FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

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October
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FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

PREFACE

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do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim
veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo
consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore
eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in
culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet,
consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore
magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi
ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in
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cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum
Professor Dato' Dr. Faisal Rafiq Mahamd Adikan, FASc.
Vice Chancellor, Universiti Sains Malaysia

1 UNIVERSITI SAINS MALAYSIA

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FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

PREFACE

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incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud
exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure
dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.
Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt
mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed
do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim
veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo
consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore
eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in
culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet,
consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore
magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi
ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in
voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat
cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum
Professor Dr. Tunku Kamarul Zaman Tunku Zainol Abidin
Director, AMDI/IPPT

2 UNIVERSITI SAINS MALAYSIA

October FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER
2021

PREFACE

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incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud
exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure
dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.
Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt
mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed
do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim
veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo
consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore
eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in
culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet,
consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore
magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi
ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in
voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat
cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum

Professor Dr. Azizah Omar
Project Leader

3 UNIVERSITI SAINS MALAYSIA

October FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER
2021
TEAM OF CONSULTANTS

Professor Dr Azizah Omar is a Professor of Marketing from School of Management.
She specializes in Branding, Services Marketing, Consumer Behaviour, and Wellness

Management

Professor Dr Zafarina Zainuddin is a Professor Dr Narazah Mohd Yusoff is a
Director of Analytical Biochemical Honorary Lecturer from Advanced
Research Centre (ABrC). She specialises Medical and Dental Institut. She
in Molecular Genetics, DNA Profiling and
speacilizes in Haematology and Clinical
Service Delivery Genetics

Dr Izzal Asnira Zolkepli is a Senior Lecturer Dr Md Aslam Mia is a Senior Lecturer
from School of Communication. She from School of Managment. He
specializes in Social Media, Digital
Consumer and Marketing specializes in Development Economics,
Communication Banking and Finance.

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LETTER OF APPOINTMENT

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FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

ACKNOWLDGEMENT
Professor Dato' Dr. Faisal Rafiq Mahamd Adikan, FASc.
Professor Dr. Tunku Kamarul Zaman Tunku Zainol Abidin
Former IPPT Director, Prof Dr Syed
UMMC
Staff IPPT
Respondents

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TABLE OF CONTENTS

PREFACE ............................................................................................................................................... 1
TEAM OF CONSULTANTS ...................................................................................................................... 4
ACKNOWLDGEMENT............................................................................................................................ 6
LIST OF ABBREVIATIONS..................................................................................................................... 10
LIST OF TABLES .................................................................................................................................... 11
LIST OF FIGURES.................................................................................................................................. 12
CHAPTER 1 | INTRODUCTION............................................................................................................ 15

1.1 PREAMBLE ............................................................................................................................15
1.3 PURPOSE AND DEFINITIONS ................................................................................................17

1.3.1 Feasibility Study ...........................................................................................................18
1.3.2 Current Problems at CTC ...........................................................................................18
1.3.3 Questions and Objectives .........................................................................................18
1.4 KEY CHALLENGES FOR CTC TRANSFORMATION TO PROFIT CENTER ...............................19
1.4.1 Internal Challenges ....................................................................................................19
1.4.2 External Challenges....................................................................................................20
1.5 SCOPE OF THE TRANSFORMATION PROCESS FROM A COST-CENTRE TO A PROFIT-
CENTRE ............................................................................................................................................. 21
1.6 OPERATIONAL DEFINITIONS ................................................................................................22
1.7 SUMMARY ............................................................................................................................23
CHAPTER 2 | LITERATURE REVIEW...................................................................................................... 25
2.1 PREAMBLE ............................................................................................................................25
2.2 SUPPORTING MODELS AND THEORIES ...............................................................................25
2.2.1 RESOURCE-BASED VIEW (RBV) ...................................................................................25
2.2.2 Service Quality Model................................................................................................27
2.2.3 Porter’s 5 Forces Model..............................................................................................28
2.2.4 Customer Based Brand Equity (CBBE) ......................................................................31
2.2.5 Business Canvas Model..............................................................................................33
2.3 STUDY FRAMEWORK OF CTC FEASIBILITY STUDY ................................................................35
CHAPTER 3 | METHODOLOGY .......................................................................................................... 36
3.1 PREAMBLE ...............................................................................................................................36
3.2 RESEARCH DESIGN ..............................................................................................................36
3.3 TIME DURATION....................................................................................................................38
3.4 QUALITATIVE METHOD.........................................................................................................38
3.4.1 In-depth Interview Interface......................................................................................39
3.4.2 Focus Group Discussion Interface ............................................................................39
3.4.3 Data Analytic and Simulation ...................................................................................40
3.5 QUANTITATIVE METHOD..................................................................................................42
3.5.1 Survey Research – Customer interface....................................................................42
3.5.1 Survey Instrument Development...............................................................................46
CHAPTER 4 | PRELIMINARY FINDINGS .............................................................................................. 55

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4.1 PREAMBLE ............................................................................................................................55
4.2 FINDINGS..............................................................................................................................55

4.2.1 Samples of Raw Data for Preliminary Study.............................................................58
4.3 CONCLUSION AND RECOMMENDATIONS........................................................................62

CHAPTER 5 | FINDINGS ON FOCUS GROUP DISCUSSION (FGD) .................................................... 63

5.1 PREAMBLE ............................................................................................................................63
5.2 FINDINGS..............................................................................................................................64

5.2.1 BACKGROUND OF RESPONDENTS.............................................................................65
5.2.2 LEADERSHIP CAPABILITY .............................................................................................67

CHAPTER 6 | CUSTOMER INTERFACE FINDINGS............................................................................... 82

6.1 PREAMBLE ............................................................................................................................82
6.2 FINDINGS FOR OUTPATIENTS SEGMENT..............................................................................82

6.2.1 Outpatient Profiling ....................................................................................................82
6.2.2 Outpatient Visitation and Payment Method...........................................................83
6.2.3 Outpatient Satisfaction Index ...................................................................................85
6.2.4 Factors Influencing Outpatient Satisfaction ............................................................89
6.2.5 Data Visualization for Outpatient Feedbacks.........................................................91
6.3 FINDINGS FOR INPATIENTS SEGMENT .................................................................................91
6.3.1 Inpatient Profiling ........................................................................................................91
6.3.2 Inpatient Visitation & Payment Method...................................................................92
6.3.3 Inpatient Satisfaction Index.......................................................................................93
6.3.4 Factors Influencing Inpatient Satisfaction .............................................................100
6.3.5 Data Visualization for Inpatients Feedbacks .........................................................101
6.4 FINDINGS FOR POTENTIAL SEGMENT................................................................................102
6.4.1 Non-Patient Profiling.................................................................................................102
6.4.2 Awareness of CTC as an Executive Health Services (EHS)...................................103
6.4.3 CTC Customer Brand-Based Equity ........................................................................104
6.5 OTHER FINDINGS................................................................................................................105
6.5.1 The Quality of Infrastructure & Facilities .................................................................105
6.5.2 The Effect of Word-of-Mouth Communication .....................................................106
6.5.3 CTC Brand Based Equity for 3 Stakeholder Segments..........................................107
6.5 RECOMMENDATION AND CONCLUSION .......................................................................108

CHAPTER 7 | FINDINGS ON COST, REVENUE AND PROJECTION ANALYSIS OF CTC ................... 110

7.1 PREAMBLE ..........................................................................................................................110
7.2 METHODS OF ANALYSIS ....................................................................................................110

7.2.1 Market Penetration...................................................................................................110
7.2.2 Staff Productivity .......................................................................................................111
7.2.3 Cost Efficiency ..........................................................................................................111
7.2.4 Data ..........................................................................................................................112
7.3 RESULTS...............................................................................................................................112
7.3.1 Market Penetration...................................................................................................112
7.3.2 Staff Productivity .......................................................................................................115
7.3.3 Cost Efficiency ..........................................................................................................117
7.3.4 Projections for Breakeven ........................................................................................119
7.4 RECOMMENDATION AND CONCLUSION .......................................................................121

CHAPTER 8 | RECOMMENDATIONS ................................................................................................ 123

REFERENCES...................................................................................................................................... 124

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APPENDICES ..................................................................................................................................... 125
APPENDIX A – PICTURES OF SITE VISITS .........................................................................................125
APPENDIX B – PICTURES OF UMMC MEETING ..............................................................................135
........................................................................................................................................................ 135
APPENDIX C – PICTURES OF ROUNDTABLE DISCUSSIONS ...........................................................136
........................................................................................................................................................ 136
APPENDIX D – FGD PENCIL WRITTEN ASSESSMENT ......................................................................137
APPENDIX E – FGD PENCIL WRITTEN RESPONSES .........................................................................145
APPENDIX F – SURVEY QR CODE ..................................................................................................230
APPENDIX G – OUTPATIENT SURVEY .............................................................................................233
APPENDIX H – INPATIENT SURVEY..................................................................................................241
APPENDIX I – BRAND VALUE SURVEY............................................................................................248
APPENDIX J - OUTPATIENT DATA...................................................................................................254
APPENDIX K – INPATIENT DATA .....................................................................................................255
APPENDIX L - NON-PATIENT DATA ................................................................................................257
APPENDIX M – ADDITIONAL SUPPORTING DATA.........................................................................258
APPENDIX N – OUTPATIENT SURVEY CONSENT FORM .................................................................261
APPENDIX O – INPATIENT SURVEY CONSENT FORM ....................................................................262
APPENDIX P – NON-PATIENT SURVEY CONSENT FORM ...............................................................263
APPENDIX Q – DESCRIPTIVE STATISTICS DATA ON COST, REVENUE AND PROJECTION ANALYSIS
OF CTC ...........................................................................................................................................264

