The importance of implementing the quality management system and using quality strategies to improve the quality of medical services and increase customer satisfaction

. The importance of medical services in the modern age is undeniable. In Romania, the state medical system faces a series of problems, which do not seem to have an immediate solution. These include: outdated infrastructure, lack of medical staff, lack of investment and poor organization. The specialized literature presents studies of patient satisfaction, performed on different sectors of the medical field. This paper aims to present the Romanian medical services market, and the users’ satisfaction with the medical services. In order to highlight the opinions and behaviors of Romanians about the medical services and the degree to which the provision of these services met their expectations, the authors conducted a qualitative marketing research among the Romanian population. The sampling method was non-random, and a questionnaire was displayed on a web page (Computer Assisted Web Interviewing) to collect the data. The research revealed that many Romanians prefer private medical services, even if they are more expensive, due to the cleanliness, promptness and quality of the medical act. The authors consider that the topic addressed is very relevant and that, based on the results of this research, the authorities involved can establish concrete measures in order to improve the quality of the medical services and increase customer satisfaction.


Introduction
The authors approached this paper primarily by deepening the literature and highlighting studies that investigate the issue of quality of medical services and customer satisfaction with these services. Then, the Romanian medical services market was described. According to previous studies, this market has constantly evolved in the last 2 decades, by increasing the number of providers in the private sector. It was also found that many Romanians prefer private medical services, even if they are more expensive, due to benefits such as: quality of medical service, shorter waiting time, more attention from medical staff, etc. Given the importance and need to implement proper quality management in the medical field, the authors also highlighted some quality strategies implemented by several medical units in Romania, which resulted in increasing the performance of these units and the customer satisfaction.
In order to survey the opinions of Romanians about the perception of the quality of medical services and the satisfaction they have after using them, the authors conducted a quantitative marketing research, using the CAWI method as a data collection technique.
The research results indicate that Romanians prefer private medical services, to the detriment of state ones. The motivating factors for choosing the services are: the quality, the cleanliness, the kindness of the auxiliary staff, the quality of doctors, as well as the quality of services they offer in general.

Literature review
The role of quality in meeting consumer needs In the literature, the notion that is most often mentioned regarding quality is that of satisfying consumer needs (Ilieș and Crișan, 2011).
The goal of any organization is to meet the needs and desires of consumers at a higher level than the competition while maintaining the profitability of the organization. In this equation, the customer plays a unique role: without the customer, most organizations do not exist. Studies aimed at meeting customer requirements have led to the emergence of marketing, as a distinct area of theory and practice, but also to the emergence of quality management. These two areas quickly gained a very important place in the organizations.
In services, quality can be assessed by comparing the actual performance of the service with customer expectations. The quality of services, according to Suhail and Srinivasulu (2020), can be a criterion for assessing the performance of a provider organization. Companies are dependent on the customer, therefore understanding their needs and expectations will lead to increased satisfaction, equivalent to a solid future of the organization. As Forero and Gómez (2007), said "Measuring user satisfaction is the subject of a wide debate in the contemporary literature in the field of health services". By measuring customer satisfaction, healthcare providers can know their point of view and identify health system problems that cause dissatisfaction. The evaluation of a health system can be done by several methods, but the literature has not reached a consensus on the best of them. The studies conducted so far have focused on specific areas of the medical system, to highlight their specific details (Almansour et al., 2020;Jung et al., 2018;Poonsiri et al., 2020). In the current health crisis, caused by the SARS-VOC 2 pandemic, the health systems of most countries in the world have revealed weaknesses and poor organization. Under these conditions, patients suffered, which led to a decrease in their satisfaction with medical services.

