The patient experience in hospitals

The patient experience in hospitals

“A service element overview,

for marketing purposes”

The patient experience in hospitals

“A service element overview,

for marketing purposes”

Marjolein Hospers

University of Groningen Faculty of Economics & Business Master Thesis BA - Marketing Management

Nieuweweg 38-9 9711 TG Groningen 0646750989 m.j.hospers@gmail.com S1747681 January, 2011

Management summary

Over the course of the last decade, costs of the Dutch healthcare system have increased significantly. This increase is observed in Euros as well as GDP share. Failures from both government and the market have caused the system to be ineffective resulting in extremely high costs. The accessibility, availability and quality of care were under pressure. In order to improve efficiency and effectiveness of the current situation, major healthcare system changes have been implemented. Following the example of the public transportation market, the postal service, phone companies and energy suppliers, the healthcare market became a free-market. These system changes stimulate a demand based and market oriented approach in which healthcare providers are allowed to make profits (within limits). It furthermore involves changes to the healthcare insurance system and facilitates patient empowerment. Altogether, these changes mean an increase in competition among healthcare institutions. The goal of these new implementations is to stimulate healthcare providers into providing quality care for reasonable and affordable prices: „customized care while keeping costs in control‟. It must increase wealth for healthcare consumers and includes different rules that allow for more freedom, choice and flexibility concerning insurance provision.

A main and impactful result of the change to a free-market concept is the fact that healthcare providers are no longer automatically guaranteed a sufficient amount of patients. Sufficient hereby refers to the number of patients necessary to keep the healthcare production retained. When patients are able to choose their healthcare provider, they can easily choose a competitor. A majority of healthcare organizations are making internal adaptations to the market changes through: reorganizations, budget cuts, efficiency improvements and planning and control activities. Although these adaptations are important, external changes need to be made as well. A focus on the market and its‟ potentials, competitions and most important the patient is required (van Leeuwen, 2007). A method to respond to the rising competitiveness is for healthcare providers to engage in marketing which will attract patients and stimulate sustaining a strong market position. Goal of this thesis is therefore the creation of a service element overview that optimizes the patients‟ experience in hospitals and can be used for marketing purposes. In this case optimizing refers to creating a positive and unique patient experience in hospitals. The interpretation of „experience‟ that is referred to in this thesis is therefore not merely a result of a service encounter but the creation of a positive and unique hospital experience for patients. It is hereby important to notice that the outcome of the medical treatment is not considered an influential service element. Reason lies within the undeniable and understandable influence this element has on experience creation as well as the difference in influence per patient due to the difference in medical treatments necessary.

problem statement: “How can a hospital use a patients‟ hospital experience to acquire new patients and sustain a strong market position“. This is researched by means of qualitative research through literature analysis and interviews with patients and experts from the field of healthcare marketing. The accompanying main research question is focused on the content of the required patient experience: “Which service elements have a strong influence on patient experiences in healthcare institutions?” The literature analysis discusses experience creation from a diverse set of research angles: retail-customer point of view, tangibility and intangibility of services, service indicators for quality, customer value and healthcare market developments that represent the five sub-research questions. The theoretical analysis in turn leads to a conceptual research model consisting of service elements that have a potentially high influence on experience: social environment, service interface, atmosphere and environment, multi-channel environment, reputation, previous experiences and service quality indicators. The model additionally tests the service element customer management in order to gain information on how the process of attract> develop>retain can be optimized with prospect for marketing purposes. Market developments in healthcare are also addressed in order to align them with marketing advice where possible. These service elements are from diverse research angles which have not been covered in research literature extensively, supporting the strength and uniqueness of this conceptual model. Conducting research on the influence of this diverse and unique set of service elements supports the relevancy of this research and represents the academic contribution.

Concluding we can answer the main research question by stating that all 7 service elements influence a patients‟ hospital experience. A ranking, based on the frequency of mentioning by patients and experts during interviews, reveals the following order: 1. Service interface, 2. Social environment, 3. Clinical atmosphere & Environment, 4. Service quality indicators, 5. Multi-channel environment, 6. Previous experience (t-1) and 7. Reputation. Although there is a ranking, a note has to be made stating that the implementation order of these results also depends on the situation of an organization. The analysis of interview outcomes furthermore revealed a strong set of service aspects (sub-elements) that corresponds with all the 7 influential elements. The service aspects are: communication, personnel, patient involvement, patient centricity and design. The answer to the problem statement and a more detailed content description of a strong and unique experience is elaborated on by means of these service aspects, because they are what the concluded service elements have in common. They also support the implementation of the advice for management of healthcare institutions.

Additional research on the possibilities of using patient experiences in marketing, supplies us with a following answer to the problem statement: the patient experience created in a hospital is advised to be strong and unique and marketed as a competitive advantage in order to achieve the required result. In the competitive and developing market hospitals operate in; having an advantage over competition is crucial. Experts and literature acknowledge the need for a competitive advantage and experts agree that an experience can well be used as differentiator. The creation of a unique and positive patient experience can be realized when a hospital organizes their services with specific attention to: 1. Communication between patients and hospital, among medical staff and channels, 2. Personnel behaviour, appearance and capabilities and reliability, 3. Patient involvement through informing on treatment processes, explanations and status updates, 4. Patient-centricity by means of service supply tailored to wants, needs and expectations where possible, and 5. Design of clinical environment and thereby created atmosphere, layout and design with a social element as goal.

Preface

Hereby I would like to invite you to read my master thesis: my final assignment towards finishing my Master Marketing at the University of Groningen. In front of you lies a research report on patient experiences within Healthcare and the marketing possibilities when combination with the current market developments within this market. My interest towards this topic has revolved from a movie project on the Hospital of the Future during my internship at Weber MC. Over the course of writing, relevancy of this topic showed when tuning in on daily news, reading through newspapers or magazines. News topics that directly or indirectly influence on a patients‟ experience in healthcare institutions were and still are continuously covered in current media. This has been a great stimulant for me to during the writing process.

There have been several people who have also been a great support throughout my thesis writing process and therefore deserve recognition. A big thank you and big hug to: my parents who allowed me to take a few extra months and have always shown their pride, my boyfriend Hielke who have pulled me through hurdles and advised me when I was stuck, my brother Gijs and sister Pien who always told me I could do it, although I think they just want a graduation party. Furthermore would I like to thank my supervisor Dr. J.E. Wieringa, who has helped me start-up, gave helpful feedback and advice and always found a free-spot in his busy agenda for me to discuss my progress and the co-assessor, Dr. K.J. Alsem for his expertise, feedback and willingness to contribute to my thesis in the role of interviewee. Thank you!

