Well Baby Clinic Transportation to the Hospital (#) (%) 30 18 12 10 8 6 5 32.3 19.4 12.9 10.8 8.6 6.5 5.4 4 4.3 47 Knowledge Survey Objective 9: To obtain the consumer's understariding of the health care industry. The third part of the survey instrument attempted to obtain a measure of the level of knowledge of the respondents. The interviewer believed that the four questions asked were something that would be common knowledge of one who read the newspaper or watched the news on television. The first question required the respondent to indicate an example of a Health Maintenance Organization (HMO) from five items. Kaiser was the correct response and was chosen by 58% of the sample. UCLA Hospital was chosen second by 23% of the sample (see Table 13). Table 13 Quiz 1 An example of a Health Maintenance Organization (HMO} is Kaiser UCLA National Medical Enterprise A nursing home A hospital that Has a ER # 54 21 sa-:-1 22 6 10 4 10.8 4.3 4 4.3 % 0 The second question asked respondents to indicate the most recent trend in the hospital industry from four 48 i terns. 68% of the respondents chose the correct response, an increase in outpatient services, with 28% of the respondents choosing an encouragement of physicians to specialize (see Table 14). Table 14 Quiz 2 The most recent trend in the hospital industry is An increase in outpatient services An encouragement of physicians to specialize 63 # % 67.7 26 28.0 3 1 3.2 1.1 An increase in length of patient stay An enforcement of visiting hours The third question asked respondents to indicate what group they felt physicians wre historically associated. This was close. 33% of the respondents chose the correct response of barbers, however, 39% of the respondents felt butchers was the correct response (see Table 15). Table 15 Quiz 3 Historically, physicians are associated with which group? Butchers Barbers Merchants Court Jesters Blacksmiths # 36 31 16 9 1 % 38.7 33.3 17.2 9.7 1.1 49 The fourth question asked respondents to indicate the health care profession in which a nationwide labor shortage exists. 87% of the respondents selected the correct profession of nurses (see Table 16). Table 16 Quiz 4 A critical labor shortage exists nationwide for which health care profession? # Nurses 81 Physicians 8 Administrators 2 Pharmacists 1 % 87.1 8.6 2.2 1.1 CHAPTER 5 Conclusions, Recommendations, and Summary I. CONCLUSION The San Gabriel Valley and "604" Corridor Regions appear to be CHLA's patients. Hospital, As such, major market areas for pediatric they represent strongholds of the and efforts should be made to maintain its share of those markets. Expansion into the Conejo Valley and Antelope Valley seems to offer the least risk and the .highest payoff, as these areas are growth markets. Ef- forts to expand into the saturated Basin Areas appear bleak because of the dominance of competitors of CHLA, such as Cedars-Sinai Medical Center and UCLA Hospital and Clinics. The San Fernando Valley may offer some oppor- tunities, with persistence. CHLA must focus its first real marketing efforts on territory with which it is familiar in the hopes that early success will reinforce the confidence necessary to overcome the intense competition which exists in all Areas. At the same time, these early successes will hopefully secure the support of physicians and employees, who are both determining factors to any future CHLA may wish to enjoy. 50 51 This project was very fruitful in its generation of findings. However, these findings are based on a non- probability sample of 93 respondents and represent investigatory outcomes which occurred in a field environment. The important con t rib uti on of this pro j e c t is the demonstration of the importance of eliciting information from the consumer-patient about his/her needs and wants. The information contained in this document should be considered part of the vital interests of the Hospital. 52 II. RECOMMENDATIONS This decade of rapid social and technological development and impending emergency impels managers of most health care organizations to examine the concept of marketing. The inability of administrators to properly use the existing body of information both for improving the effectiveness of their hospital organizations and for facilitating their adaptation to changing environments appears to be a salient feature of today's health care organizations. CHLA's Hopefully, an outsider's perspective of situation of this project generated the following recommendations for CHLA: 1. To develop new services that are distinctive to the pediatric health care market and CHLA, i.e. nutritional services, walk-in treatment, child obesity clinic, embryonic surgery. 