The Romanian medical services market
An operational, practical, productive and easily accessible health system participates in economic development, progress and well-being. Thus, it will allow the population to achieve a convenient state of health and maintain it, thus ensuring increased productivity, but also the level of contributions to the health budget.
In over 70% of EU member states, health spending is paid from the public sector budget. This issue poses a risk to the sustainability of public finances, especially in a context of an aging European population. Figure 1 shows, as a share of GDP, the level of funding of the public and private health system for the European Union (European Commission, 2017). According to the European Commission in the report "Country profile in 2019 in terms of health for Romania", health spending has the lowest level in the European Union per capita (€ 1,029 for an EU average of € 2,884), as well as on the percentage of GDP (5% against 9.8% in the EU). The share of health expenditures financed from public money (79.5%) is in line with the EU average (79.3%) (European Commission, 2017).
The transition to ambulatory healthcare is at an early stage, with over 42% of the health spending being directed to hospital services (compared to the EU average of 29%). An additional 27% is spent on pharmaceuticals and medical products. This value is particularly high compared to other countries and, as a percentage, ranks third in the EU after Bulgaria and Slovakia. The absolute value of expenditure per capita on pharmaceuticals (EUR 280) remains relatively low compared to the EU average (EUR 522) (European Commission, 2017). In 2017, there were 2.9 practicing physicians per 1,000 inhabitants, ranking third among the lowest in the EU (EU average of 3.6) and 6.7 nurses per 1,000 inhabitants (EU average being 8.5) (European Commission, 2017).
In the last ten years, the public health sector has been overtaken by the private one. The latter gave patients modern medical units, which use state-of-the-art technology, highly trained medical staff, and management systems designed to provide the best quality to consumers. 9 out of 10 medical units in Romania are private. This situation is maintained in rural areas, with a slightly different weight compared to urban areas. 91.5% of the units in the villages are private, while in the city the percentage is 89.4% (Hotoboc, 2018).
In November 2019, Reveal Marketing Research conducted a study on Romanians' perception of the quality of medical services in urban areas to find the exact explanations for this spectacular increase in private services in the last 2 decades (Wall Street, 2021). The results of this study show that this boom is due both to young people receiving private health insurance and to the cleanliness, comfort and short investigation time in private clinics. The study reveals that 30% of those interviewed said they use private services more frequently, the percentage being even higher (43.1%) among young people under 25 and those living in Bucharest-Ilfov (42.2 %). State hospitals are generally preferred by people over 35 and by men and residents of Transylvania (75.5%), Moldova (74.4%) and Banat-Crisana (72%). The motivations of those who choose this option (68.3%) are financial. Cost is the only positive attribute of the state service preference. On the other hand, private medical services are preferred by Romanians, because they have many strengths, including cleanliness (81%), respect received by the patient (75%), short time in which investigations are conducted (74.7%), doctors' professionalism (57.5%) and general trust (51%).
According to NIS data (2020), compared to 2018, in 2019 the most significant changes in the number of health units were determined by the increase by 652 units the independent medical offices, by 339 units the independent dental offices, by 84 units the school and student medical offices. It also increased by 79 units the specialized medical civil societies and with 66 units the medical laboratories. In parallel with these increases in the number of health units, the most significant decreases in the number of units were registered in the independent family medicine offices, with 78 fewer offices than in 2018. The distribution of the network of health units by areas of residence highlights the fact that the health network has developed mainly in urban areas. The network of independent family medicine offices included, in 2019, the most offices in the North-East (1593 offices), Bucharest-Ilfov (1545 offices) and South-Muntenia (1470 offices) regions, and the fewest in the regions West (1162 cabinets) and Southeast (1134 cabinets). In 2019, the number of doctors was 63,303 people (4.5% more than in 2018), the number of dentists was 1.7003 people (3.3% more than the previous year), and that of pharmacists was 18093 people (2.7% less than in 2018).
The marketing environment produces both threats and opportunities (Balasescu andBalasescu, 2020, Borges et al., 2020), so the medical institutions, both state and private, must carefully analyze its environment to avoid threats and take advantage of opportunities (table 1).

Table 1. SWOT analysis of the Romanian medical services market Strengths
Weaknesses -diversity of medical services offered; -balanced geographical distribution of medical institutions on the territory of the country; -existence of alternatives in the public system and the private health system; -important private investments in the field; -examples of the private networks Medlife and Regina Maria; -diversity of medical services reimbursed by CNAS.
-high costs for hospitalization, treatments, hospitalizations and services offered in the private sector in parallel with the settlement of medical services in the private sector only to a small and limited extent; -our country's health spending is just under 5% of GDP, while in Europe the average is 6.5% and at EU level it reaches 8.7%; -only 18% of health spending in Romania comes from the private sector, a percentage that is very low compared to Bulgaria (41%), Poland (28%) and other neighboring countries; -the quality standards imposed by the European Union are not respected in many medical units in the state service; -lack of access to medical services, especially for the poor people; sometimes they need medical services, but do not ask for them due to lack of money.

Opportunities
Threats -in the context of the aging population at the level of the Member States of the European Union, more investments are being made in this field of medical services; -the emergence of more and more private insurance solutions. -the standards imposed by the European -migration of medical staff to deficient European Union countries (e.g. France). It is difficult to create a sustainable medical system without the most important resource: the doctor; -the migration movement of young people to EU countries, which leads to the lack of another Union on the Member States regarding the standards of medical services contribute to their continuous development and improvement; -more organizations are investing in research and innovation to find sustainable, sustainable investment solutions. The healthcare sector is no exception to this trend in recent years.
important resource in the field of medical services: the patient. It takes patients and people who pay contributions to the insurance company to ensure the sustainability of the healthcare market; -the countries' aging population and the tendency to live longer, but not necessarily in good physical shape; -the economic and financial environment in Romania is also a threat because there is no predictability.
Source: Own research of the authors.