At last, I would like to express my appreciation to all the participants who were willing to participate in this research and allowed me to interview them which led to interesting and new insights. Thank you!

Table of Content

Management summary ... 3

Preface ... 6

Table of Content ... 7

1. Introduction ... 9

2. What does theory say about experience creation? ... 14

2.1. A customer-store point of view ... 15

2.1.1. Element description ... 16

2.1.2. A translation to healthcare ... 21

2.2. Tangibility and intangibility of services ... 23

2.2.1. Level of tangibility ... 23

2.2.2. Importance of intangibility ... 24

2.2.3. Service environment ... 24

2.2.4. A translation to healthcare ... 27

2.3. Service indicators for quality ... 29

2.3.1. Determinants of service quality ... 29

2.3.2. SERVQUAL ... 30

2.3.3. A translation to healthcare ... 31

2.4. Customer value; the role of the experience ... 32

2.4.1. Customer Management ... 32

2.4.2. Customer acquisition strategies ... 33

2.4.3. Firm value ... 33

2.4.4. A translation to healthcare ... 35

2.5. Market developments ... 36

2.5.1. Healthcare market liberalization... 36

2.5.2. Mergers of healthcare institutions ... 37

2.5.3. Rise of healthcare-hotels ... 37

2.5.4. Sustainability ... 37

2.5.5. Patient involvement ... 38

2.5.6. Electronic Patient Dossier ... 38

2.5.7. Healthcare insurance costs... 38

2.5.8. Social Media ... 38

2.5.9. Dr. Yep ... 39

2.5.10. Potential for hospital marketing and influence on experiences ... 39

2.6. Conceptual research model ... 40

2.6.1 Research element reasoning ... 40

3. Research Design ... 43

3.1. Data collection ... 43

3.1.1. Literature analysis ... 43

3.1.2. Interviews ... 44

4. What do patients and experts say about experience creation? ... 46 4.1. Patients’ opinion ... 46 4.1.1 Interview topics ... 46 4.1.2 Interview outcome ... 48 4.2. Professionals’ opinion ... 51 4.2.1 Interview topics ... 51 4.2.2 Interview outcome ... 52

5. Conclusion & Recommendations ... 57

5.1 Conclusion ... 57 5.2 Recommendations ... 59 6. Discussion ... 63 6.1. Research limitations ... 63 6.2. Future research ... 64 Literature list ... 67 Appendices ... 73

Appendix 1a: Patient background ... 73

Appendix 1b: Patient interview ... 74

Appendix 2a: Professional/expert background ... 78

1. Introduction

After years of debates and research the Government made the decision in 2006 to liberalize the healthcare market, in order to stimulate the free market concept. Previous attempts failed. Nonetheless, in 2006 a newly released research report had been the last push the Government needed. The report is written by the Dutch hospital association NVZ and TNT N.V. wherein CEO P. Bakker reveals that three billion Euros in healthcare were wasted each year due to inefficiency. Goal of the free market concept is to stimulate healthcare providers to supply quality care against sharp prices: customized care while regulating costs (van Leeuwen, 2005).

The gradual introduction of free-market processes in healthcare has led to the development of a new healthcare system. In 2009 this system (still) showed more regulation of the market than a completely „free-operating‟ market, especially in case of healthcare providers: hospitals and AWBZ1

institutions. The previous Dutch healthcare system was based on the direction of supply which has shown to be a failure proven by increasing and unacceptable waiting lists, scarcity and strong increasing health expenditures. The new healthcare system is therefore designed to foster demand, is based on competition of services to the benefit of consumers and designed within a framework of basic public interest guarantees. This change in direction means a stronger position for patients against the healthcare suppliers and - insurance companies (Sauter, 2009).

A free market is not to be regarded as a goal in general but more as a tool that increases wealth for consumers. It furthermore does not mean an increase in rules but instead different rules that allow for more freedom and flexibility. Since October 2006 the Dutch Healthcare Authority (NZA) supervises, guides and advices the new healthcare system existing of healthcare provision, purchasing and insurance. NZA has been formed in order to secure fair competition and protect the general consumer interest in terms of access, quality and affordability of healthcare insurance.

For consumers (patients) the increase in consumer wealth led to a choice of healthcare insurance company and provider, protected by consumer rights. The balance between free consumer choice of both insurer and providers is „key‟ to the new healthcare system but also means the end of a guaranteed, sufficient amount of patients at all times (van Leeuwen, 2007). Healthcare providers have to compete, or so called „fight a battle‟, referring to the fact that they have to engage in marketing in order to survive. In this case we refer to marketing with the goal to regulate demand and costs, and whereby it is necessary to attract patients, stimulate hospital- activity as well as developing a strong marketing position in case of fierce competition.

Laeven (2008) stresses the importance for marketing in healthcare based on her study on the external orientation of forty-one hospitals. Study results showed that, as a reaction to the introduction of the free-market in 2006, hospitals are in a transition phase where government involvement decreases with the goal to stimulate free-market operations. In general are the majority of healthcare organizations adapting to the market changes with a so called “anorexia strategy”. This includes reorganization, budget cuts, efficiency improvements, planning and control (van Leeuwen, 2007). Although these changes are important they are solely focused on the internal organization of hospitals. In order to sustain a strong market position in a free market, adaptations need to be made on external grounds as well. This means marketing with a focus on the market itself: on market potentials, competition and most important: the customer (van

Leeuwen, 2007). Fred Lee, an expert in the field of experience development in clinical environments agrees with the potential of focus on the impact a service encounter has on a patient. In his books he advices all hospitals to stop thinking that they solely provide medical services, but include thoughts on how this service provides an experience for patients (Benedictus, 2010).