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LIST OF ABBREVIATIONS Research University
Advanced Medical and Dental Institute
RU Focus Group Discussion
AMDI Service Quality
FGD Clinical Trial Center
SERVQUAL Executive Health Services
CTC Public-Private Partnership
EHS University Teaching Hospital
PPP Ministry of Health
UTH Ministry of Higher Education
MOH
MOHE

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FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

LIST OF TABLES

Table 1. 1: Clinical Services Offered at CTC..................................................................... 16
Table 1. 2: Reasons for CTC Financial Lost........................................................................ 18
Table 1. 3: CTC Transformation Challenges ..................................................................... 19
Table 1. 4: Operational Definitions .................................................................................... 22

Table 2. 1: Underpinning Theories and Models ................................................................ 25
Table 2. 2: SERVQUAL 5 Dimensions .................................................................................. 27

Table 3. 1: Number of Respondents for Pencil Written Assessment............................... 40
Table 3. 2: Data Collection Size & Response Rate .......................................................... 46
Table 3. 3: Variables Conceptualization........................................................................... 46
Table: 3. 4: Instrumentation for Outpatient ...................................................................... 47
Table 3. 5: Instrumentation for Inpatient ........................................................................... 50
Table 3. 6: Instrumentation for Non-Patient...................................................................... 53

Table 4. 1: Summary of Preliminary Data Collection....................................................... 55
Table 4. 2: Major Findings from the Round Table Discussion .......................................... 55
Table 4. 3: Major Findings from the In-Depth Interview................................................... 56
Table 4. 4: Major Findings from Observation of Service Space ..................................... 56
Table 4. 5: Area of Concern Affecting CTC Progress Based on Preliminary Findings.. 56

Table 5. 1: Theme & Data Categorization........................................................................ 63
Table 5. 2: Demographic profile of Key Informant Person.............................................. 65
Table 5. 3: KIPs Responses for Leadership Capability...................................................... 68
Table 5. 4: KIPs Responses for Workforce Capability ....................................................... 71
Table 5. 5: KIPs Responses for Utilities Capability ............................................................. 73
Table 5. 6: KIPs Responses for Equipment Capability ...................................................... 75
Table 5. 7: KIPs responses for Fund & Budget Capability ................................................ 76
Table 5. 8: KIPs Responses for Customer Interface & Service Delivery .......................... 77
Table 5. 9: KIPs Responses for Profit Centre & Strategic Planning.................................. 79

Table 6. 1: Demographics Profile of Outpatient .............................................................. 82
Table 6. 2: Visitation to CTC as an Outpatient ................................................................. 83
Table 6. 3: Satisfaction Index.............................................................................................. 85
Table 6. 4: Demographics Profile of Inpatient.................................................................. 92
Table 6. 5: Satisfaction Index.............................................................................................. 93
Table 6. 6: Demographics Profile of Non-Patient........................................................... 102
Table 6. 7: CTC Brand Value as a Healthcare Service Delivery & Performance ....... 105

Table 7. 1: Correlation Analysis (Total Cost, Workforce, and Patient)......................... 118

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LIST OF FIGURES

Figure 1. 1: Quadruple Helix Operational Framework of CTC........................................ 16
Figure 1. 2: The Transformation Process of CTC From a Cost-Centre to A Profit-Centre
Hospital ................................................................................................................................. 22

Figure 2. 1: PORTER’S Five Forces Model........................................................................... 28
Figure 2. 2: Keller’s Equity Model ....................................................................................... 32
Figure 2. 3: Business Canvas Model................................................................................... 34
Figure 2. 4: Feasibility Study Framework............................................................................ 35

Figure 3. 1: Data collection phases of CTC feasibility study........................................... 36
Figure 3. 2: Flowchart of Research Design ....................................................................... 37
Figure 3. 3: Duration for CTC Feasibility Study ................................................................. 38
Figure 3. 4: Summary of data collection interface.......................................................... 42
Figure 3. 5: Studied Variables for CTC Three Customer Segment (Outpatient, Inpatient
and Non-Patient)................................................................................................................. 43
Figure 3. 6: Sampling Protocol ........................................................................................... 44
Figure 3. 7: Screenshot of Screening Question Used in Questionnaire ......................... 45

Figure 6. 1: Cross Tabulation between Reason to Visit & Frequency of Visit ................ 84
Figure 6. 2: Treatment & Payment Outpatient................................................................. 85
Figure 6. 3: Service Tangibility Satisfaction Index............................................................. 86
Figure 6. 4: Service Reliability Satisfaction Index.............................................................. 86
Figure 6. 5: Service Responsiveness Satisfaction Index ................................................... 87
Figure 6. 6: Service Assurance Satisfaction Index............................................................ 87
Figure 6. 7: Service Empathy Satisfaction Index .............................................................. 88
Figure 6. 8: Service Fee Fairness Satisfaction Index ......................................................... 88
Figure 6. 9: Infrastructure and Facilities Satisfaction Index ............................................. 89
Figure 6. 10: CTC Outpatient Satisfaction Index in Healthcare Service Delivery &
Performance........................................................................................................................ 90
Figure 6. 11: Text Data Visualization for Outpatient Feedbacks .................................... 91
Figure 6. 12: Treatment & Payment for Inpatient............................................................. 93
Figure 6. 13: Access and Admission Index........................................................................ 95
Figure 6. 14: Treatment and Related Information Index ................................................. 96
Figure 6. 15: Physical Environment Index .......................................................................... 97
Figure 6. 16: Discharge and Follow Up Index ................................................................... 98
Figure 6. 17: Hospital Experience in CTC Index ................................................................ 99
Figure 6. 18: Infrastructures and Facilities Satisfaction Index........................................ 100
Figure 6. 19: CTC Inpatient Satisfaction Index in Healthcare Service Delivery &
Performance...................................................................................................................... 101
Figure 6. 20: Text Data Visualization for Inpatient Feedbacks...................................... 102
Figure 6. 21: CTC EHS Service Awareness ....................................................................... 104
Figure 6. 22: Agreement Scale for CBBE ......................................................................... 105
Figure 6. 23: Comparison Between Two Patient Segments on Infrastructures and
Facilities .............................................................................................................................. 106

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Figure 6. 24: Word-of-Mouth Effect Between Current and Potential Patient ............. 107
Figure 6. 25: Brand Equity Mean Value Comparison between 3 Stakeholder Segments
............................................................................................................................................. 108
Figure 7. 1: Trend of Patients served at CTC................................................................... 113
Figure 7. 2: Market penetration of CTC (100% population as potential market)....... 114
Figure 7. 3: Market penetration of CTC (50% population as potential market)......... 115
Figure 7. 4: Staff Productivity- Patient’s perspective ..................................................... 116
Figure 7. 5: Staff Productivity (Revenue Perspective) ................................................... 117
Figure 7. 6: Cost Efficiency (Overall perspective).......................................................... 118
Figure 7. 7: Revenue cost gap: Narrowing or widening? ............................................. 119
Figure 7. 8: Scenario analysis for breakeven of CTC ..................................................... 121

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FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

EXECUTIVE SUMMARY

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CHAPTER 1 | INTRODUCTION

1.1 PREAMBLE

As essential health care institutions, hospitals play a critical role in the quality of
healthcare services provided to society. Their optimal performance relies on their
efficient coordination of internal resources capabilities. There are two types of hospital
categories in Malaysia: namely public hospitals and private hospitals. The public
hospitals’ category comprises government (or public) hospitals under the Ministry of
Health, while Teaching Hospital (TH) is under the Ministry of Higher Education. The
objectives of TH are to provide clinical education and training to future and current
doctors, nurses, and other health professionals in addition to delivering medical care
to patients, as well as carrying out medical research. Currently, there are 125 public
hospitals and 6 teaching hospitals in Malaysia. The teaching hospitals are managed
and governed by their respective universities, which include the overall management
and operation of the hospitals from matters concerning the hospital governance,
workforce, equipment, budget, customer interface and related facilities. Effective
operation management that provides a clear vision and mission of the healthcare
institution with good leadership and skillful staff will ensure the institution’s healthcare
delivery and meet the patients’ expectations and satisfaction. In addition, efficient
resources allocation at the right time, with the right services, would enable the hospital
to gain a competitive advantage over other healthcare institutions by adding value
to clients/ users and achieving excellence in a course that improves their competitive
position. In this context, the achievement of competitive advantage refers to the
hospital exploitations in various capabilities to enhance the value that the customers
understand for the products and services provided by the healthcare institution. Thus,
teaching hospitals must continuously step up their strategic planning and closely
monitor the efficiency and quality of their performance in delivering services to their
customers. Failure to do so will escalate the hospitals’ expenditure and subsequently
jeopardize the image and reputation of the university. And the worst-case scenario,
the life of the patients will be at stake due to poor hospital management.