Quality strategies applied in the Romanian medical services system
Quality management evaluates the performances of the activities carried out at the customer interface. This assessment reflects the impact on quality and is done by introducing relevant indicators. By implementing appropriate quality strategies, managers can meet the needs of customers to the greatest extent possible, but at the same time, they can benefit the organization (Hudona et al., 2020;Visnjic et al., 2016). Implementing sustainable development practices is an effective solution to counteract these negative effects (Neacsu and Madar, 2020;Ivanka et al., 2016).
In the field of medical services quality, due to the competition in this market, operators must fight to meet the needs of customers as much as possible. The quality of medical services is defined by the American Institute of Medicine as: the degree to which health services for individuals and the population increase the probability of desired health outcomes and are consistent with current professional knowledge.
In order to increase the quality of medical service and, in this way, customer satisfaction, providers in the field can implement different quality strategies, which can be influenced by many factors such as: -compulsory accreditations and authorizations for units operating in the medical field; -the organization's marketing policy; -the development policy of the organization; -the strengths and weaknesses of the company; -market positioning and evolution possibilities; -quality strategies applied by the main competitors; -type of unit -state or private; -number of employees; -technological innovations etc.
Studies conducted in this field are focused on different areas of the medical services: Laboratory management (Shailesh et al., 2020;Pulido, 2018;WHO, 2011); patient safety in pediatrics (Fernández-Oliveira et al., 2020;Pawar et al., 2020;Mueller et al., 2019); case management, as a method that can improve the quality of the life of frequent users, of medical services, and the satisfaction of medical service providers, while reducing costs for the medical system (Zoltani et al., 2021, Hudon et al., 2020Brousselle et al., 2009;Grover et al., 2010).
From this perspective, quality management and strategies in the field of health services are a balanced mix between achieving their own performance indicators and identifying the best levers to provide services with a high degree of professionalism, physical and financial accessibility, accompanied by compassion, empathy and a deep respect for people and their quality of life. From the analysis of the information provided by the different operators on the medical services market, the authors identified some of the quality strategies used in this market: The strategy of maximum performance aims to achieve the leading position on the market of medical services by integrating a quality management system and providing services that meet in all respects the requirements of the users. MedLife, as a leader on the private medical services market in Romania, has set the highest medical standards by offering its customers complex integrated medical services, hospitalization and accommodation conditions with a high degree of comfort and safety and state-of-the-art technology.
The strategy of quality domination can refer to making very important investments either to obtain certifications or to adapt quickly to market changes or user expectations. Regina Maria implements this strategy in order to create the most appreciated network of medical services at national level. They propose, for example, an automated feedback system, which aims to monitor the level of satisfaction after each visit to a clinic, hospital or network partner. Regina Maria is concerned at the same time with the satisfaction of the employees and offers them both continuous training and wellbeing programs (www.reginamaria.ro).
Strategy to focus on a quality level is used to maintain a known and accepted quality level offered to a well-defined group of beneficiaries. Săcele Municipal Hospital is a public medical unit that became known due to the Pediatrics department. The quality offered by this hospital -medical staff and facilities -following the modernization in 2018 is recognized at the county level. Bioclinica is a nationally recognized laboratory network for the high quality of medical tests. It is nationwide and provides users with more than 100 harvesting centers (www.bioclinica.ro).
Certification strategy is based on the certification by an authorized body of its management systems. It aims to confirm, through authorized bodies, the quality of the services provided, the concern for the environment and the safety and health of the employees and collaborators of an organization. MedLife has an integrated quality-environment-safety and health at work management system certified by SRAC, to verify compliance with the requirements of the standards SR EN ISO 9001: 2015, SR EN ISO 14001: 2015 and SR EN ISO 45001: 2018.

Methodology
In order to highlight the Romanians' behaviors and preferences of the quality of private and state medical services, as well as their perceptions of their satisfaction as users with these services, the authors conducted a quantitative marketing research.
Research objectives: -Determine the degree to which the Romanian population accesses medical services; -Determine the reason for which the health services in Romania are accessed; -Determine the preferences of the respondents for private and state medical services; -Establish criteria that are important in choosing a health care provider.
A non-random sampling method and the CAWI (Computer Assisted Web Interviewing) technique were used to collect the data. This technique involves displaying the questionnaire on a web page, and respondents fill in the answers directly in the browser. The research took place between December 6-16, 2020. The data was collected based on a questionnaire containing 16 questions, to which 298 people answered. After answering the first question (if they use medical services in Romania), there were 296 people left in the sample. The questionnaire has two parts, the first contains questions about the type of medical services accessed and the sustainability of the external services, and the second part includes questions to identify the respondents' profile (age, gender, income category, residence).
In terms of gender distribution, the sample had the following structure: 68% women and 32% men. The distribution of respondents by age group was: 12.3% between 18-24 years, 55.1% between 25-34 years, 24.5% between 35-44 years, and 8.2% between 45-54 years. Furthermore, 91.8% of respondents live in urban areas and 8.1% live in rural areas.