To prove that focus on patient experiences within a hospital can indeed have a positive effect on hospital operations, the success story of the Flevo hospital in the Netherlands can be considered. In 2007, this hospital has taken on the Planetree healthcare concept and has meanwhile increased their position significantly on the Hospital top 100 list. In 2009 they arose sixty-eight places (from ninety-seven to twenty-nine) and this year they hold the first place. Criteria of this top 100 include quality and patient-focus, patient-friendly criteria (Geenen et al. 2010). Planetree is a concept that focuses on quality care while creating an inspiring culture for employees and patients. Uniqueness of Planetree lies is the combination with durability. The concept existing of twelve components is built around the themes: Better Care, Healing Environment and Healthy Organization2_{. These}

themes are in line with the experience and focus on creating a positive, healing and healthy experience for patients and/or medical staff. In 2004, Douglas & Douglas conducted research on the perceptions and attitudes of patients towards hospital environments. The goal was to increase knowledge on design excellence for use of future hospitals. Their research supports and contributes to this specific research as it confirms the potential of a patient experience. The research revealed that a hospital environment influences the healing process and has a direct effect on patients‟ recovery. Additionally, the research confirms the fact that patients perceive a hospital environment as a supportive environment.

Hospital care involves either one-day-care or multiple days of care. Multiple days make the experience increase in importance. As a patient, you would want the experience to be strengthening, supporting, inspiring, motivating. The research conducted in this report investigates the influence of a variety of service elements on multiple-day-care and how this influence can be regulated by hospitals in order to positively develop a patient experience. It is hereby taken into account that the success of the treatment or surgery is of most influential of a patients‟ experience. Another variable influencing a patients‟ experience and uncontrollable for hospitals, is the need for care: the level of emergency. Whether a patient has a choice of hospital most definitely has an impact on how this patient experiences the hospital stay. Especially when referring to usability of the patient experience in marketing. It is important for this research to specify that it is only of (potential) influence on patients having a choice. Using a patient experience as marketing tool is other research topic within this report that needs clarification. When discussing Experience Marketing we do not refer to acts of amusement or participation in health fairs or community events for example. We refer to marketing based on a patient experience. Marketing focussed on its‟ outstanding elements in order to appeal to potential patients. Hereby we clarified the meaning of patient experience and experience marketing.

The overall goal of this thesis is to increase knowledge on important and influential service elements by creating a service element overview that optimizes the patients‟ experience in hospitals and as such can be used for marketing purposes. In this case optimizing refers to creating a positive and unique patient experience in hospitals. The findings resulting from theory

2

and analysis will be considered for use of marketing in hospitals to support hospitals fight against the consequences of the market privatization. The problem statement accompanying this goal is:

Experiences come in numerous forms, are influential and somewhat personal when it comes to satisfaction. Pine & Gilmore (2001) conclude that experiences indeed differ between individuals because the experience derives from interaction between an „event‟ and the individual‟s state of mind. It is therefore interesting to gain knowledge on this matter through an overview of service elements that (potentially) influence an experience or are involved with experience creation. Multiple interpretations of „experiences‟ are available, making it relevant to elaborate on the form of experience referred to throughout this thesis. In general an experience can be defined as the result of a service encounter formed in a (in this case) patients‟ mind. A service encounter exists of numerous service elements that all influence the total experience in their own way. In this thesis however, we refer to an experience as a positive and unique feeling gained through a hospital service encounter: a feeling that stimulates recovery and positively enhances a patients‟ hospital experience. Research is conducted from diverse angles concerning service providing in order to find a combination of general service elements that together create a positive and unique experience for patients in a clinical environment. It is important to note that the outcome of the medical treatment as an influential element is not considered in the research for a positive and unique experience. Reason lies within the understandable influence this element has on experience creation as well as the different influence per patient due to the difference in medical treatments necessary.

Verhoef et al. (2009) support this research topic as they agree that the importance and applicability of customer experience (research) is not fully recognized. Relating this potential thought to healthcare resulted into the following main research question:

“Which service elements have a strong influence on patient experiences in healthcare institutions?”

To gain thorough knowledge on building a patient experience, a wide range of research perspectives is discussed. Majority of literature and (previous) research are written from a retail- service point of view which is also used within the theoretical discussion in the first chapter. The sub research questions underneath are thus written from a retail angle and all represent a paragraph in the theoretical chapter. The applicability and difference towards healthcare and thereby a patient experience is additionally made per research perspective.

1. Experience creation in retail: a customer-store perspective

What service elements influence the creation of a customer experience in retail?

According to Verhoef et al. (2009) a customer experience is an experience that derives from a set of interactions between a customer and a store, service or organisation, which provokes a reaction. Their article contributes to theory on experience marketing from a customer-store point of view and discusses the reasoning behind elements that are of influence on experience creation.

“How can a hospital use a patients‟ hospital experience to acquire new patients and sustain a

A conceptual model is constructed as a guide throughout their discussion and is used to illustrate this research topic (see figure 1.). The service elements reflected upon in figure 1 are: social environment, service interface, retail atmosphere, assortment, and price, customer experience in alternative channels, retail brand and previous customer experience. Situation- and consumer moderators are furthermore discussed.

2. Tangibility and intangibility in services

What tangible and intangible service elements may influence a patient experience?

The second research perspective is a more basic consideration towards tangible and intangible elements involved with the experience creation process. The importance of considering tangibility and intangibility of services is due to their influence on performance and the control a retailer has or does not have over them.

3. Service quality indicators.

How do patients evaluate the quality of healthcare services?

This perspective discusses how customers, and/or patients evaluate the quality of an experience. What elements of a service do they take into consideration while doing this? These indicators are strongly related to customer satisfaction and therefore important to consider. Within this research facet quality according to customers is discussed via SERVQUAL: a multi-item scale (Parasuraman et al. 1991 and Lonial et al. 2010). A conceptual model on the determinants of perceived service quality (Parasuraman et al. 1985) is discussed and a Consumer Quality Index feature is taken on which has proven to be an effective tool in reality.

4. The process of Value Creation.

How is patient value created and what role can an experience play within this process?

As the goal of this research report is increasing knowledge on how to create a valuable experience, it is important to address the process of value creation. The role of an experience as marketing tool within the value creation process is furthermore addressed, once a valuable experience has been created.

5. Market developments in healthcare.

To illustrate the dynamics and innovations in the healthcare branch, market developments are included in research. Furthermore is the potential of these developments for use of hospital marketing mentioned when applicable and is the impact of all market developments on a patient experience discussed.

Report outline

As a result of the developing need for hospitals to perform marketing combined with the potential of using an experience as marketing tool, creating a strong and positive patient-experience is the leading theme throughout this research. Additionally, focus on research is placed on what service elements are necessary to build such a patient experience. Data in order to answer the problem statement and main research question are collected by means of three research facets: theory, experts and patients.