1.2 OVERVIEW OF CLINICAL TRIAL CENTER (CTC), ADVANCED MEDICAL AND DENTAL
INSTITUTE (AMDI)

Universiti Sains Malaysia is one of the Research Universities (RU) that provides and offers
healthcare services to patients through its teaching hospital - Hospital Universiti Sains
Malaysia (HUSM) in Kelantan and Advanced Medical and Dental Institute (AMDI) in
Bertam, Penang. AMDI was established in 2002. The establishment is based on a top-
down project from the Ministry of Higher Education to USM. AMDI covers different
areas of specialization such as Oncology, Nuclear Medicine, Transfusion Medicine
and Translational Research and many more as depicted in Table 1.1. Currently, AMDI
workforce comprise of 700 staff, including 100 academicians for clinical and non-
clinical services.

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Table 1. 1: Clinical Services Offered at CTC

MEDICAL MEDICAL DENTAL

SPECIALTY SPECIALTY SPECIALTY
Paediatrics - General Paediatrics; Paediatrics Dental Public Health
Anaesthesiology Immunology, Paediatrics Allergy Oral Pathology
Family Medicine Pathology - Anatomical; Chemical Orthodontics
Haematology Psychiatry; Mental Health Paedodontics
Internal Medicine - Cardiology Public Health Prosthodontics
Nuclear Medicine Radiology - General Radiology; Muskuloskeletal
Obstetrics and Gynaecology Imaging; Cardiac Imaging *Oral and Maxillofacial Surgery
Oncology - Radiation Oncology Surgery - General Surgery; Hepato-pancreato-
Ophthalmology biliary Surgery; Breast Oncoplastic and
Orthopaedics - General Orthopaedics; Hand Reconstructive Surgery
Surgery Transfusion Medicine
Otorhinolaryngology (ENT); Sleep Study; Anatomy, Medical Genetics, Integrative Medicine
Allergy Testing

AMDI main objectives and functions are to perform high-end or translational research
(Research Division), offering academic post-graduate studies (Academic Division),
and offering clinical trial services to referral patients (Clinical and Healthcare Services
Division). The clinical and healthcare services division, known as Clinical Trial Center
(CTC), acts as a healthcare service center to treat referral patients from other primary
and secondary healthcare providers. The CTC operational framework is based on the
“From Bench-To-Bed” concept, which begins from its unique role in combining
teaching, research, and services. Ideally, this concept reflects the Quadruple Helix
Model consisting of several actors: researchers, physicians, academics, clinical trials,
and patients as depicted in Figure 1.1.

Patients-Centric
Interphase

Physicians Researchers

AMDI Pat
Organizational
Academics
Culture

Clinical Trials

Quadruple Helix CTC healthcare setting

Figure 1. 1: Quadruple Helix Operational Framework of CTC

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FEASIBILITY STUDY: TRANSFORMATION OF CTC AS A PROFIT CENTER

In this model, effective coordination of the actors is one of the critical factors for the
success of CTC. The four major stakeholders must play their roles to support each other
to ensure the sustainability of the CTC, not only in the short term but also in the long
run, with the primary focus on delivering excellent healthcare services to the patients
or consumer-centric interphase. The patients are the primary recipients or the end-
user of all the services offer by the other four actors. The patients’ informal caregivers
(usually relatives or carers) will also be part of the end-user. The recipients will measure
the success of CTC from their experience receiving the treatments and engaging with
CTC during the service encounters. Thus, CTC must continuously measure its current
service delivery performance in the view of its clientele. The coordination of all the
actors requires efficient implementation of systematic strategic planning, effective
data management, and monitoring system.

1.3 PURPOSE AND DEFINITIONS

CTC currently operates as a “cost-center” health service provider rather than a “profit-
center” where the center does not directly add to profit but still costs AMDI money to
operate. Improper or mismanagement of resource capabilities and inadequate
budget will hamper the growth of CTC in future. The “check-and-balance”
performance delivery assessment and evaluation by internal and external experts,
audit and healthcare panels must adequately be in place by CTC. Such evaluations
ensure all resource capabilities are utilized correctly with optimum output and meet
the internal and external stakeholders’ expectations and perceived value. Thus, CTC
needs to seek an alternative business model in managing and operating the
resources’ capabilities to optimize the usage of current capabilities. One way of doing
it is to ensure that CTC will have sufficient funds or budget to run the hospital in the
short term and long term. CTC can achieve this mechanism by adopting its current
“cost-centre” operation to “profit-centre”. Peter Drucker introduced the term “profit-
center” in 1945. A profit-center unit/department/institution of an organization directly
adds or is expected to add revenue to the entire organization’s bottom line. It is
treated as a separate, standalone business responsible for generating
its revenues and earnings. Its profits and losses are calculated separately from other
areas of the organization.

Adopting the “profit-center” business model will help CTC gain benefits to becoming
a self-sustainable health center, cost independent and no longer relying on the
operational budget from AMDI and USM. Many studies have found a strong
relationship between resource capabilities, customers’ expected values, values
offered by the institution, and those providing similar services by the competitors
determine the organization’s competitive advantage (Article 1). Thus, CTC requires to
explore all the current resources capabilities to gain a competitive advantage that
can meet the expectations, needs and desires related to its internal and external
customers. CTC should conduct a thorough feasibility study to measure the readiness
of its current state of “cost-centre” to a “profit-centre” hospital.

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1.3.1 Feasibility Study

The objectives of the CTC feasibility study are as follows:

i. To identify whether the transformation of the current business model from “cost-
centre” to “profit-center” is feasible, doable, and relevant as a way forward for
self-sustainable entity, fully independent licensing hospital, and referral medical
center that specializes in oncology, dental and medical precision.

ii. To identify the capabilities of the internal resources to transform CTC from a
cost-centre to a profit-centre hospital.

iii. To identify challenges that will hinder the transformation of CTC to a profit
centre.

1.3.2 Current Problems at CTC

It has been identified that currently, CTC is running at a financial loss due to the
following reasons as indicated in Table 1.2.

Table 1. 2: Reasons for CTC Financial Lost

Cost Operation cost is very high
Financial Inefficient financial investment
Workforce The number of employees is too high (staff-patients ratio)
Market Share Not making any profit or breakeven due to small market share
Equipment Utilization of equipment is not optimum (input vs output)
Uniqueness Weak in point of parity (POP) and point of difference (POD)
Offerings Undifferentiated product and services offering in the hospital
industry
Branding Low brand awareness of CTC among the existing and potential
customers
Positioning Weak positioning of CTC as a medical centre due to poor market
segmentation, targeting and positioning of CTC

1.3.3 Questions and Objectives

To achieve the goal of the feasibility study, several burgeoning questions need to be
answered by CTC before adopting the “profit-centre” approach. The questions and
objectives are:

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Study Questions

i. What is the current situation of CTC’s performance in healthcare service
delivery?

ii. What are the critical success factors of CTC capabilities and competitive
advantage in healthcare service delivery performance?

iii. What is the impact of CTC’s capabilities on healthcare service delivery
performance?

iv. What is the impact of CTC’s competitive advantage on healthcare service
delivery performance?

v. How capabilities and competitive advantage can contribute to long-term
strategic planning for CTC’s service performance towards a profit center?

Study Objectives

i. To assess the current situation of CTC’s performance in healthcare service
delivery.

ii. To identify critical success factors of CTC capabilities and competitive
advantage in healthcare service delivery performance.

iii. To assess the impact of CTC’s capabilities on healthcare service delivery
performance.

iv. To assess the impact of CTC’s competitive advantage on healthcare service
delivery performance

v. To recommend possible solutions for the strategic development of the CTC
towards a profit center.

1.4 KEY CHALLENGES FOR CTC TRANSFORMATION TO PROFIT CENTER

It is imperative for CTC to identify possible gaps or issues that may hinder the
transformation from a cost-centre to a profit-centre hospital.

1.4.1 Internal Challenges

Several challenges for the CTC transformation to a profit-centre hospital have been
identified during the exploration stage of the feasibility study. The challenges are as
indicated in Table 1.3.

Table 1. 3: CTC Transformation Challenges

No Challenges
1 Lack of medical officers
2 No internal medicine unit
3 No anesthetics
4 No physician at the Rehabilitation unit

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5 No emergency rooms
6 Overlapping roles and category of staffing - research, clinical, and academic
7 The undifferentiated segment of services – clinical and non-clinical
8 No marketing unit and marketing activities to engage with potential

customers (various stakeholders)
9 No canteen/cafes/convenience shop
10 Readiness of staff to accept high demand from the market (unsure)
11 Distribution and allocation of medical staff may not be appropriate to job

function and demand.
14 Equipment is not fully utilized in few departments
15 Few units are under staff
16 Ownership status of CTC – uncertain on land status

1.4.2 External Challenges

In view of public-private partnership (PPP) between EHS and CTC, the study foresees
some challenges in the following areas:

i. The CTC acts as a public health services entity and EHS as a private entity. The
set-up of the public entity, guidelines, and policies are based on the ministry of
health Malaysia. In contrast, the EHS is a private entity with complete control
and autonomy to operate the health services to their patients and other
stakeholders according to the profit-making or income generation.

ii. The EHS runs by USAINS Holding Sdn. Bhd. and, thus, has complete control over
the fund/budget and cost of expenditure to manage and operate the private
entity. On the other hand, CTC must operate based on a stringent budget/fund
from USM OPEX. Continuous inadequate budgetary allocation over the years
may hinder the progress or growth of CTC. High overhead cost, and escalation
of healthcare expenses have made things worst.