2. To bolster current "star" services to safeguard the Hospital against market penetration by competitors, i.e. Neonatal, Oncology Programs. 3. To utilize a horizontal integrative strategy and purchase firms serving children's interests, i.e. day-care centers, amusement parks. 4. To correct systems errors, i.e. waiting time, admitting procedures, discharge and communication gaps between referring and attending physicians. s. To sponsor a mobile clinic through contracts with schools for immunizations, examinations. 53 6. To set up and/or sponsor community education programs through P.T.A. 's and community governments, and community organizations. 7. To build loyalty and trust among consumers toward the Hospital through quality advertising and image enhancement campaigns. 8. To institute a Marketing Information System in which data is available on current interval events and external environments, with a goal toward achieving more rigorous findings from information by applying advanced statistical procedures and models utilizing a computer. 54 III. SUMMARY This project undertook a study of the primary service area of Childrens Hospital of Los Angeles (CHLA) to ascertain the attitudes and preferences of the consumer-patient toward pediatric care and the Hospital. A survey instru- ment was developed with input from members of CHLA's Department of Planning and Public Affairs and a review of the literature. The Los Angeles Area was divided into six major areas and 93 respondents were interviewed. collected on the demographic, status of respondents~ respondents~ Data was cultural and socioeconomic the attitudes and preferences of and the level of understanding of the health care industry of respondents. Analysis of the data was conducted using the Statistical Package for the Social Sciences. Open-ended questions were compiled by hand. Findings were reported relative to the objectives of the project. The overall goal of establishing the need for input from the consumer of care to the design of programs and services in health care was achieved. Future studies of this kind should be conducted on a regular basis. Though the consumer-patient is the primary user of the hospital's services, be examined for their input. other parties should also Third-party payors, manu- 55 facturing agents of pharmaceutical and laboratory supplies, government agencies, and the employees of the organization are some of the groups which need to be considered for input if the hospital is to design its services to match the demands of its various constituents. Additionally, studies relating physician demands versus patient demands of the hospital organization need to be examined, and contradictory demands lessened. Marketing research is aimed at providing more specific information about one problem area. It should pro- vide information to management that will effectively eliminate the range of choices available in solution to a problem and making a decision. the selecting a In this way, information obtained as a result of a research effort becomes knowledge, and marketing hopefully in- creases the effectiveness of the organization. Marketing is a relatively new field in health care administration, and many misconceptions surface about the role of marketing in health care. It is equated with selling and promotion, and perceived as a threat to the medical profession. As a result, marketing programs when first launched, must market themselves to all potentially affected parties, especially the physicians. Given the recency of most health care marketing programs, it is imperative that a firm marketing data base be established. Most of this information is already owned by 56 the hospital, but dispersed By establishing a throughout the organization. Marketing Research Division within the Marketing Department, this data can begin to be collected and provided to top management as knowledge to make effective decisions. 57 BIBLIOGRAPHY 1. Aci to, Franklin. "Consumer Decision Making and Health Maintenance Organizations: A Review," Medical Care, January, 1978, pp. 1-13. 2. Bloom, Paul N., and Greyser, Stephen A. "The Maturing of Consumerism." Harvard Business Review, November/December, 198~pp. 130-139. 3. Brooks, Charles H. "Associations Among Distance, Patient Satisfaction, and Utilization of Two Types of Innl~r-City Clinics," Medical Care, September/October, 1973, pp. 373-383. 4. Clarke, Roberta N., and Shyavi tz, Linda. "Marketing Information and Market Research - Valuable Tools for Managers." Health Care Management Review, Winter, 1981, pp. 73-77.---- s. Cooper, Phillip Germantown, 1979. 6. Cooper, Phillip D., and Maxwell, Richard B., III. "Marketing: Entry Points and Pitfalls." Hospital and Health Services Administration, Summer, 1979, pp. 34-53. 