2. What does theory say about experience creation?

“As goods and services become commoditized, the customer experiences will matter most “

(Pine & Gilmore, 2001) This quote represents the increasing importance of the experience within marketing. In combination with the previous stated research questions, it is therefore most interesting to find out how to build or contribute to a strong customer experience: what are important and influential (service) elements? The relation towards a patient experience is made throughout all paragraphs. To get a better view on what it takes to create an experience we first look at definitions of experience. Early research focused on the qualities that formed an experience (Pullman et al. 2004). According to their research an experience includes involvement and progression over time, expectations, emotional involvement, uniqueness that makes the experience stand out and some sort of completion in the end. Gentile et al. (2007) say that an experience develops from personal contact between a customer and a company/service provoking a reaction. The personal aspect reflects the level of involvement. Meyer & Schwager (2007) also include contact (direct or indirect) with the company/service as a vital element in their definition of experience and make a clear distinction between direct- and indirect contact referring to planned- unplanned contact. Verhoef et al. (2009) add to these definitions the involvement of a customers‟ cognitive, affective, emotional, social and physical response to the retailer. Pine & Gilmore (1999) say that an experience is successful when customers find it unique, memorable and sustainable over time. They would want to repeat the experience, build upon it and promote it via Word of Mouth (WOM).

There are numerous examples that indicate the success of marketing based on experiences. Look at Starbucks, Dell and Singapore Airlines for example, who all promote their products and services based on the great experience they provide. The goal is to grasp customers with this specific experience in order to build a strong customer base. It is known that the success of Starbucks, for example, is based on the distinctive customer experience they create for their customers (Michelli, 2007). Focusing not only on the product, in this case coffee, but instead focus on the service environment surrounding the core product has proven to be successful marketing. Customers do not only choose for the product or service itself but for the entire package existing of the core product and service environment. They choose for the experience of consumption.

organisations that wish to improve customer loyalty and enhance their profitability, regard the creation of a perfect customer experience as a tool to reach their goal. Additional to the above mentioned reasons why a customer experience is important, is a recent research conducted by IBM that identified that customer experiences are key factors for companies building loyalty (Badget et al. 2007).

The following five paragraphs provide an overview of service elements that are of potential influence on experience creation and include different research facets. How retail service elements influence a customer experience is discussed first, followed by tangible and intangible service elements, the elements representing quality through customers‟ eyes are discussed next and last the creation of customer value and market developments within healthcare that influence patient experiences. These research topics correspond with the sub-questions presented in the introduction and all paragraphs discuss a translation towards a clinical environment, explaining the differences and or similarities.

2.1. A customer-store point of view

As most publications focus on managerial actions and outcomes when it comes to experience creation and not on theories behind the elements of creating an experience, Verhoef et al. (2009) constructed a conceptual model discussing determinants of a customer experience: figure 1.

This model discusses which antecedents and moderators are of influence to a customer experience, how they are influential and the need for management to include certain (service) elements in strategy. In their conceptualization of customer experience, Verhoef et al. (2009) explore not all elements of their model. All eleven elements are discussed and considered upon their influences on customer experience management strategies design. Concluding, a translation of these elements to healthcare is discussed.

2.1.1. Element description

Customer Experience management: This is a retail strategy supporting the design of a customer experience whereby value for both a retailer as well as customers is created through focus on the current experience instead only focussing on the previous experience (Verhoef et al. 2009). Previous marketing research demonstrates that firms, who adopt a revenue emphasis strategy focussed on customer satisfaction and customer loyalty, perform best (Rust et al. 2002). Mittal et al. (2005) additionally finds through research that efficient firms with satisfied customers perform better than competitors. This indicates that customer experience based strategies might give a firm a competitive advantage. However are these customer experience based retailing strategies only performing sufficient when combined with efficient processes, according to Mittal et al. (2005). Last, it is important to be aware of the fact that a customer experience creation process is comprised of a mix of the above mentioned elements: a mix of contact points throughout consumption process (Verhoef et al. 2009).

1. Social environment: Previous research on the social environment has been on the interaction between the company, sales personnel and customers when discussing the social environment (Tsiros & Parasuraman, 2006). The current research should be on the contact between customers and its effect on service experiences as this is increasing in importance (Verhoef et al. 2009). The social environment is referred to as a variety of social contact forms, available during the service process with a potential influence on the total experience. This includes a reference group, experience reviews (mostly available online), tribes, co-destruction (by co-customers) and service personnel. Co-customers can be either a friend you experience the service with or „just‟ another customer in the store. Too many customers in one store in general has a negative influence on the experience but also a friend you are shopping with will not necessarily have a positive impact on the shopping experience.

There has been a shift in literature focus going from a focus on creating relationships with customers to creating relationships between customers. The need for bonds in general has been realized but actual relationships, which usually have a stronger effect, has been mostly ignored. This stresses the growing influence of the social environment as a whole on experience development (Verhoef et al. 2009). They furthermore suggest that customers among each other can either have a negative or positive effect on each other‟s experience and besides have an effect on satisfaction and loyalty rates. Because customers share the same retail environment, customers need to be „grouped‟ in order to control their influence on each other‟s service experience. Grouping according to behaviour with the goal to create customer-customer interactions that enhances satisfaction is referred to as compatibility management (Martin & Pranter, 1991) for which the need has emerged.

provided or received. Within these varieties of interfaces, technology is becoming more and more important referring to new technology shopping methods as online-retailing and new in-store methods for example self-service checkout counters. Parasuraman (2000) explains the emerging involvement of technology within the service process by including its‟ influence as a climax into the services marketing pyramid: company-customer, company-employee and customer-employee interaction. These forms of interaction most likely take place via a form of technology.

The previously mentioned self-service checkout counters are an example of a „new‟ technology for co-creation whereby the customer is involved into the service interface (Verhoef et al. 2009). New technologies including customers into the service process without the involvement of service personnel does ask attention from a firm concerning the level of service and appearance. In case of the checkout counters, these need to be user-friendly and available at all times similar to a cashier (personnel). Another technology, online-retailing, asks for the same approach: website appearance has to match with the store appearance and similar accounts for the user-friendliness and informative aspect. Berry et al. (2002) says that all clues during a service process should be corresponding and communicating the same message.