iii. Shared resources between EHS and CTC can contribute to some conflicts in
managing resource capabilities if specific demarcation is not clearly defined
between the two entities. At present, both entities are utilizing the same
resources from CTC to offer health services to the same group market segment
(in-patients and out-patients). Patients are given options to choose EHS or CTC
health services. However, no clear indicators of how the EHS and CTC
operationalize the payment lead to not being sure who will get what? Was it a
percentage-shared approach? This current practice causes dissatisfaction
between both entities and members of CTC.

iv. Complex current PPP setting: Perception by the CTC staff that resources of CTC
are based on the public funding. However, at the same time, the same

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resources are utilized by the EHS? Thus, issues concerning resources allocation,
procurement, integrity, and transparency are among major concerns.
v. Patients pay more for the EHS services with less waiting time. In comparison,
patients for the CTC services may take longer waiting times with lower prices. Is
it ethical to create differences for health services between patients in the same
center? Can CTC staff who also work for EHS manipulate the system to gain
extra income? This can create less demand in the CTC, perceived price fairness
and health equality among staff and patients
What would be an ideal benchmark/ standard indicator for CTC to refer to and
compare to ensure the PPP approach's success? Recommendation: University
Malaya Medical Center

1.5 SCOPE OF THE TRANSFORMATION PROCESS FROM A COST-CENTRE TO A PROFIT-
CENTRE

While the feasibility study needs to capture vital information concerning the CTC
transformation, this does not mean it attempts to cover the whole aspects of CTC.
Figure 1.2 depicts the main scope of the study, which is divided into three categories
as follow:

i. The current state consists of:
a) Leadership & governance - institution policy, vision, and mission.
b) Human Capital - Employees and Customers; and
c) Physical Capital - Equipment, Fund/ budget, Utilities.

CTC must measure and assess the efficiency of internal resources to ensure the
capability of CTC to reach its desired state.
ii. Process: internal stakeholders’ attitude and perception towards the readiness
of the capabilities of the internal resources to adopt/adapt transformation.
iii. Desired State of CTC transformation is a way forward where CTC expects to
accomplish as a self-sustainable entity, fully independent licensing hospital,
and referral medical centre that specializes in oncology, dental and medical
precision.

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CURRENT STATE PROCESS DESIRED STATE

•Inefficient •Does CTC leading •Self-sustainable
financial to become a self- entity (Profit
investment sustainable entity center)
(Profit center) ?
•Operation cost •Fully independent
very high •Does CTC ready hospital by itself
to become a and not under
•Manpower too profit medical HUSM license.
high center?
•Referral Medical
•Equipment not •What will take for center (Partially
fully utilized (input CTC to reach the comprehensive
vs. output) desired state? i.e. specialise in
Oncology, Dental,
•Not making any •How long for CTC Medical precision)
profit or to reach from
breakeven Current State to
the Desired State.

Figure 1. 2: The Transformation Process of CTC From a Cost-Centre to A Profit-Centre
Hospital

1.6 OPERATIONAL DEFINITIONS

As explained in Table 1.4, the operational definition is as below:

Table 1. 4: Operational Definitions

No Theme Definition
1 Leadership Refers to how the CTC’s leaders or decision-makers
(executives) administer and monitor contractual
(Vision, Aspiration, relationships.
Leadership, Top
Management) People related to CTC services whose primary intent is
2 Workforce to enhance healthcare delivery include clinical staff,
and support staff, i.e., those who do not deliver services
3 Fund/Budget directly but are essential to the performance of the CTC
health systems.
4 Customer Interface A budget allows CTC to understand better which funds
can be spent on a specific project or section and how
much spending should be allotted to each.
The customer (CI) is a component that describes how
CTC interacts with its patients (in-patients, out-patients,
and companions/caretakers).

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5 Utilities Services and the facilities provided are considered
essential to CTC's long-term performance and help
6 Based Budget attract visitors.
Procedure based budget is defined as strengthening
7 Competency the links between the funds provided to CTC entities and
their outcomes through formal performance information
8 Skills & Talent from the allocation decision-making.
Skills, experience, and knowledge of the workforce in
9 Service Delivery managing the health and safety of the patients to
Performance achieve optimal performance outcomes, i.e., to
prevent patient harm while improving clinical
10 Competitive outcomes.
Advantage- Skills in the healthcare system are defined as specific
Performance health professions disciplines that will help to facilitate
work and aim to optimize the roles and responsibilities to
improve patient care
The ability to design, develop, deliver, and operate the
services effective, predictable, reliable, and meets the
expectations of customers/stakeholders.
Competitive advantage is defined as the ability gained
through attributes and resources to perform at a higher
level than others in the same industry or market.

11 Profit-Center A long-term plan is used to provide the formulation for

Planning Orientation any organization about the directions and how to

allocate the resources to achieve the main goals over a

specific time in various possible environmental

conditions

1.7 SUMMARY

This feasibility study is very important to identify and analyze the current standing of
CTC and the likelihood of transforming its business model from a cost-centre to a profit-
center. This study includes in-depth analysis of the current Leadership & governance,
Human Capital (Employees and Customers) and Physical Capital (Equipment, Fund/
budget, Utilities). It also covers the attitude and perception of CTC’s stakeholders
towards this transformation and their readiness to embrace the challenges. It is very
important to ensure a minimum acceptable standard of the facilities, clear process,
quality assurance and accountability of the health practitioners are being upheld in
the operation of CTC.

Based on the data collected from the pilot study, CTC is currently operating at sub-
optimal condition, especially for few important key features such as financial stability,
utilities, expertise and supporting environment (equipment, wards, support staff etc.).
There are several departments lacking basic medical equipment needed to treat

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patients, not having enough number of support staff to run concurrent clinics and the
payment system in place is very inefficient. Other challenges such as land title, shared
license with HUSM and funding are among pertinent issues need to be addressed
during the transformation process. Understanding the legislative requirements,
infrastructure design and financial sustainability are very critical when dealing with
issues and activities associated with health and safety of the people.
Analysis of the project cost and return of investment from this study shall provide insight
for USM Top Management to determine the risk, design action plan and decide the
future direction of CTC. If transformation of CTC into a profit center is taking place, the
management must ensure Accessibility, Equality, Safety and Quality are in the
framework and being practiced in order to protect the public and the university from
any harm or adverse implications of activities within the healthcare system. While
having the ambition of making CTC/AMDI as a profit centre, we must always
remember the main objectives and functions for its existence is to perform high-end
translational research-from bench to bed.

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CHAPTER 2 | LITERATURE REVIEW

2.1 PREAMBLE

Healthcare systems throughout the world, whether in developed or developing
countries, are struggling with managing healthcare delivery in cost escalation and
resource constraint conditions. Thus, proper strategic planning and effective
coordination of internal resources capability are required to deliver efficient services.
This chapter will describe relevant existing literature, theories and models concerning
the feasibility study of CTC to transform from a cost-centre to a profit-centre health
centre. The supporting theories and models selected in this study are based on their
strength, applicability, suitability, credibility, and validity in healthcare business
management, strategic planning, resource capabilities, users’ readiness, service
quality, brand management, and competitive advantage. The theories and models
are used as the underpinning of the study framework is depicted in Table 2.1.

Table 2. 1: Underpinning Theories and Models

RBV Resource-Based View Model
SERVQUAL Service Quality Model
PORTER Porter’s 5 Forces Model
CBBE Customer Brand-Based Equity
BC Business Model Canvas

2.2 SUPPORTING MODELS AND THEORIES

Customer perceptions of service performance are critical to validate/the actual
performance delivered by the medical centre. CTC has internal customers (i.e., the
employees/staff) and external customers (i.e., outpatients, inpatients, and non-
patients). Each of these customers’ groups has its set of expectations towards CTC. If
the expectation of these customers is met, then CTC has created a satisfied customer.
On the other hand, if CTC could not fulfil the customers’ expectations, they become
dissatisfied customers. Therefore, it is crucial for CTC to continuously measure and
assess its competitive advantage to ensure that CTC offers excellent health services
to its customers.

2.2.1 RESOURCE-BASED VIEW (RBV)

The RBV model focusses on a firm’s capabilities and competitive advantage. RBV
views a firm as a unique package of distinctive resources and capabilities. Moreover,
in strategic healthcare management, RBV has been closely regulated over the last
forty years of payment structure changes, supervisory demands together with
uncertainties on the dependencies on external as reflected in healthcare strategic

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planning (Kash et al., 2014). The management is tasked to place the firm in a
competitive position to maximize value by exploiting existing capabilities. Therefore, it
is the healthcare provider's role to develop organizational capabilities based on its
core competencies and supported by the organizational culture to deliver excellent
service quality to patients. The capability of a healthcare provider represents the
ability to provide its employees with sufficient human and material support to help
them efficiently perform their jobs. In this regard, Day (1994, p.38) referred to
organizational capabilities as “complex bundles of skills and collective learning,
exercised through organizational processes that ensure superior coordination of
functional activities.”