7. Cunningham, Robert M., Jr. "Consumerism: The Tables are Turning." Hospitals, March 1, 1981, pp. 7882. 8• Fa 1 be r g , \'l a r r en C • and Bonne m , S hi r 1 e y. "Good Marketing Helps a Hospital Grow." Hospitals, June 1, 1977, pp. 70-72. 9. Fink, Daniel J., M.D. "Developing Marketing Strategies for University Teaching Hospitals." Journal of Medical Education, July, 1980, pp. 574-579. D., ed. Health Care Marketing. MD: Aspen Systems Corporation, 58 10. Flexner, William A., McLaughlin, Curtis p., and Littlefield, James E. "Discovering What the Health Consumer Really Wants." Health Care Management Review, Fall, 1977, pp. 43-49. 11. Goldsmith, Jeff c. "The Health Care Market: Can Hospitals Survive?" Harvard Business Review, September/October, 1980, pp. 100-112. 12. Houston, Charles s., M.D., and Pasanen, Wayne E. "Patients' Perceptions of Hospital Care." Hospitals April 16, 1972, pp. 70-74. 13. Hulka, Barbara s., Kupper, Lawrence L., Daly, Mary B., Cassel, John c., and Schoen, Frederic. "Correlates of Satisfaction and Dissatisfaction with Medical Care: A Community Perspective." Medical Care, August, 1975, pp. 648-658. 14. Ireland, Richard c. "Using Marketing Strategies to Put Hospitals on Target." In Marketing in Nonprofit Organizations, pp. 123-13~--Ed1ted by Patrick J. Montana. New York: American Management Association, 1978. 15. Kotler, Philip, ed. Marketing for Nonprofit organizations. Englewood-Cliffs-;-New_J_e_iSey! Prentice-Hall, Inc., 1975. 16. Kotler, Philip. Principles of Marketing. Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1980. 17. Lebow, Jay L. "Consumer Assessments of the Quality of Care." Medical Care, April, 1974, pp. 328337. 18. Lovelock, Christopher H. "Concepts and Strategies for Health Marketers." Hospital and Health Services Administration, Fall, 1977, pp. 50-62. 19. Luft, Harold s., Hershey, John C., and Morrell, Joan. "Factors Affecting the Use of Physician Services in a Rural Community." American Journal of Public Health, September, 1976, pp. 865-871. 20. MacStravic, Robin E. Marketing by Objectives for Hospitals. Germantown, MD: Aspen Systems Corporation, 1980. MacStravic, Robin E. "Marketing: Changing Prospective Patients' Behavior." !:!~~.E~t~_!_ Progress, June, 1979, pp. 47-49. 21. 59 22. Metzner, Charles A. and Bashsur, Rashid L. "Factors Associated with Choice of Health Care Plans." Journal of Health and Social Behavior, December, 1967, pp-.-291-299. 23. Miller, John A. "Marketing Basics for Hospital Managers." Hospital Forum, July-August, 1980, 1980, pp. 7-12. 24. Nelson-Wernick, Eleanor, Currey, Hal s., Taylor, Paul w., Woodbury, Marion, and Cantor, Alan. "Patient Perception of Medical Care." Health Care Management Review, Winter, 1981, pp. 65-72. 25. Pollard, Michael R. "Fostering Competition in Health Care." In Regulating Health Care, pp. 158-167. Edited by Arthur Levin, M.D. New York: The Academy of Political Science, 1980. 26. Ross, David E., and Tripoli, F.J. "Fiscal Risks, Methods, Rewards Shape Community Outreach Success." Hospitals, July 16, 1977, pp. 86-88. 27. Scitovsky, Anne A., McCall, Nelda, and Benham, Lee. "Factors Affecting the Choice Between Two Prepaid Plans." Medical Care, August, 1978, pp. 660-681. 28. Stratmann, William C. "A Study of Consumer Attitudes About Health Care: The Delivery of Ambulatory Services." Medical Care, July, 1975, pp. 537548. 29. Stuehler, George, Jr. Planning Relate." 96-99. 30. Ware, John E., Jr., and Snyder, Mary K. "Dimensions of Patient Attitudes Regarding Doctors and Medical Care Services." Medical Care, August, 1975, pp. 669-682. 31. Zimmerman, James P. "Service Areas and Their Needs Must Be Reassessed." Hospitals, September 1, 1975, pp. 46-48. 32. Zuckerman, Alan M. "Patient Origin Study Profiles Service Area, Evolving Patterns." Hospitals, July 16, 1977, pp. 83-85. "How Hospital Marketing and Hospitals, May 1, 1980, pp. 60 APPENDIX A Thank you for agreeing to take the time to complete this survey! I am a graduate student in Health Care Administration at Cal State University, Northridge. I hope this survey will answer some questions I have about the consumer's attitudes and understanding of the health care field. Your responses will be used to create and eliminate health programs to better meet your needs as health care consumers. The responses you provide will remain confidential. Please answer all questions by circling the appropriate or correct response. All questions must be answered; otherwise your survey wT11 be invalidated. ·Thank you 1 61 DEMOGRAPHIC PROFILE Under 19 20 - 29 30 - 39 40 - 49 50 - 59 60+ 1. AGE 2. MARITAL STATUS 3. SEX 4. NUMBER OF CHILDREN Single Married Widowed Divorced Separated