The third element of service interface, service person, is an influential element and can be received physically (face-to-face) or via technology (call-centre, online helpdesk). Both forms of contact require different competences from the service person. Consumers‟ perceptions of face-to-face interaction have traditionally been considered one of the most important determinants of service quality, satisfaction and loyalty (Wang, 2009). The role of emotions within this interaction has gained attention as an element of customer experience understanding (Wang, 2009).

Emotions of service personnel influence the mood of a customer (Burns & Neisner, 2006). In this case we talk about facial expression, vocalisations, posture and movements through which emotion is expressed. Retail service encounters and, most important, personnel performance influence brand perceptions, support future intentions and (service) personnel satisfaction

(Grace & O‟Cass, 2004). Cohesion between different interfaces is important in terms of the clues or impressions they leave behind during the experience process. Clues of influence on the experience process (so called experience clues) and important for a service interface are the product/service for sale, the physical setting and the employees through gestures, comments and dress (Berry et al. 2002).

3. Atmosphere: In the model by Verhoef et al. (2009), the retail atmosphere with a potential influence on a customer experience is the music played in a store or even the volume, the temperature, the use of scents, type of scents (flavours) and the lay-out of the store (design). The influences of these elements differ based on shopping motivations (Arnolds & Reynolds, 2003).

Kotler (1973) recognizes that the atmosphere at the point-of-purchase is of important influence on the entire purchasing process. The role of a successful atmosphere is to generate emotional reactions from buyers in order to increase the probability of (re-)purchase. Therefore, the retail atmosphere should be structured to appeal to all shoppers‟ senses. Temperature, scent, music and lighting are so called ambient factors and are important elements of a retail atmosphere. Baker & Grewal (1992) found that music and lighting affect arousal and pleasure as well as willingness to buy. Preferences for (background) music were, furthermore, found to influence both the shopping time and purchased amount (Herrington & Capella, 1996).

you from shopping because of its distracting nature or harmful impact. This clarifies that an environment may include a psychological meaning for shoppers that influence the entire experience (Wright & Noble, 1999). Turley & Bolton (1999) agree that the design of a retail environment can alter the consumption behaviour of retail shoppers. This is termed atmospherics in retail and Servicescape in services. This indicates the need to carefully design a marketing environment in order to encourage certain consumer behaviour and evaluations as well as appeal to a specific target market (Turley & Bolton, 1999). In order to attract, an experience has to be worthwhile to invest time in according to customers. Hereby play excellent design, marketing and delivery a vital role (Verhoef et al. 2009).

4. Assortment: The available assortment is a potential influence on a customers‟ experience. These two antecedents are influenced by the reason for shopping: an „idea‟ shopper will most likely prefer a large assortment to choose from and a „value‟ shopper is triggered by low prices and price promotions (Arnolds & Reynolds, 2003).

Verhoef et al. (2009) their vision on assortment includes the elements variety, uniqueness and quality. Levy & Weitz (2004) name providing an assortment of services or products to consumers a key function of retailing, which is agreed upon by Hart & Rafiq (2006) who even call it fundamental. Furthermore is it a major dimension of store image and is it an important element of the retail-mix. The variety of an assortment can be the depth or width of an assortment, referring to the number of products within a product category or the number of product categories. The definition of assortment has changed over the years interpreted as „the total merchandise offer or total store assortment‟ to an updated approach defining assortment as „a selection or range of merchandise offered‟. This new approach presents customers with a choice, a choice of style, range, size or colour or quality level for example (Hart & Rafiq, 2006). However a large assortment, thereby a lot of choice, can increase choice postponement or even lead to switching (Diehl & Poynor, 2010). They also tell that satisfaction is higher when a choice is made out of a small assortment compared to a choice made out of a large assortment. Uniqueness of an assortment refers to either the unique type of product within the assortment or the unique brands carried by the retailer that are difficult to find elsewhere (Hoch et al. 1999).

We may assume that a unique assortment is most likely to be smaller in size (both depth and width) in order to keep the items sold unique.

For customers to be attracted by price promotions they need to be price-sensitive whereby targeted price deals are more efficient (Acquisti et al. 2005). Targeted pricing can take place via loyalty programs, for example by offering special prices or discounts to loyalty program members only (Barone et al. 2010). However, not all (loyal) customer segments are attracted by exclusive price deals, some are more positive about promotion deals that are available for a wide range of customers (Barone & Tierthankar, 2010). Price promotions are most attractive to value shoppers referring to customers that are always searching for the best deals: the best value for money (Arnold & Reynolds, 2003).

The effect the loyalty program can have on the customers‟ experience depends on the level of involvement (Youjae et al. 2003). Research showed that high involved customers prefer direct rewards regardless of reward timing. In case of low-involved customers, immediate rewards are more effective and therefore positively support value creation compared to „delayed‟ rewards. In this case a purchase is made in order to receive an incentive at the same time (Youjae et al. 2003). Delayed rewards could be effective for high-involved customer when they initiate value enhancing rewards.

Designing a loyalty program with a positive effect on the overall customer experience is difficult task. It should be attractive to customers but also affordable to the retailer (Nunes et al. 2006). Even with a strong program design, true loyalty is difficult to obtain from customers. However, companies will most likely have a long-term relationship with satisfied customers which can be regarded as the best competitive advantage reachable (Nunes et al. 2006).

6. Alternative channel experiences: The number of available channels or customer contact points increases as a result of technological developments. For retailers this means that managing customer behaviour becomes more complex. Verhoef et al. (2009) acknowledges the difficulty of the influence of a multi-channel environment on customer‟s choice. They realize that an experience through one channel, for example the internet, can be obtained differently in comparison to an experience gained from face-to-face contact with a store. Multi-channel customers are valuable customers. Therefore, retailers need to learn to understand their search and purchase behaviour (Neslin et al. 2006). However, the presence of multichannel shoppers may lead to several challenges for retailers including losing the customer within the course of the purchasing process (Nunes & Cespedes, 2003). Verhoef et al. (2007) refer to this as the “research-shopper” phenomenon: the chance that customers search for a product in one channel (usually the internet) but purchase via a different channel (for example in-store). Multichannel customer management can be supportive when focussing on the design, consumption, coordination and evaluation of channels through which customer contact takes place. The goal hereby is effective acquisition, retention and development of customer segments (Neslin et al. 2006). Knowing the consumer channel behaviour is hereby important in order to increase knowledge on which customer segments to reach via which channel (Konus et al. 2008). Customer characteristics can hereby be and can, for example, be retrieved via loyalty programs.

case of a routine service encounter (Birgelen van, 2006). The advantages of a multi-channel service for customers can be more service outputs, increasing convenience, time saving and reliability. For retailers the advantage of offering service via multiple channels can come from cross-selling opportunities, service innovations, cost reduction, customization and flexibility (Birgelen van, 2006).