Numerous studies found that organizational capabilities enable companies to deal
with and solve business problems, showing continuity elements in sustaining their
operations. A study from (Priem & Butler, 2001) explained that RBV is applied to focus
on competitive advantage in internal resources of organizations that develop the
model to administer specific market strategies, especially in healthcare settings. It is
related to a previous study by (Grant, 1991) that stated resources to be the source for
an organization’s capabilities as it is the main source for the competitive advantage
thus, creating new strategies that are different from other competitors. Next, a
different study conducted by (Krishnan et al., 2013) observed the implementation of
RBV in the growth of the medical tourism industry among hospitals that covers the
aspects of specialist services, quality services and cost for internal factors and
government regulations for the external factors. It is found that the factors play a
crucial role to become a good resource for economic activity as the demand for
healthcare services has a huge impact on the healthcare industry. In the same
context, it is related to another early study from (Teh, 2007) that showed healthcare
centers efforts such as Raffles Hospital with Parkway Groups take their own initiative to
market Singapore healthcare services and medical tourism to South Asia, China,
Indonesia as well as the Middle East in order to remain in the emerging industry. Other
than that, hospitals in Thailand are also embarking their way to collaborate through
affiliations with referral agencies and different patients’ home-country hospitals to
increase their investment in the medical latest technology, attracting skilled doctors,
quality certification (ISO) and also accreditations. The hospitals believe that
healthcare services have a great entrepreneurial opportunity to venture into
international business, especially when there is a huge demand from different
countries.

In the context of CTC, the organization’s capabilities are a set of differentiated
processes, technologies, and assets owned by CTC to maintain a sustainable
competitive advantage. Hence, CTC needs to measure and assess its current state of
resources to help the medical centre plan and strategies to elevate its productivity,
service performance, and market share.

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2.2.2 Service Quality Model

SERVQUAL model was first developed by Parasuman et al. in 1985, which led to the
understanding of institutions and sectors’ successes despite the difference in services
and customer needs (Salleh et al., 2018). SERVQUAL model is already known to be a
valid model and a reliable instrument used to measure a firm’s service quality
performance. It associates with five dimensions and certifies the dimensions applied
in different service situations (Rohini & Mahadevappa, 2006), such as hospital
environments (Babakus & Mangold, 2014; Ali & Raza, 2017). The five dimensions of
SERVQUAL are as explained in Table 2.2.

Dimension Table 2. 2: SERVQUAL 5 Dimensions
Responsiveness
Assurance Functions
Tangibles
Empathy Readiness to help customers and provide immediate/ prompt
Reliability service
Employees’ knowledge, courtesy, ability, and skills to gain trust
and confidence from the customer
Appearance, physical facilities, personnel, equipment, and
communication materials.
Caring and provides one-to-one attention for the customers,
understanding the customers
Ability to perform the promised service dependably and
accurately

Numerous studies in healthcare institutions have shown strong applicability of the
SERVQUAL model to evaluate the relationship between patients’ perception
(outpatient, inpatient and services in emergency room). And later to examine
patients’ perception of the hospitals’ service quality and satisfaction and how the
patients were willing to promote the services that hospitals offered to others.
According to Pakdil and Harwoord (2005), the SERVQUAL model is a practical model
to examine the differences between patients’ fondness or liking with their actual
experiences in the hospital. Another related study on service quality also confirmed
that patients’ perceptions of service quality performance could influence positive
satisfaction and lead them to choose health care providers that they prefer
(Andaleeb, 2001). For example, a study by Sirohi & Singh (2016) found that patients
satisfied with the service quality in the hospitals would spread positive words through
word–of–mouth promotion and recommendations to others who require health care
services in which later maximizes patients’ satisfaction. Thus, the hospital can continue
to improve and remains competitively in the healthcare market. A study (Aman &
Abbas, 2016) found out that public hospitals in district Kohat were seen as failing to
deliver good quality services to their patients based on the major reasons that include
the irresponsible behaviour of the government towards the healthcare sector. Main
issues such as overcrowded patients in the outpatient department (OPD) made it
harder for doctors and nurses to give full attention to patients’ health problems.

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Similarly, a study by (Abuosi & Atinga, 2013) also observed that patients’ expectations
were not being met during their medical treatment. Perceived service quality was
rated lower than other expectations for all variables, which created a large gap. This
is because the patients do not receive the medical services they expected, especially
those with critical conditions, which would create dissatisfaction. Thus, CTC must
evaluate its service quality performance from both outpatient and inpatient settings
in the hospital. The SERVQUAL model will help CTC identify and prioritize the
performance improvements needed to ensure that these improvements meet the
patients’ expectations.
2.2.3 Porter’s 5 Forces Model
Porter’s Five Forces Model is applied in different industries to assess competitive forces
and develop strategies related to their customers, which includes the competitive
rivalries (competition in the industry), threats of new entrants, the bargaining power of
suppliers, bargaining power of customers/buyers and the threat of substitute
products/services (Catherine, H, 2016). Like any other organization, private and public
hospitals face the same competitive forces to establish good operational focus by
targeting particular markets (Mburu, 2007). Figure 2.1 illustrates the five forces firm will
encounter in a real business market.

Figure 2. 1: PORTER’S Five Forces Model

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2.2.3.1 Competitive Rivalry

Key changes to healthcare industry structure are focused on competitive rivalry and
industry growth where it will also have an impact on the rivalry existing. In healthcare
services, private and public hospitals operate in competitive environments where
private hospitals focus on profit-oriented services that function in a competitive
environment. Meanwhile, all public hospitals are subsidized; hence private hospitals
must understand the importance of competitive strategies to withstand competition
from public hospitals (Omari et al., 2017). Industry growth in specific industries such as
healthcare can be one of the contributing factors that can impact competitive rivalry
in the existing industry. In contrast, if the growth is slow, it is expected that other rivalry
from the same industry will increase from time to time (Johnson et al., 2008). The
statement is aligned with the study from Catherine, H (2016) that market growth, rival
diversity and the number of firms in the industry are the factors that impact the industry
growth along with the intensity of rivalry. Competitor’s rivalry can occur based on the
price offered, advertising styles, increased customer service and new product
introduction (Mburu, 2007). In the same study, it is found that the intensity of rivalry
among competing organizations tends to increase due to the increased number of
competitors as they become equal in size and the capabilities demand declines, as
well as the price-cutting trend, is becoming more common. More than that,
consumers can switch brands easily and also increases the rivalry and competition
among organizations. A study by (Sudirman, 2012) focused on understanding the
competition in Indonesia healthcare organizations found out that the intensity of the
healthcare industry in Indonesia is low and moderate even though the number of
pharmaceutical companies and the number of hospitals is huge due to the
asymmetry of information, horizontal and vertical integration between the
contributors who have governing power. Another study conducted by (Bintang
Janaputra et al., 2021) explained how the competitive rivalry in Indonesia could be
measured as moderate even though there are many hospitals available in
Tulungagung, such as Prima Medika Hospital, Bahyangkara Hospital, Orpeha Islamic
Hospital, Satiti Prima Husada Hospital and other hospitals, none of these hospitals
mentioned in Tulungagung can challenge with regional public hospitals (RSUD).

2.2.3.2 Threats of New Entrants

New entrants bring new capacity, and there are high barriers to entering this industry
in healthcare services. The threat of new entrants relies upon the amount and strength
of barriers to make way as markets with high entry barriers and low exit barriers will
have low levels of competition because it is challenging to enter the market but still
can exit easily. With the growth of hospitals, there is enormous competition among
hospitals to win the market in the industry, where many public hospitals have been
forced to function as organizations that manage their finances fully (Bintang
Janaputra et al., 2021). Thus, government policies can obstruct the new entry into the
specific market by influencing the power of the entry barriers (Gupta et al., 2015).
From the previous study, it is mentioned that by the implementation of policies in the

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government such as the certificated of need (CON), hospitals are demanded to
demonstrate that a clinically legal need for care might not be met by current
providers, which lead to a need for new entrants for expansion. Still, CON laws can
lower the threat of new entrants and reduce market competition, specifically in
healthcare services. Moreover, the difficulty in searching places and building new
hospitals in specific locations, together with high capital costs, presents a menacing
obstacle for new entrants to make their way into the industry (Perrott & Hughes, 2005).

2.2.3.3 The Bargaining Power of Suppliers

The power of suppliers can employ the bargaining power of consumers in different
industries whether to increase the prices or opt to reduce the quality of services and
goods as the suppliers’ power can be more prominent if it is influenced by a few
suppliers (Mburu, 2007). Furthermore, in healthcare services, the hospitals must hire
highly qualified and skilled staff. Hospitals are labor intensive, and suppliers for medical
equipment, consumables supplies, and pharmaceuticals are the vital key players in
competitive force for suppliers. According to (Perrott & Hughes, 2005), in Australia,
nursing staff are among medical practitioners who have a strong image with the
consumers and public thus, they have a strong bargaining power with private hospital
groups and secure position to negotiate on behalf of their organizations. Moreover,
for consumable medical supplies mostly are used in private hospitals supplied by
industries that are organized in structure hence companies who supply individual
supplies can have some control over the supply conditions and price. For medical
equipment, over the years, the private health industry has become more dependent
towards advanced technologies that require high capital cost equipment which are
used in treatments and diagnostics together with limited suppliers, it later creates
limited opportunity for competitive buying. In other words, suppliers hold a great
power in negotiating supplies to the healthcare service industry. There are several
studies with different results as example, a study from (Marešová & Kuča, 2014) found
that in terms of the power of suppliers, it can be measured as weak or moderate
because the company in healthcare services has the chance to choose from
different suppliers and a change in supplier may be associated with cost. Another
finding from different study (Bintang Janaputra et al., 2021), concluded that
bargaining power from the suppliers in healthcare services is low because the regional
public hospitals (RSUD) are unable to produce their services and goods on their own
and they depend on other suppliers and not one supplier only.