Female Male 0 1 2 3 4 or over 5. HOME mVNERSHI P Own Rent Other 6. TU1E AT PRESENT ADDRESS 7. OCCUPATION Less than 1 year 1 - 3 Years 3 - 5 Years 5 - 10 Years 10 - 25 Years More than 25 Years Managerial Skilled Trade Laborer Office Worker Technical Professional Homemaker Student Retired 62 8. EDUCATION 9. INCOME 10. Less than 12 Years High School Graduate Technical/Vocational School Some College College Graduate Professional Degree Under $10,000 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $49,999 $50,000 & over HOW MEDICAL EXPENSES ARE PAID Self-Pay Private Insurance MediCare MediCal Blue Cross/Blue Shield HMO Member (i.e. Kaiser) 11. RACE Caucasian Black Hispanic Asian Indian Other 63 ATTITUDE SURVEY 1. Name a hospital in the Los Angeles area. 2. Can you name two more hospitals? 3. Have you ever had to bring your child to a hospital? YES NO 4. If yes, which hospital? s. If you had to use a hospital for your child, factor would be more important? a. b. c. d. e. f. g. h. i. j. doctor's recommendation peer's recommendation (i.e. word of mouth) reputation of the hospital distance from home cost of medical services type of payment required employees are friendly and understanding quality of care ease of parking other (specify) which 64 6. Please rank the criteria in #5 in order of importance Least _Important Host Important 7. Do you have a regular family physician? YES 8. If mychild had to be admitted to the hospital, would choose a. b. c. d. e. f. g. h. i. 9. I Northridge Hospital Foundation Glendale Advertist Medical Center Tarzana Medical Center Long Beach Memorial Hospital Childrens Hospital of Los Angeles Huntington Memorial Hospital Cedars Sinai Medical Center UCLA Hospital other (specify) Which of the following factors determined your choice in #8 the most? a. b. c. d. e. f. g. h. i. 10. NO distance from home reputation of the hospital cost of medical services employees are friendly and understanding parking convenience personal physician selected hospital have been there before quality of care other (specify) Please rank importance. Most Important_ the criteria in #9 in order of Least _Important 65 11. The most desirable quality of any hospital is a. b. c. d. e. f. g. 12. the personal interest shown in the patient's medical condition friendly and helpful staff privacy good doctors explanations given about medical/surgical condition/treatment accessibility and convenience of services other( specify) Please rank importance. the criteria of NO Outpatient Clinic Emergency Room A Special Unit Inpatient Other (specify) How would you rate the service you received Childrens Hospital of Los Angeles overall? a. b. c. d. 16. order If you answered YES to # 13, please indicate the service area utilized otherwise, go to #17. a. b. c. d. e. 15. in Have you or anyone in your family ever been a patient at Childrens Hospital of Los Angeles? YES 14. #11 Least Important Most Important 13. in Excellent Satisfactory Poor No Opinion Please indicate the reason for your choice in #15. at 66 17. If you had to say something positive about Childrens Hospital of Los Angeles, what would you say? 18. What changes or recommendations would help improve the services at Childrens Hospital of Los Angeles? 19. Which one of the following outpatient services do you feel Childrens Hospital of Los Angeles should provide to children in the community? a. b. c. d. e. f. g. h. 20. Walk-In Treatment Trauma Center Transportation to the Hospital Well Baby Clinic Poison Center Mobile Clinic Community Health Education Other {specify) I encourage you to write any comments you may have in the space remaining. 67 HEALTH CARE INDUSTRY QUIZ 1. An example of a Health Maintenance Organization (HMO) is a. b. c. d. e. 2. The most recent trend in the hospital industry is a. b. c. d. 3. an an an an increase in length of patient stay encouragement of physicians to specialize enforcement of visiting hours increase in outpatient services Historically, physicians are associated with which group? a. b. c. d. e. 4. UCLA Hospital a nursing home a hospital that has an emergency room National Medical Enterprises Kaiser court jesters barbers butchers blacksmiths merchants A critical labor shortage exists nationwide for which health care profession? a. b. c. d. physicians nurses pharmacists administrators 68 APPENDIX B DEFINITIONS! To acquaint the reader with some of the marketing terminology used in this page, the following definitions of marketing terms is provided: 1. Hospital Marketing Opportunity - An attractive arena of relevant marketing action in which a particular hospital is likely to enjoy superior competitive advantages. 