7. Retail brand: This element is included as a component because of the potential interaction between a customer and a brand and the influence this relation may have on the total customer experience. Prior to a store visit a customer usually has expectations of two types of brands in a retailing environment: the retailing brand and the manufacturers‟ brand which is the brand(s) sold in the retail store including a potential private label brand. Figure 1 merely considers the interaction between the retail brand and a customers‟ experience.

The perception customers hold of a retail brand, potentially influences a customers‟ experience. Through research on brand perceptions and customer experience, Fitzsimons et al. (2008) found a strong bond between these two variables and the influence they have on consumer behaviour. Furthermore, brand expectations that are developed prior to a service encounter are of significant effect on the evaluation of the total experience at the end of a service delivery (Offir & Simonson, 2007). Not only are brand associations of influence on the overall experience developed before or after a service encounter. The effect of a brand „over time‟ is of high importance as well referring to the interaction between a (retail) brand and a customer (Verhoef et al. 2009).

Regarding the brand influence throughout the entire service encounter (search-purchase-consume-after sales) Keller and Lehman (2003) suggest that a customers‟ mind-set is a key-driver of brand performance. They refer to mind-sets as customer awareness, associations and attitude with a significant effect on performance metrics such as price elasticity and market share.

Further research by Keller and Lehman (2003) suggests that a strong brand can allow a retailer to charge premium prices. However, whether a strong brand allows for a difficult introduction or a one-time, poor service encounter is unsure (Aaker et al. 2004). This uncertainty is a fair reason for retailers to constantly focus on brand perception developments and is a reason to invest in extended research on the relationship between retail brand versus customer experience and thereby the influence from determinants.

different importance to a value shopper than to a gratification shopper (Arnold, 2003). The impact of price, as an experience variable, is therefore (potentially) influenced by the reason someone is shopping. Shopping goals influence the total shopping experience because they influence the way a customer perceives the retail environment. This basically means influence on all experience elements discussed above as well as the shopping behaviour and a customers‟ satisfaction (Puccinelli, 2009). Goals are otherwise influenced by a customers‟ need to go shopping. Someone who has an immediate need to purchase a certain product will most likely be bothered by a crowded store leading to a negative retail experience. However, when the need for the purchase is lower, crowding would be of less influence on the shopping experience. Therefore, need recognition influences the customer experience as well (Puccinelli, 2009). Consumer goals are shaped through, for example, personality traits, socio-demographics and situational circumstances. Need recognition is an example of a situational circumstance as is illustrated by figure 1.

10. Situational moderators: These represent the influence on an experience through: the type of store (full- service versus discount), purchasing channel (in-store versus online), season (holiday versus regular day), location (city centre versus shopping mall), the economic climate (recession versus expansion) and competitive intensity (Verhoef et al. 2009). For example, influence coming from the retail atmosphere on the total customer experience is impacted by the type of store. A discount store provides a different atmosphere and thereby experience compared to a full service retailer. The same can be said for the service interface: the service level differs per type of store as well as the ability for service assistance in case of the different purchasing channels. The purchasing channel moderator refers to the influence from the „research shopper phenomenon‟ whereby a customer uses different channels throughout the purchase process. In this case it is important for a retailer to manage the cross-channel synergy in order for the purchasing channel moderator to positively influence a customers‟ experience (Verhoef et al. 2007).

2.1.2. A translation to healthcare

How are the determinants and moderators of influence on a customer experience different in case of a clinical environment? How do they influence a patient experience?

Creating outstanding customer experiences is regarded as the main objective in the world of retail. World-wide have retailers adopted the concept of customer experience management (Badget et al. 2007). Its success has paid off, triggering the questions whether it will also work in clinical environments.

influence on consumer behaviour thus on a patients behaviour and on the creation of a patients experience.

Service interface plays an influential role during the patient experience as well. Patients need to obtain information which is usually acquired via a service person (in this case a nurse or general practitioner). Orientation or additional information on a medical condition might take place via technology such as the internet which is an increasingly used channel among patients. Co-creation and customization in case of a patient-hospital relationship means involving a customer in the treatment process by thoroughly informing them on what treatment will be performed and what the condition and treatment entails. This throughout all phases of the process: pre-, during and after-care.

Retail atmosphere is referred to as a clinical atmosphere in healthcare and influences a patient experience. Previous research has found impact of colour, music and sent usage for example. New built hospitals show in their „new designs‟ a new approach to atmosphere illustrating the role it can play in the patients‟ experience. For example day-light in all rooms, providing a homely impression by furniture, colour and material use, private rooms, more attention to routes throughout the hospitals. For example the new built hospital of the future: Orbis in Sittart-Geleen. Douglas & Douglas (2004) identify the need for patients for patients to a homely, welcoming atmosphere and a supportive environment. The overall hospital environment is considered a healing landscape with a distinct effect on the health and recovery of patients (Douglas & Douglas, 2004).

Assortment is not a common word in case of hospital treatments. As assortment refers to the different products to choose from in case of a customer-retail experience, we may translate this to the choice of different physicians, hospitals or procedures in case of a patient-hospital experience. Not all patients have the ability to choose which is caused by situational moderators, for example the need or emergency for treatment/surgery. In case of having the opportunity to choose the location for necessary treatment a recent introduced magazine called Dr. Yep can be of great assistance. This Michelin guide of healthcare supports Dutch patients in their decision making process by providing them with information on conditions, the best treatment possibilities and in which hospital(s) these treatments are performed3_.

Although not commonly used, assortment in clinical environments refers to the different conditions that can be treated in a hospital: the varieties of specialism. When treated for one condition it might be necessary (unexpected) to get treatment for a new, recently developed condition as well. When this new condition can be treated in the same hospital, it assumingly will positively influence the patient experience in the end.