2.2.3.4 Bargaining Power of Customers/Buyers

In Porter’s Five Forces Model, bargaining power of the buyers resorts to the extent
where the customers in different industries can extract terms (quality of goods/services
or prices) advantageous to them by persuading and pressuring the sellers. In
healthcare contexts, consumers which are the patients do not require to pay the full
amount for the services that they receive as third-party payers such as insurance

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companies will cover the costs. Therefore, patients and insurance companies
represent the buyers in healthcare services and later dominate hospitals’ service
quality (Gupta et al., 2015). This statement lines up with previous study by (Mburu,
2007) that with the presence of healthcare insurance or experts in management care
has affected the increase of buyer power as rivals from other health care
organizations may offer special services or even warranties to obtain customer loyalty.
This is because the buying power has become more centralized in the healthcare
industry and medical indemnification policies are evolving (Marešová & Kuča, 2014).

2.2.3.5 Threat of Substitute Products/Services

Substitutability is a vital factor especially in healthcare industry as hospitals face many
different substitute providers in the same service because hospital outpatients’
services need to compete with other providers such as doctor owned practices, nurse
practices in other clinics including herbalists, ambulatory services and other health
organizations (Mburu, 2007). Research from (Gupta et al., 2015) showed how the
threat of substitutes allows other services or products that can fulfil the consumers’
needs by offering similar function as the original services thus, the threat of substitution
for hospitals is increasing specifically in ambulatory and surgery services. With this
situation, hospitals need to step up their quality or care to satisfy their patients in order
to maintain their competitive advantage. Different organizations can venture into
developing new products (goods or services) or improving their existing products
(goods/ services) or develop new production process in order to meet with
consumers’ expectation and requirements towards the services which later affect the
organization’s performance to be the best in the competition market (Petrariu et al.,
2013). A study conducted by (Bintang Janaputra et al., 2021) found out that substitute
of products and services threat allow the consumers more reflection and thought in
making decision is high due to the existence of referral policy made for BPJS
Kesehatan users compared to regional public hospitals (RSUD) that require patients to
obtain referral letters from other health facilities.

In summary, CTC should identify and analyse all the possible competitive forces to
overcome any challenges and obstacles to move forward and stay competitively in
the healthcare industry. The Porter analysis will help CTC to determine its strengths,
weaknesses, opportunities, and threats as well as finding suitable strategic business
planning for firm’s self-sustainable and long – term profitability.

2.2.4 Customer Based Brand Equity (CBBE)

Customer-based brand equity (CBBE) is also known as Keller’s brand equity model.
According to Keller (2000), brand equity is known as the power of the brand that is
constructed and planted in consumers’ minds based on what they have seen, heard,
felt and learnt about a certain brand. More than that, brand equity focuses on the
cognitive aspects of the consumers especially in terms of marketing. Brand equity is

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also defined as a set of assets that correlated and connected with the brand and the
assets which include brand association, brand awareness, together with brand loyalty
and perceived quality from the consumers (Aaker, 1991). Figure 2.2 illustrate the
development of brand equity in mind of a customer towards a product or service.

Figure 2. 2: Keller’s Equity Model

This statement was later supported by Keller (Keller, 1991) that the implementation of
brand equity in terms of brand knowledge is related to brand image and awareness
perceived by consumers which later leads to the marketing activities of certain
brands. Furthermore, expanding and enlarging positive brand equity in a brand will
result in strengthening and increasing customer loyalty, effective communications,
higher margins and also market share. Similar to another study (Kim et al., 2003) stated
that brand equity is measured with the application of brand image, perceived quality
which later affects the brand awareness and loyalty.
It can be observed that brand equity is a crucial tool to associate a brand and
influence the consumers in making decisions as some of the brand equity dimensions
do include brand association, brand loyalty, perceived quality and brand awareness
(Charanah & Njuguna, 2015). Brand association is often known to include the feelings,
perceptions, experiences, conceptions, beliefs, feelings and thoughts towards the
brand or services of the consumers (Ernawaty et al., 2020). Meanwhile, brand
awareness is the intuitive – level understanding on the attributes of services or brand
and the level of importance towards the consumers (Karam & Saydam, 2015). Greater
brand knowledge about a product/ service among consumers would generate good
brand equity (Keller, 1991). The statement is also supported by (Latif & Mdnoor, 2014)
that stated certain brands will have further values for customers if they can create a
strong brand towards customers with effective approach and strategies.

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Health care services nowadays are vital and essential as most parts of the world are
experiencing the growth in health care systems and markets (Odoom et al., 2019) . To
add more, health care contexts have been focusing on the areas of brand equity
that emphasize on health care branding, consumer perceptions and service quality
(Agyapong et al., 2017). Another study believed that customer/patient satisfaction,
brand image and trust, gaining brand awareness, perception towards health care
services and reputation can play a big role in contributing to the health care brand
equity (Wu, 2011). A study on brand equity has been conducted in Airlangga Health
Care Center (AHCC) by (Ernawaty et al., 2020) concluded that brand equity does
influence patients visits to AHCC as the brand equity remarkably affects patient visits
and how promotion is able to create good impression to enhance brand equity and
improve health care utilization.

Therefore, CTC should not neglect the power of its brand from the customer’s point of
view. It is critically important for CTC to assess and measure how their customers view
CTC in the current healthcare and surrounding market. CTC needs to identify and
explore the level of perception its customers have concerning the image, reputation,
service quality, and overall customers satisfaction towards the CTC service delivery
performance. CTC must identify a set of elements of brand assets and liabilities linked
to the CTC brand, names and symbols that are added or subtracted from the value
given by CTC to various stakeholders. Specifically, CTC must evaluate its brand equity
in the following manner:

1 The perspective of the consumer.
2 The power of a brand lies in what resides in the minds and

hearts of customers.
3 The differential effect that brand knowledge has on consumer

response to the marketing of that brand.
4 How brand knowledge exists in consumer memory?

2.2.5 Business Canvas Model

Nowadays, the evolution of business model concepts starts with simple definitions and
grow into real models that are applied and used in the management. Hence, business
models aid is crucial in understanding, capturing, and communicating through
business logic (Korpimaki, 2017). Business model canvas (BMC) is defined as the
central starting up a template to document existing business models or new ones in
expanding the varieties of different models in the future(Najib, 2020). Another study
(Osterwalder & Pigneur, 2010) also agreed that the BMC is the blueprint for the
strategy taken in any companies, governmental institutions, or corporations. A study
from (Bekhradi et al., 2016) believed that BMC is a pertinent tool for the development
of business and representing the business as it allows creating a common language
between the team members with external stakeholders. From the same study, it is
believed that BMC and Value Proposition are useful to help and manage a business.
However, a firm must be cautious with the BMC application in any attempt to go

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straight into BMC development without analyzing systematically the “design problem”
that might lead to failures.
Business Model Canvas (BMC) contains nine building blocks that include the topics of
the offer, infrastructure, financial and customers (Korpimaki, 2017). The customer
segments block is the core of any business model because, without any valuable
customers, the business aims for failure. In terms of customer relationships, it describes
the type of relationships that the company wants to initiate with customer segments,
and through channels, the company can communicate and achieve the customer
segments in order to successfully deliver the value proposition (Osterwalder & Pigneur,
2010). A study conducted by (Korpimaki, 2017) found that Business Model Canvas
(BMC) impacted health care services, especially in terms of co-creation and how the
value proposition is delivered for the customers. It is also mentioned that there has
been an increase in customers’ awareness towards the companies after the status
and reputation grow. The topic of the offer includes the value proposition, which
focuses on the services or products in a firm that creates value for a particular
customer segment and has been the main cause why customers choose a certain
company compared to other competitors. The value proposition generates value
through a combination of elements that serve specific customer segments. Following
the next topic of infrastructure, it covers key resources block that incorporates the
most vital assets required to ensure the business model works. For key activities, it is the
most important action that a company must take to operate smoothly.

Figure 2. 3: Business Canvas Model

In contrast, the key partnership represents the networking among partners and
suppliers to assist the companies in optimizing the business model while reducing risks
and at the same time obtaining resources. Lastly, financial viability includes cost
structure block that explains all costs acquired to operate the business model and

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revenue streams that showcase the cash a company generates from different
customer segments (Osterwalder & Pigneur, 2010). Figure 2.3 presents the overall BMC
blocks for a business value proposition.
Thus, the BMC model is considered an ideal and suitable instrument for CTC to identify
a clarification of foundation aspects within the organization’s structure and the
relationships built within itself and exceed its border. It is a strategic management
template used for developing new business models and documenting existing ones.
It offers a visual chart with elements describing CTC’s or product’s value proposition,
infrastructure, customers, and finances, assisting CTC to align its activities by illustrating
potential trade-offs.
2.3 STUDY FRAMEWORK OF CTC FEASIBILITY STUDY
Based on the supporting literature, theories and models discussed, we have
developed a study framework as illustrated in Figure 2.4. The framework outlines the
overall variables processes involved to achieve the goal of this study.

Figure 2. 4: Feasibility Study Framework

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CHAPTER 3 | METHODOLOGY

3.1 PREAMBLE
This chapter further explains the procedures of the methodological approaches that
are used in this study. It covers the research design of the study, sampling size,
instruments of the study, data collection procedures, data analysis, scope of the study
and limitations.