2. Consumerism - An organized social movement seeking to strengthen the rights and power of consumers vis-a-vis sellers (the hospital and/or physicians). 3. Culture - Anything that is learned. 4. Demand - Wants which one is able and willing to satisfy through purchased behavior. s. Environmental threat - A challenge posed by an unfavorable-trend-or-specific disturbance in the environment which would lead, in the absence of purposeful marketing action, to the stagnation or demise of a hospital, service, or speciality. 6. Expectations-performance theory - A consumer's sat.1sfa-Ctlon-rs-afunctfon-of-the-consumer IS service expectations and the service's perceived performance. 7. Image persistence - The result of people's continuing to-5ee what they expect to see, rather than what is. 1 These definitions are from Philip Kotler, Principles of Marketing (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1980), PP• Gl-G9. 69 a. Market - The set of all actual and potential buyers of a service. 9. Marketing - Human activity directed at satisfying needs and wants through exchange processes. 10. Market demand - The total volume that would be bought by a defined customer or patient group in a defined geographical area in a defined time period in a defined marketing environment under a defined marketing program. 11. Marketing concept - A management orientation that holds the key to achieving organizational goals consists of the organization's determing the needs and wants of target markets and adapting itself to delivering the desired satisfactions more effectively and efficiently than its competitors. 12. Marketing information system - A continuing and interacting structure of people, equipment, and procedures designed to gather, sort, analyze, evaluate, and distribute pertinent, timely and accurate information for use by marketing decision makers to improve their marketing planning, execution, and control. 13. Marketing mix -The particular blend of controllable marketing -variables - Product, Price, Promotion, Place - that the hospitals uses to achieve its objectives in the target market. 14. Marketing research - The systematic design, COl"lection, -analysl.s 1 and reporting of data and findings relevant to a specific marketing situation facing the hospital. 15. Marketing strategy -The fundamental marketing logic by which the hospital intends to achieve its marketing objectives. Marketing strategy consists of a coordinated set of decisions on target markets, marketing mix, and marketing effort. 16. M~E~e:!::_ E~~~tE~:!::_~o~ The ho spit a 1' s seeking increasing revenues for its current services in its current markets through more aggressive marketing efforts. 70 17. Market Potential - The limit approached by market demand as industry marketing expenditure goes to infinity, for a given set of competitive prices and a given environment. 18. Market ~mentation - The act of dividing a market into distinct and meaningful groups of buyers (consumers-patients) who might merit separate services and/or marketing mixes. 19. Needs -A feeling of a sense of self-deprivation. 20. Product concept - A management orientation that assumes that consumers will favor those products that offer the most quality fdr the price, and therefore the hospital should devote its energy to improving service quality. 21. Production concept- A management orientation that assumes that consumers will favor those products and/or services that are available and affordable, and therefore the major task of management is to pursue improved production and distribution 22. Selling concept - A management orientation that assumes that consumers will either not buy or not buy enough of the hospital's services unless the hospital makes a substantial effort to stimulate their interest in its services. 23. Service - Any activity or benefit that one party can offer to another, is essentially intangible, and does not result in the ownership of anything. 24. Strategic planning - The managerial process of developing and maintaining a strategic fit between the organization and its changing market opportunities. 25. Target market -A well-defined set of customers/consumers-patients whose needs the hospital plans to satisfy. 26. Wants - Needs shaped and modified by culture. 