Price is not as important to a patient as to a customer and will therefore never be a motivation that supports decision-making. The costs are paid via medical insurances and are therefore more of interest to insurance companies than patients. A patient will pay more attention to costs in case of treatment in a private clinic or in case of treatment that is not covered by the insurance companies. The fact that Verhoef et al. (2009) regard price promotions and loyalty programs among price supports the non-relevancy.

Experience from alternative channels or multiple channel environments: Healthcare experience have a more personal aspect compared to a shopping experience and are difficult to receive via

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another channel than a personal channel: the doctor. However, there are alternative channels when talking about the doctor in a hospital referring to alternative care, medicine or so called spiritual healing. Concerning the search for information besides the personal channel, an experience can be gained through different information sources such as websites or patient organizations. Cohesion and clarity of information through different channels is therefore very important.

Branding in case of hospitals has a different connotation when compared to retail branding. A hospital does not carry a brand but is able to perform branding activities. A hospital is able to create a brand including brand-associations, with the goal to attract patients. Brand loyalty supports may be expected to reaching potential patients and brand loyal customers or patients are more likely to engage into WOM.

Previous experiences influence a patient experience similar to a customer experience. Where a customer has a choice to visit a retail premise multiple times, does a patients rather not re-visit a hospital either does not have a choice whether or not to go back to a hospital. As is mentioned above, a customer does not always have the opportunity to choose the treatment location depending on the necessity of the treatment. However, the assumption is made that in case of having a choice the previous experience in a hospital or with a certain doctor or specialist definitely influences a next hospital experience.

Similar to a retail environment do patient and situation moderators influence the patient experience. Compared to a retail experience are location and the goal of treatment of more importance and influence to the experience creation. Location depends on the ability and willingness to travel and the goal of the treatment may be an emergency or specific treatment not able to provide by all hospitals.

2.2. Tangibility and intangibility of services

The most basic and commonly mentioned difference between goods and services is intangibility (Zeithaml & Bitner, 2003). Because services are performances or actions rather than objects, they cannot be seen, felt, tasted or touched in the same manner that we can with physical products. Services are not tangible and as Berry et al. (2002) say: “A service is a deed, a performance, an effort. A good is an object, a device, a thing”. We therefore conclude that services are intangible. A service that is purchased generally has nothing tangible to show as physical proof. That is because services are consumed and not possessed (Berry et al. 2002). Possession referring to ownership matches the essence of service according to Lovelock & Wirtz (2004). They define the essence of service as a performance act from one party to another and as an economic activity that does not necessarily result into ownership. They furthermore add that a service process creates benefits through facilitation of a desired change of customer themselves, a change in physical possession and tangible assets.

2.2.1. Level of tangibility

service. Palmer (1994) says that the level of tangibility of a service offer derives from three different principal sources:

 Tangible goods, included in the service offer,  Tangible evidence of service performance and

 The physical environment in which the service production and consumption takes place. Lovelock & Wirtz (2004) state that a physical environment is represented through tangibles such as: buildings/landscape, interior design/furnishing, equipment, personnel grooming/clothing and sounds and smells. Palmer (1994) notes the physical environment as a tangible element as well referring to the design of the building, the cleanliness and the appearance of staff for examples. Moreover they name the exchanged goods (physical goods) as the main tangible element of a service.

2.2.2. Importance of intangibility

Intangible elements dominate value creation. Providers should make highly intangible services more concrete by creating and communicating physical images and tangible clues (Lovelock & Wirtz, 2004). Zeithaml & Bitner (2003) furthermore emphasize the importance of intangible elements in combination with quality perceptions. Because services are not ready for use at all times or easily communicated, quality may be difficult to assess. Furthermore are a number of intangible service process characteristics only experienced after consumption. For example: reliability, personal care, attentiveness and friendliness of staff (Palmer, 1994).

Creating organizational value is highly impacted by both tangible and intangible elements. Culture, communication and knowledge are important intangibles for this matter. In addition, Carmeli et al. (2004) say that a firm‟s superior value through performance depends on its ability to defend and use intangible assets such as knowledge. Intangible resources are, furthermore, more likely to produce a competitive advantage than tangible resources.

2.2.3. Service environment

The environment of an organization or retailer has been mentioned by numerous researchers as an influential element towards service experience existing of a mix of tangible and intangible elements (Baker et al. 1996). An environment, either social or physical, is shaped through an organization or retail design. A social - or physical design allows for the development of a retail environment and following creates the atmosphere for both customers and employees. Design as a service element is considered as part of the service environment by Baker et al. (1996). Elements influencing a service environment also influence consumers their condition through the level of pleasure, excitement or satisfaction (Baker et al. 1996). Bitner et al. (1992) suggest that a service environment affects consumers‟ emotional, cognitive and physiological response which consequently influences their evaluations and behaviour towards a (service) organization. Baker et al. (1996) furthermore propose a three component typology of environmental elements:

 Ambient elements  Design elements  Social elements.

Turley & Bolton (1999) indicate that a retail environment can alter the consumption behaviour of customers. Because of the influence of these three elements on retail atmosphere and the overall customer experience more detail is presented.

subconscious effect on an experience. Examples of ambient factors are lighting, temperature and colour that all require focus in design in order to positively contribute to an experience.

Lighting: Research indicates a relationship between lighting and preferences and between a social situation and the visual attention required for an activity or situation (Baker et al. 1996). A merely social setting prefers a low level of lighting compared to an active setting. This indicates that customers prefer a minimum level of lighting and depending on the type of activity hold a preference above or below the minimum level. Baron et al. (1990) moreover conclude that a low level of lighting in general leads to a more positive effect on the experience compared to the effect coming from the minimum level of lighting. Perceptions of comfort are furthermore higher in case of a low level of lighting compared to a high level (Baron et al. 1990).

Temperature: Psychological research indicates a negative effect on experiences from certain temperature levels (Baker et al. 1996). An increase in temperature increases the likelihood of negative associations and anti-social behaviour such as aggression (Anderson, 1989). Furthermore, Anderson (1989) concluded from research that a high temperature has a negative impact on the perception of time passing by which is regarded as a negative impact most often. Baron et al. (1996) additionally conclude that a low temperature (av. 62˚F) is associated with a negative impact on the overall experience satisfaction. Heat and cold are more intense and affective stimuli compared to comfortable temperatures. However, opinions on comfortable temperatures are different per person. This indicates a range of comfort levels concerning temperature within service settings. Temperatures outside this range are likely to have a negative effect on an experience (Baker et al. 1996).