Results and discussions
After answering the first question (if they use medical services in Romania), it turns out that the vast majority of respondents (98.97%) access these services (Figure 2).

Figure 2. Recourse to medical services by respondents
Source: Own research of the authors.
Another question asked was the frequency with which respondents turn to medical services. It can be seen (figure 3) that 55.4% of those interviewed use medical services once or twice a year, 20.6% of respondents use services quarterly, 6.8% monthly and the remaining 17.2% are occasional medical service consumers. The research shows that 13.41% of respondents use medical services strictly for preventive purposes, 21.64% only in case of emergency and the majority, i.e. 64.95% use them both for preventive purposes and in case of emergency (figure 4).  Respondents were asked if they would prefer to turn to state or private health services, the question having multiple answers. It turned out that 43.92% prefer large private clinics, 20.6% prefer private doctors' offices, 18.24% opt for family medical offices and 17.24% go to state offices (figure 5). The subjects were asked to say how important certain quality criteria are for them, when choosing a medical service of a certain provider. The results showed that: cleanliness is very important for 89.69% of respondents, waiting time is very important for 47.4% of respondents, medical staff is very important for 83.5% of them and kindness of staff indirectly involved in the medical act is very important for 57.7%. The area where the clinic is located is not of high importance to the respondents (38.5% stated that it is neither important nor unimportant). Instead, the possibility to access the services through CAS is very important for 37.1% of the subjects and the value for money is very important for 58.8% of respondents.
All respondents (including the two who answered that they do not use medical services in Romania) were asked how important it is for them for the employer to provide medical insurance and / or packages with medical benefits. Figure 6 shows that 65.98% of those interviewed consider it very important to provide medical benefits by the employer, 26.80% consider this important, 5.15% consider it neither important nor unimportant, 1.03% considers it unimportant, and 2.06% consider that it is not at all important to grant these benefits.  At the end of the research, the subjects were asked if they had heard or knew about the concept of sustainability in the medical services sector. The answers indicate that 36.08% of those interviewed know this concept, 38.14% do not know the concept, and 25.78% said they heard, but do not know exactly what it refers to (figure 7). The COVID-19 pandemic caused, in Romania, the closure of many hospitals for the treatment of patients with diseases other than COVID-19, so that according to Spătaru (2020), the access of Romanian patients to medical services and medicines decreased dramatically, between 30% and 80% during the pandemic, after the transformation of hospitals into COVID-19 centers. With a challenging 2020 year for all areas of activity, the private health services sector has had to assist the public sector. In this context, many patients turned their attention to private medical services. This trend is also confirmed by Ovidiu Palea, the founder of Provita Medical Center, who says that "the main changes in the medical system will be from fewer patients in the state to higher costs for people and increasing rates in the private system, which will fight to maintain quality standards " (Mihalache, 2020). Private clinics, since the beginning of the pandemic, have developed new products to meet the needs in this epidemiological context, have thought of special projects adapted to support employees of partner companies and have increased the segments of medical services and investigations required priority. As a result of the increase in the number of patients, these clinics recorded very good financial results in 2020. An example is the MedLife clinic which, according to the Department of Analysis and Market Strategies SSIF Goldring SA (2021) registered after the first 9 months of 2020 a net profit at Group level of 43.99 million lei, respectively a turnover of 770.8 million lei.

Conclusion
Ideally, quality management should play a major role in all organizations. A functional and efficient quality management system contributes to the satisfaction of users with the services or products and ensures the development and continuity of the organization on the market.
It is very important that the quality strategies chosen and applied by the quality management department are in line with the company's values and policy.
In the field of medical services, the accreditations confirm the quality of the medical act and the continuous process of improving the value of the units operating in this field.
The research results indicate that Romanians prefer private medical services, to the detriment of public ones. The motivating factors for choosing the services are: the quality, the cleanliness, the kindness of the auxiliary staff, the doctors, as well as the services they offer in general.
The authors consider a positive fact that most interviewees use medical services for preventive purposes, leading us to conclude that the population pays more attention to health and does not reach the doctor only in case of emergencies. This is also clear from the fact that medical benefits are very important when it comes to work.
The paper highlights that those medical units, private or state, which have implemented a quality management system and know how to apply appropriate quality strategies, have very good results, which translate into an increase in customer satisfaction.
One thing is certain, however: Romanians tend to choose the large chains of private clinics due to the quality of the services they offer, quality obtained by paying special attention to quality management. There are also medical units in the state system that manage to maintain the implemented standards, but there are very few at national level.