In terms of business management, health services can be considered as marketing activities. Patients are the ultimate customers of these activities. Therefore, strategies for customer satisfaction used in marketing facilities can also be utilized for the management of patient satisfaction. The marketing communication model proposed by Albrecht and Zemke for hospitals and outlined in the following scheme may be implemented to determine an accurate service strategy (
Figure 1) ( 9).
Figure 1. Marketing communication model for hospitals
According to this triangular-shaped model, not only the patients’, but also their family’s satisfaction is an essential instrument of the marketing process (bottom-right corner). In addition, hospital personnel are also considered as “internal customers” (top corner). Likewise, they should be happy first in order to ensure patient satisfaction (
10, 11). It is important to understand that each internal customer is a critical point in fulfilling patients’ needs. Thus, programs intended to develop relationships in health units are crucial. The third leg of this model is defined as referral authorities (bottom-left corner). Referral authorities function as counselor and policy maker, and patient satisfaction is essential for them.
Institutions providing healthcare should expand their customer satisfaction programs to include patients and their families, hospital employees and directive authorities, based on the model above.
The progress, made as the result of growing interest regarding customer satisfaction, led the term “relationship marketing” to emerge, as described in the model above. The word “relationship” means the relations among people who offer the service (internal customers). A good rapport necessitates having shared values in the service production, mutual trust, the establishment of frequent communication, collaboration and commitment to goals (
12). Otherwise, lack of communication between the doctors who provide primary health care becomes an issue, which leads to time and financial loss. This lack of communication can result in poor patient care.
It is evident that the relationship described above plays a vital role in preparing clinical guidelines. Clinical guidelines are the documents developed with the aim of creating criteria for diagnosing certain diseases or guiding their treatment (
5). Otherwise, lack of communication between the doctors who provide primary health care becomes an issue, which leads to time and financial loss. This lack of communication can result in poor patient care.
It is expected that the decision concluded as the result of teamwork is more efficient than the decision made by any one of the parties.
How do groups make a decision?
The group’s output of decision-making is associated with both the input and the process factors. The input factors include:
1. Individual factors (individuals’ skills, status, and personality structure)
2. Factors related to the group (group structure, size, and maxim)
3. Environmental factors (task quality, environmental stress level, and reward structure)
These factors affect the process and hence the “output” (
13). The process factors contain elements such as intragroup communication, information interchange, an alliance among the members, and the tendency to develop a strategy for fulfilling a duty. Input factors determine the group potential. The process loss is the loss of potential earnings which result from motivation and coordination errors ( 13). Therefore, group performance can be defined as follows:
Group Performance = Group Potential - Process Losses
However, process factors can produce more earnings expected from the inputs. For example, interaction may improve motivation and may contribute to a more efficient combination of the resources and hence to process earning. On the other hand, process and input factors are not independent of each other and are usually interrelated. Thus, for example, a specific group structure can influence the intragroup communication process.
The concept of “group thinking” was developed to explain group members’ efforts to build consensus and the group’s decision-making process. Group thinking can also lead to bad decisions in group interaction. In particular, those who are isolated from out-group individuals, who manifest high interdependence, who have a dominant leader and who are engaged with stressful decision-making can make wrong decisions. Behavioral models constructed by experimental research in social and cognitive psychology have revealed that the following factors stand out in the group’s decisions (
1. Group members who are planned to reach a consensus to make a decision should benefit from both their experience and new information presented in the group.
2. The relationship of the people with knowledge (manner of examining, organizing and recalling the information) determines which information will be used, what impact will this information have, and possible bias that may be effective in using the information.
3. Efforts to reach a consensus may need the perspectives of some people on the event to change. This change may be through persuasion and social influence.
4. The intragroup behavior is shaped by the perceptions of the group members towards group work: Do members consider themselves as a group with a common purpose or are sub-group identities residing at a more salient position? In turn, does consensus lead to a conflict of interest among sub-group members?
This last statement summarizes the purpose of our work.
Upon the need to develop a corporate attitude towards preventing reactions to contrast agents, clinicians working in the institution were requested to fill in a questionnaire and were asked who should become dominant about prevention of the reactions. When we reinterpret the figures in the result section:
1. The number of physicians who preferred the clinician to maintain an active or collaborative dominant attitude in the decision-making mechanism was 30 (40%).
2. The number of physicians who preferred the radiologist to maintain an active or collaborative dominant attitude in the decision-making mechanism was 25 (33.3%).
3. The number of physicians who preferred a collaborative attitude was 46 (61.3%) when those who preferred both parties to take equal responsibility in the decision-making mechanism were added to the collaborative physicians.
4. The number of non-collaborative physicians was 29 (38.7%). Of these, 18 (24%) and 11 (14.6%) wanted the clinicians and radiologists to be active in the decision-making mechanism, respectively. This ratio was at a considerable level and posed an obstacle to the issue that a consensus is needed for prevention of such reactions to the contrast agents.
Clinicians’ attitudes may depend on various factors. Statistical inferences drawn from the current study may provide partial insight into this situation. Accordingly, physicians in surgical specialties prefer the radiologist to become dominant in the decision-making process, with a significant difference. This tendency suggests that surgeons are focused on surgical repair by isolating their clinical interests from patients’ internal problems.
Surgeons may have a tendency to solve their patients’ internal problems by consulting internal specialists, but this trend may put patients at risk in some outpatient cases or in reactions to contrast agents. In conclusion, the physician is first and foremost, a general practitioner regardless of the specialty, and the patient does not consist of a single system that only concerns a single specialty. This fact is a fundamental tenet that is also taught in medical school.
On the other hand, female physicians prefer an equalitarian attitude in the decision-making process, with a significant difference. This finding indicates that female physicians are more prone to group work that requires cooperation and communication. However, good communication within the group does not mean that good clinical practice, which is our main aim, will take place. Because of that no matter what decision the group makes, practical application will be interrupted due to the ratio (38.7%) of doctors who have a non-cooperative attitude. In other words, group performance seems to be low from the beginning. However, any decision should not be made on this topic without seeing the process losses during practice, because being non-cooperative is a first preference according to the scale that we have implemented. It may be possible that non-cooperative doctors maintain a cooperative attitude during group work. In other words, the process losses remain less than expected.
14.6% of non-cooperative physicians want only the radiologist to be active in the decision-making mechanism. In our opinion, this ratio is not high. However, it does not mean that the radiologist will not play an active role in clinical practice. The most significant challenge of accomplishing this task is that radiology is a laboratory branch. In other words, the radiologist is often unaware of the clinical and laboratory findings of a patient whose examination is requested. Trying to identify these (meeting each patient who has exposure to contrast agent and questioning risky situations) will lead to assigning a separate physician to the task, thereby leading to labor loss. This already seems impossible to implement in many organizations, including ours.
In conclusion, when we attempt to establish a clinical guideline committee towards preventing reactions to contrast agents, the ratio of physician clinicians with non-collaborative attitude may lead us to encounter difficulties in developing a consensus. However, it is difficult to foresee what the final group performance will be and we do not think it will be understood unless clinical practical work begins.
The study conducted by Sepuca et al., which used 17 different measurement methods to evaluate decision-making processes, was not able to find a single measurement method determining decision-making process and its quality. We also agree with them.
As in the present study, preliminary studies using various scales about the preferences of physicians to form groups may help in predicting future application difficulties.