Colour: Research generally divides colours into warm and cold colours: red, orange and yellow versus blue and green. Research additionally reveals that warm colours can be physiologically and psychologically arousing and sometimes even stressful. Cold colours on the other hand, are perceived as relaxing and tend to decrease feelings of stress (Baker et al. 1996). Dimensions of colour that influence the perception are the tone, brightness and saturation. Colour categorization (warm versus cold) needs to take these three dimensions into consideration. High levels of brightness and saturation can produce feelings of disturbance (negative effect), whereas weak colours usually give a calm impression (Baron et al. 1996). Additionally, the effects of colour will differ based on variety and location.

 Design elements represent the components of the environment that tend to be visual and more tangible in nature (Baker et al. 1996). According to Pine & Gilmore (2001) originality and innovation in design will lead to growth in revenue. Furthermore do they expect that experience design will become equally, if not more, important than product design currently is. This has also been shown by their previous research on the experience economy.

et al. (2010) furthermore indicates that consumers satisfaction concerning consumption, does not result from gathering products (tangibles), but from consuming while seeking experiences (intangible) such as having a friendly conversation with a member of staff or enjoying an ambiance.

Carbone and Haeckel (1994) propose two types of design contexts. The physical context, consisting of, so called, mechanic clues such as sight, smell, sound and texture that are generated through tangible items. The second type is the relational design context, or so called humanic clues, referring to those clues coming from peoples‟ behaviour.

According to Bitner (1992), design context can be viewed as the Servicescape indicating what an organization should consider in terms of: environmental dimensions, customer responses, customer and employee behaviour, commitment and loyalty expressions, budget spending and how to realize organizational goals. The social environment plays an important role within the Servicescape because people within a physical environment have the ability to shape and influence the physical space and thereby its impact on an experience (Pullman et al. 2004).

 Social elements are the people (customers and employees) within a service setting. Employee appearance and customer interaction will be discussed as examples. According to Lin et al. (2008) many studies on the influence of service personnel lack a comprehensive focus on the effects from emotional expressiveness on customer emotions, satisfaction and loyalty. Research merely considers the effect of emotions on customers. Emotional expressiveness entails the use of facial expressions, voices, gestures, and body movements. In developing economies economic value derives from commodities, goods and services including the experience gained through them. In this perspective, service providers influence consumer experiences by adding emotional value, especially when service personnel their behaviour serves to induce positive, affective and memorable experiences (Lin et al. 2008).

Service personnel can create emotional value through interactions with customers and therefore are able to influence satisfaction and loyalty. In case of positive emotions during a service encounter, customers usually try to reinforce and keep the positive feelings. Negative emotions, however, can have a strong influence on a customers‟ opinion towards the service provider (hate) as well as the chances of retention (low). Therefore it is important for service providers to focus on emotion development whereby employees learn about customers‟ emotions. This way customer value and a strong customer relationship will likely be developed (Lin et al. 2008). Prior research on store environments suggests that the knowledge of a salesperson, their appearance and friendly attitude encourages a positive customer experience. This can be established by providing solutions to customer problems, promoting positive emotions and enhance the perceived value as well as purchase intentions (Baker et al. 2002). Additional

research found that service personnel their friendliness in behaviour and polite attitude positively effects customer emotions (Lin et al. 2008). Their research furthermore showed how customers are impacted by social service elements:

 Service personnel affect customers‟ emotions through their appearance, attitudes and behaviours,

 Service personnel their emotional expressions influence customers‟ emotions and thereby satisfaction, thus

service providers want to create positive emotional experiences for their customers starting by managing the emotions of service employees. Personality and emotional expressions could be considered during the recruitment process or enhanced through training. Thereby, managers should create healthy working environments by supplying a supportive business culture and motivational incentives for employees.

Another social factor characterizing a service environment and also part of the Servicescape is contact among customers: customers influencing each other‟s experiences (Grove et al. 1997). Service encounters often take place in company of other customers who share the same service environment. However, this does not always result into positive experiences. The accompanying person(s) influencing your service experience can either be someone‟s own choice in case of social shopping with a friend (Arnold & Reynolds, 2003) or involuntarily when entering a crowded store while desperately needing to purchase something. In both cases the „other customer‟ may affect the quality of customer/service provision and eventually a customers‟ service experience. This can have either a positive or negative effect on your experience whereby negative is seen as conflict (Grove et al. 1997). Presence and behaviour of „other‟ customers, influence the interactive dimension of an organization‟s service quality which can be even more influential than contact with service personnel. The conflict usually occurs from a difference in needs or wants while sharing the same service environment, leading to dissatisfaction of customers (Grove et al. 1997).

Service marketers have been devoting time and effort towards creating an organization that ensures customer satisfaction by attending to the significant role customers can play on the service experience of the other. Grove et al. (1997) present an example of the need for compatibility management to stimulate the occurrence of an appropriate customer mix and customer-to-customer relationship. Another incentive to increase the likelihood of a satisfying service experience is customer portfolio management, based on characteristics such as customers‟ appearance, behaviour and age (Lovelock & Wirtz, 2004). At last Grove et al. (1997) state that service marketers need to guard service providing to ensure correct, satisfying behaviour among customers and that acquisition of customers is equally important as recruiting personnel.

2.2.4. A translation to healthcare

How tangible and intangible service elements that influence a customer experience are different in case of their influence on a patient experience.

In case of healthcare/hospitals the main performances are medical actions such as diagnoses, examinations or surgeries. All these actions are services and therefore tangible in nature. Healthcare is therefore in general a tangible service, existing of a variety of intangible elements contributing to the overall service performance. From a patients‟ point of view is the performance of the hospital intangible because they have no „ownership‟ over the outcome of the service (success/no success). Tangible elements a patient may be confronted with are for example (technological) equipment in a hospital room or service personnel (Zeithaml & Bitner, 2003). The chance of having your own television is intangible, but when you have your own TV in your hospital room, you become owner making TV a tangible. Difference in tangibility is similar in case of a hospital room in case of a private room and the hospital bed. Shopping facilities and eating facilities are tangible because you are physically able to participate in the activity, you decide whether to participate or not. The experienced quality of care is intangible and provided by medical personnel who are tangible in nature but intangible in case of their performance.