3.2 RESEARCH DESIGN
This study aims to focus on qualitative and quantitative analyses to achieve the stated
research objectives. Figure 3.1 shows the general process of conducting this study
using a qualitative and quantitative design.
There are four (4) phases of data collection as illustrated in Figure 3.1. The qualitative
method consists of Phase 1, Phase 2, and Phase 4. On the hand, the quantitative
method comprises of Phase 3.

•In-depth Phase 2 •Online/ Phase 4
interview Offline
•Focus survey •Data
Phase 1 group analytic
discussion Phase 3

Figure 3. 1: Data collection phases of CTC feasibility study

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Figure 3. 2: Flowchart of Research Design
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3.3 TIME DURATION
The study begins effectively from April to July 2021 (4 months). However, the study has
been delayed for three (3) months due to the Covid-19 pandemic and strict MCO
enforcement throughout Malaysia. Figure 3.3 illustrates the time duration for the
feasibility study.

Preliminary In-depth Focus Group Questionnaire Data Analytic Data Analysis Report
Studies interview Discussion Survey & simulation & Findings Submission
(FGD)

PHASE 1 PHASE 2 PHASE 3 PHASE 4 PHASE 5

April 2021 May 2021 September 2021* October
2021

*The delaying of data collection due to Covid-19 Pandemic and MCO enforcement in Malaysia

Figure 3. 3: Duration for CTC Feasibility Study

3.4 QUALITATIVE METHOD

The purpose of the qualitative approach is to gain an in-depth understanding of
pertinent issues concerning CTC transformation from a cost-centre to a profit-centre.
The method aims to obtain data from a purposely selected group of individuals rather
than from a statistically representative sample of a broader population. Scope of
discussion related to current state of internal resource capabilities, staff readiness and
competency, customer interface and desired outcome (self-sustainable) for the CTC
transformation. There are two phases in this method namely Phase 1 - In-depth
interview and Phase 2 - Focus group discussion (FGD). Site-visit approach was also
performed at the hospital in order to support the qualitative method.

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3.4.1 In-depth Interview Interface

Method : Round-table discussion
The in-depth interview could not be conducted individually due
to the nature of healthcare centre and pandemic Covid-19.
Thus, a round table discussion was recommended by the CTC
management.

Respondents : Key person at management level of CTC
a) Director of CTC
b) Deputy Directors of CTC

Instrument : Open structured questions pertaining to the current state of
internal resource capabilities, leadership and governance, staff
readiness and competency, competitive advantage,
customer interface and CTC transformation as profit-centre.
Strength, opportunities, challenges and limitation of CTC were
discussed.

Data analysis : Input and feedback from the KIPs are used to explore any
possible major concerns related to CTC transformation as a
profit-centre medical centre.

3.4.2 Focus Group Discussion Interface

Method : Pencil written survey as depicted in Table 3.1
Note: This approach has to be carried out instead of focus
group discussion due to the pandemic of Covid-19 and MCO
enforcement throughout Malaysia.

Respondents : Respondents were the workforce of CTC, IPPT and referred to
as the Key Informant Person (KIP). The KIP represents the unit of
analysis of the unit/ department in the health centre. The KIPs
were selected based on their position and job functions, and
roles. Thus, head of sections/units were selected for this method.
(Refer Table 3.1 for full details of respondents)

Instrument : Semi Structured questions pertaining to variables stated in the
study framework (Refer Appendix D)

Data : An email with attached survey was sent to each identified
Administration respondent. KIPs were given TWO (2) weeks to complete and
return their responses effectively from 15 – 30 August 2021. Two
follow up emails were sent to KIPs as reminder notifications after
1 week and end of the data collection timeline.

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Data analysis : The thematic analysis method was performed in two stages:
i. Transcripts of FGD
ii. Category and theme search

The thematic analysis method means that the researcher
obtains the main themes (primary meaning units) to understand
the current scenario, then answer the objectives and research
questions. Data categorization was made based on themes to
answer the research questions of the study.

Table 3. 1: Number of Respondents for Pencil Written Assessment

No. Sections/ Units No. of Respondents
9
1. Seksyen Perubatan 8
2. Seksyen Pembedahan & Anestesiologi 4
3. Seksyen Radiologi, Onkologi & Perubatan Nuklear 7
4. Seksyen Makmal Diagnostik Termaju (ADL) 5
5. Seksyen Senaman & Rehabilitasi 3
6. Seksyen Pergigian Ortodontik & Deformiti Kraniofasial 2
7. Seksyen Pembedahan Oral & Maksilofadial &
4
Rehabilitasi 5
8. Seksyen Restoratif & Pergigian Estetik 7
9. Seksyen Pergigian Am 5
10. Seksyen Farmasi 4
11. Bahagian Klinikal, Kelestarian & Piawaian 4
12. Ketua Penyelia Jururawat 1
13. Penyelia Jururawat 1 68
14. Penyelia Jururawat 2
Total of Respondents

3.4.3 Data Analytic and Simulation

The primary objective of Phase 4 is to assess the CTC resource competitiveness and
market projection. In this phase existing secondary data were obtained from a person
in-charge at CTC’s Unit Record. Data analyses involve as follow:

1) Identifying available and existing data with names of variables/ indicators/
labels when key in the data. Then, the researcher can extract most appropriate
data for analysis.

2) Extracting relevant data by matching the variables with the study framework
and construct.

3) Projecting the market demand
a) Trend analysis
b) Supply and demand
c) Input vs. Output

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d) Expenditure
e) Unit record, annual report, data simulation and analysis.

Phase 4 also covers the following assessment:

1) Input Efficiency

Purpose: to assess the Input Efficiency (Resource Competitiveness) of CTC over
the years.

Labor Ratio between total patients served and number of doctors.
Aspects
Ratio between total patients served and non-doctors
Capital Ratio between doctors and non-doctors
Aspects Ratio between capital expenditure (e.g.: machines and
equipment) and patients
Time Ratio between capital expenditure and doctors
trend Ratio between capital expenditure and non-doctors
Allow us to evaluate CTC whether they are using less or more
resources to serve the clients over the years.

2) Cost and Revenue Trend

The purpose of looking at cost – revenue trend is to examine whether the

gap is widening or narrowing over the years

Total Revenue (all income) Total Cost (all expenses)

Each of the ratios highlighted above will be compared with a benchmark
hospital, given the availability of data (e.g.: UMMC)

3) Business Projection in Short Term & Long Term

Based on the existing cost and revenue data, the study proposed to come out
5- and 10-years plan (assuming that there is no breakeven yet). Thus, the
following questions are developed:

a) How much growth in revenue is needed to attain breakeven if we consider
the next 5 and 10 year?

b) How much cost reduction (total) should be needed to make breakeven
within the next 5 & 10 years?

c) Do we need to increase prices of the services/ increased number of
patients/make substantial promotion/marketing to attain breakeven within
the stipulated time?

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In summary, Figure 3.4 illustrates the overall data collection interface and respondents
involved in the feasibility study of CTC. The right selection of respondents in this study
is crucial as they would provide an insightful information for CTC to planning,
implementing, and monitoring the success of CTC transformation as a profit-centre
hospital.

• Unit Record • Director IPPT
• Deputy Directors
• Annual report
• Data simulation/ of the CTC
• Director/Members
analysis
of UMMC (Visit)
(PHASE 4)
(PHASE 1)
DATA
SIMULATION IN-DEPTH
INTERVIEW

• In-patients (PHASE 3) (PHASE 2)

• Out-patients SURVEY FOCUS GROUP
• Patients’ QUESTIONNAIRE DISCUSSION
(FGD)
companions
• All the members
• Suppliers of Clinical
Department
• Potential customers

Figure 3. 4: Summary of data collection interface

3.5 QUANTITATIVE METHOD

3.5.1 Survey Research – Customer interface
The application of service quality management practices by health care providers is
becoming more prevalent. Berry et al. (1988) define service quality as compliance
with client standards, impacting customer satisfaction. Customer satisfaction results
from the provision of goods and services that meet or exceed customer needs. It is

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widely acknowledged that there is a need for quality and patient satisfaction
monitoring in health and medical care service. Quality management monitoring
would be able to develop ways to improve service quality. As such, Phase 5 focuses
on assessing CTC's current service and performance in healthcare service delivery.
The success of CTC service and performance depends on the quality of functional
and technical service it offers. In a healthcare setting, functional service quality is
determined by the method used, and technical service refers to the equipment and
machine used for the healthcare treatment. Quality control, service quality, and the
effectiveness of medical treatment have grown increasingly crucial due to
competitive pressures and the growing need to provide patient happiness. In order to
understand this, three CTC customer segments were studied that is (i) outpatient, (ii)
inpatient and (iii) non-patient. As indicated in Figure X, a different segment used
different variables to study satisfaction, service quality, & CTC brand value.

Figure 3. 5: Studied Variables for CTC Three Customer Segment (Outpatient,
Inpatient and Non-Patient)

The SERVQUAL instrument, created by Parasuraman et al. (1988), is used to assess the
relative relevance of service quality in outpatient satisfaction and service quality
performance. In a hospital setting, the SERVQUAL instrument has been experimentally
validated and has shown to be a reliable and valuable tool. We utilized Public
Hospitals in Australia (2005) for the in-patient segment and Keller's Customer Brand
Based Equity for the non-patient segment (1993). Figure 1 shows the details of the

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examined variable. The Task-Force Committee and IPPT Top Management Team
scrutinized, evaluated, and approved the studied variables.