71 APPENDIX C Respondent's comments to the question: If you had to say something positive about Childrens Hospital of Los Angeles, what would you say? 1. You will get help if you wait long enough 2. Tremendous capabilities; a variety of specialities 3. Heard care is excellent 4. Extensive research in childhood diseases outstanding reputation for treating extremely ill children 5. What the name Childrens stands for is good - health care for children 6. Gave explanations and knew what they were doing 7. very thorough and up-to-date knowledge 8. Concerned and helpful staff 9. Competent medical care 10. Great that CHLA is a hospital just for kids 11. Heard that CHLA has a good reputation 12. My sister has nothing wrong with her eyes to this day 13. Seems like CHLA has good care in critical situations 14. Excellent care in emergency situation, treating childhood injuries and diseases 15. My friends have spoken highly of CHLA 16. CHLA offers specialized care for children good in 72 17. CHLA is known for good doctors, good equipment, and state of the art technology 18. CHLA is in a good location, Angeles 19. CHLA is a full-service hospital, well located, at little or no cost to patients 20. Close by, accessible by bus, has a good staff 21. CHLA has good quality of care and expertise in children's health care; facilities are good 22. CHLA has good advanced equipment and good doctors; heard this from other people 23. Cedars-Sinai has better quality of care: My husband is a pediatrician on staff at both hospitals, I should know. 24. I heard that CHLA flys children in from other areas 25. CHLA must be the best place for children since they specialize in pediatric health care and therefore know the needs of children 26. CHLA had a good staff in the early 1970's 27. It's good that CHLA has a special interest in children and does not spread its attention among other groups 28. CHLA has research 29. I have read articles about the NICU 30. Excellent care, good doctors, expertise central to all of Los I 73 APPENDIX D Respondent's comments to the question: What changes or recommendations would help improve the services at Childrens Hospital of Los Angeles? 1. More adequate staff to cut down on waiting time 2. Expedite the ER process and give the patient more explanation about medical condition 3. Increase Public Relations so CHLA will become more familiar to the consumer 4. Offer full services so there is no need for transfers or waiting 5. Parking needs improvement 6. Find a cure for asthma 7. Increase training for doctors and nurses 8. Wider publicity and exposure of Hospital 9. CHLA is like a clinic - not a warm atmosphere and too much red tape services of the 10. Staff should adopt more friendly attitudes 11. Terrible location 12. ER waiting time is ridiculous, resident on call should be in the hospital regardless of speciality 13. Long waiting time 14. Take in ER cases faster 15. Faster admitting, more nurses 16. Lodging facilities for parents coming from a long distance 17. Should have counselors 74 18. Staff should pay attention to the patient, the person paying the bill 75 APPENDIX E Respondent's comments when encouraged for any additional information that they felt was important to include in the survey 1. ER should not be used as a walk-in or outpatient clinic 2. CHLA should build inform public of should let people the USC School of 3. Pasadena has excellent pediatricians and have some that specialize in cardiac care 4. There should be a nutritional approach to children's health care including more natural therapies~ i.e. vitamins and diet, and less medication via drugs. s. I wish I knew more about CHLA 6. CHLA has no right to make the cancer child a victim of their "best interests." The parents should always be kept informed and given the right to choose the medical care that they feel is appropriate for their children - the father seemed very caring and concerned for this child's security and welfare~ CHLA doctors felt they knew best and did not. 7. When my child needs medical care, insurance coverage is considered first, but in a serious case, the best doctor is most important. Distance, parking and even the cost are secondary factors. In any case, doctors and the hospital will provide free services when they know you cannot pay. a. My choice of hospital for my child would depend on the medical problem. Besides, my children are covered by Kaiser so they would most likely go to a Kaiser Hospital 9. CHLA should provide all pediatric services. satellite clinics and reach out to existence and capabilities~ CHLA know that they are affiliated with Medicine 76 10. My husband owns a substantial amount of stock in National Medical Enterprises - is CHLA a National Medical Enterprises Hospital? 11. I prefer university-teaching hospitals, however, UCLA Hospital care is terrible as there is no provision for the parent to remain in the room with the child; UCLA Hospital lacks sensitivity to emotional needs of children. 12. Billing system needs improvement; housekeeping needs improvement. 13. CHLA is a specialized hospital and should not offer general pediatric care such as a well-baby clinic or walk-in treatment, as a general hospital can handle this.