Using the survey method, data collection was done from 1st July until 30th August 2021.
Respondents were gathered using both offline and online channels. Questionnaires
were sent through the Internet via the Vice Chancellor's office's internal email blast
and social media platforms such as IPPT, Facebook and USM staff, CTC doctors, and
nurses' personal social media channels. Facebook and WhatsApp are examples of
social media. Meanwhile, the pen and paper approach were utilized for the offline
channel, with the printed questionnaire being put at CTC’s clinics, departments, units,
and wards. The data-gathering technique is intended to be as convenient as possible
for the respondents.

CTC Outpatient 17,884* N = 379
CTC Inpatient
General Public (Malaysian) 1,114* N = 341

32 million* N = 384

* 2020 data

Convenience Sampling Voluntary Response Sampling

Purposive Sampling Snowballing Sampling

Figure 3. 6: Sampling Protocol

Considering the three-sample segment that has been derived earlier, the sample
population was determined based on 2020 data received from IPPT Database, where
for outpatient number is noted at 17,884, inpatient at 1,114 and non-patient at 32
million (generalizing it to the whole Malaysian population). Out of this total number,
the sampling size is determined, as explained in Figure X. The sampling size
determination following Krejcie and Morgan (1970). We adopted a non-probability
sampling strategy employing four methods at the same time for both online and
offline that is (i) convenience sampling, (ii) voluntary response sample, (iii) purposive
sampling and (iv) snowball sampling.

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The survey is designed in bilingual, considering the diversity of the CTC and Malaysian
population. The back-to-back translation was used because the survey instrument
was adapted from the English version. The translation process was actively monitored
by the Task-Force Committee and the IPPT Top Management Team. The following is
the URL for collecting survey data:

o Outpatient https://forms.office.com/r/keJEJLNV9x
o Inpatient https://forms.office.com/r/m3CMWctDYc
o Non-patient https://forms.office.com/r/ZKZ6Ybei7N

Outpatient

Inpatient

Non-Patient
Figure 3. 7: Screenshot of Screening Question Used in Questionnaire
A screening question is included in the questionnaire to guarantee that only the
eligible respondents answer the questions as indicated in Figure X. There is also a
survey consent form included at the beginning of the survey (detail is attached in
Appendix L, M & N)

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The questionnaire was divided into three sections: visiting, payment, treatment, and
awareness of EHS, demographic questions, and a section that examined the variables
under investigation (the survey is attached in Appendix E, F and G). The final number
of data collected is presented in Table X. We obtained a 73% response rate for
outpatients, a 26% response rate for inpatients, and a 100% response rate for non-
patients.

Table 3. 2: Data Collection Size & Response Rate

Sample Size Outpatient Inpatient Non-patient
Collected 379 341 384
Useable (After screening) 277 90 415
Response Rate 241 51 323
100%
73.08% 26.40%

3.5.1 Survey Instrument Development

Books, annual reports, journals, and the Internet were the secondary sources in
developing the instruments. Overall, we have 20 studied variables for all three
segments. The conceptualization of all variables is as explained in Table X.

Table 3. 3: Variables Conceptualization

No Instrument
1. Service Tangibility à Physical facilities, equipment and appearance of the CTC

doctors, nurses, and staff
2. Service Reliability à The ability to perform the promised service dependably

and accurately
3. Service Responsiveness à The willingness to provide service, help patients and

provide prompt service
4. Service Assurance à The knowledge and courtesy of CTC doctors, nurses and

staff and their ability to inspire trust and confidence
5. Service Empathy à The caring, individualized attention CTC doctors, nurses,

and staff provides to the patients
6. Service Fee Fairness à The patient's assessment of whether CTC fee (in

comparison with other hospital fees) is reasonable, acceptable, or justifiable
7. Condition of CTC à The extent to which patients assess the state of CTC

infrastructure and facilities.
8. Access & Admission à The process of staying at a hospital for at least one night

or more for treatment

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9. Treatment and Related Information à Patient rights and information shared on
treatment, procedures, laboratory results, and other related information during
the hospital stay

10. Physical Environment à The place where the patient stay that includes room,
food and ward condition

11. Discharge & Follow Up à The care given to a patient during the hospital check-
out and after completing hospital stay and treatment

12. Patient Satisfaction à The extent to which patients are happy with the

healthcare services
13. Patient Experience à It encompasses the range of interactions that patients

have with the health care system, including their care from health plans and
doctors, nurses, and staff in hospitals, physician practices, and other health

care facilities
14. Word-Of-Mouth Communication à Stakeholder interest in health provider's

service that is reflected in their daily dialogues and referral that is free from
advertising triggered by other experiences
15. Brand Awareness à The ability of the public to recognize CTC and recall CTC

as a health service provider
16. Brand Associations à linking CTC with USM reputation and Ministry of Health as

a shareholder and able to interpret the brand.
17. Brand Trust à The confident expectations of CTC perceived credibility and

benevolence in situations entailing risk to the public or stakeholders
18. Brand Image à Certain values and visuals associated with CTC
19. Brand Equity à CTC brand equity that comprises knowledge equity, benefit

equity and relationship equity
20. Perceived Quality à Public and stakeholder overall impression of the relative

superiority of CTC as a health service provider and USM and the owner

3.5.1.1 Instrument for Outpatient

The instrument used for the outpatient survey consisted of 10 variables. The responses
were recorded on a five-point Likert scale to measure patient satisfaction, word-of-
mouth communication, and CTC brand equity. The final list of items used for the survey
is as in Table 3.4.

Table: 3. 4: Instrumentation for Outpatient

No Instrument Scale

1. Service Tangibility 1= Poor

i. CTC has modern-looking medical equipment 2= Fair

ii. CTC is clean, neat, and well-maintained 3= Good

iii. CTC has a cozy atmosphere 4= Very Good

iv. CTC physical facilities are visually appealing 5= Excellent

v. Staff uniform in CTC is clean, nice, neat, and

professional looking

2. Service Reliability

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i. CTC provides services as promised
ii. CTC performs services as expected
iii. CTC bill patients accurately
iv. Patient medical record is kept correctly
v. Doctors and nurses performed the service as expected
3. Service Responsiveness
i. Doctors and nurses give clear and easy to understand

information
ii. Doctors and nurses give appropriate and prompt

services
iii. Doctors and nurses informed about the treatment that

will be performed
iv. Doctors and nurses are willing to help anytime
v. Doctors and nurses are always ready to respond to

patient request
4. Service Assurance

i. Doctors and nurses have the knowledge to answer
questions

ii. Doctors and nurses explain how much the treatment
will cost

iii. Doctors and nurses instill confidence inpatient
iv. Doctors and nurses have been consistently courteous
v. Operational support personnel are knowledgeable,

skillful and helpful
5. Service Empathy

i. Doctors and nurses understand patient needs
ii. Doctors and nurses give individual attention
iii. Doctors and nurses have the patient best interest at

heart
iv. Doctors and nurses learn about patient-specific needs
v. CTC has convenient operating hours
6. Service Fee Fairness

i. CTC provides a variety of pricing plans
ii. CTC makes it easy to change pricing plans that meet

patient need
iii. CTC offers the best possible plan that meets the patient

need
iv. CTC charges a reasonable price
v. CTC provides superior pricing options compared to

other hospitals
vi. I believe it is fair for CTC to increase the price based on

its current medical service market value
7. Overall Condition of CTC

i. The reception counter is...
ii. The registration counter is...
iii. The canteen is...
iv. The toilet is...

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v. The waiting area is... 1= Strongly
vi. The lift is... Agree
vii. The stairs are... 2= Agree
viii. The vending machine is... 3= Not Sure
ix. The carpark is... 4= Disagree
x. The praying room (surau) is... 5= Strongly
xi. The pharmacy is... Disagree
xii. The chairs and sofas are...
xiii. The changing room is...
xiv. The storage/locker to keep my belongings is...
xv. The recovery room is...
xvi. The signages are...
xvii. The lightings are...
xviii. The temperature in every place and room is...
xix. The scent/smell in CTC is...
xx. The medical instruments/infrastructures are...
8. Patient Satisfaction

i. How do you rate your overall experience with the
service you received in CTC?

ii. How do you rate the treatment you received in CTC?
iii. How do you rate the doctor service in CTC?
iv. How do you rate the nurse service in CTC?
v. How do you rate your waiting time in CTC?
vi. How do you rate the treatment charges in CTC?

9. Word-Of-Mouth Communication
i. I heard and known about CTC before from my friend,
family, or colleagues
ii. I heard about CTC excellent services
iii. I heard about CTC reliability in medical treatment

iv. I heard about CTC as a trustworthy health provider
v. I heard that CTC is a trusted, reputable, and credible

name
vi. Within a healthcare provider, I heard that CTC is

among the best

10. CTC Brand Equity
i. Even if another hospital has the same facilities as CTC,
I will prefer to choose CTC
ii. If another hospital is not different from CTC in any way,
it seems wiser to choose CTC
iii. If there is another hospital as good as CTC, I prefer to
choose CTC

iv. It makes sense to choose CTC instead of any other
hospitals, even if they are the same

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