To Develop the Strategies of the Medical Tourism Industry in Taiwan by Using GRA and TRIZ: The Japanese Consumer Viewpoint

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Chiao Da Management Review Vol. 30 No. 2. 2010 pp. 147-187

應用 TRIZ 發展以消費者角度為基礎之


To Develop the Strategies of the Medical Tourism

Industry in Taiwan by Using GRA and TRIZ: the


apanese Consumer Viewpoint

林千車 Chien-Hui Lin

DigiWin-Data Systems 公司行銷部

Department ofMarket Development. DigiWin-Data Systems 李宗儒(溶紳 Y Tzong-Ru(Jiun品len) Lee


Department ofMarketing, National Chung Hsing University 李佳珊 Chia品lan Lee


Department, Uni-President Cold-Chain Corporation

摘 要:為追求醫療與觀光產業升級許多國家已著手規劃觀光醫療服務,因 而各國對於觀光醫療也逐漸重視,因此,我國在觀光醫療的推廣也需邁向國 際化的腳步,所以為全面性椎動觀光醫療產業,本文將採消費者決策程序並 融入劇場理論來做為設計問卷的基礎,以台灣主要觀光客源、國日本為實證對 象,利用灰關聯作為分析問卷的工具,藉此找出在推廣觀光醫療峙的關鍵成 功因素,以及針對分析結果找出在推動觀光醫療時,將造成推動不易的問題 利用 TRIZ 理論來研擬出 15 項策略,藉此有助於觀光醫療在未來規劃之參考 依據。 關鍵字:觀光醫療;消費者決策程序;劇場理論;灰關聯分析; TRIZ

Abstract: In order to improve Medical Tourism industry, many countries have

1 Corresponding Author: Department of Marketing, National Chung Hsing University, Taichung


148 To Develop the Strategies 01 the Medicul Tourism lndustη in Taiwan by Using GRA and TRIZ: the Japanese Consumer Vìewpoint

been working on services in Medical Tourism. Since other countries have already highly developed Medical Tourism market, Taiwan should promote its Medical Tourism intemationally as well. To create an overall promotion strategy for Medical Tourism industry in Taiwan, this study uses Consumer Decision Process and Dramaturgical Theory to design a questionnaire. The Japanese tourists, as the main source of foreign tourism in Taiw阻, are the empirical object of this study. By using Grey Relational Analysis as the tool to analyze the data collected through the questionnaire, we determine the key factors that can make the promotion of Medical Tourism successful. As a result, we define problems that may occur in promoting Medical Tourism and then apply the TRIZ theory to develop 15 strategies to solve them. The contribution of our study is a reference for managers on planning Medical Tourism promotion.

Keywords: Medical Tourism; Consumer Decision-Making Process,;

Dramaturgical Theory; Grey Relational Analysis;TRIZ.



Healthcare demand has been increasing rapidly for three reasons: aging population, popularization of health care, and rising medical expenses in westem countries. Since we are living in a global village, more‘and more people in the

deve10ped countries, such as USA and UK tum to developing countries like India, Malaysia, and Thailand for high quality medical treatment at lower prices, rather than staying on public waiting lists for expensive medical treatment in their own countries (Connell, 2006).

According to the British statistics, in 2006 around 250 000 of British people travelled abroad for medical treatrnent; it is estimated that by 2010 the number will be 50% higher than in 2006. Furthermore, Bloomberg Businessweek estimates that 500 000 of Americans are travelling abroad to receive medical treatment. During the treatment period, they also trave1 around for touristic purposes. Medical Tourism in Asian coun仕1es lS ge前ing popular because the price

is 30 to 80% lower than ofthe medical treatment in the US.


Chiao Da Management ReνiewVol. 30 No. 2, 2010 149

however, seldom customer perspective is considered. Our research is designed for understanding the customers point of view by using Consumer Decision Process (CDP). ln the questionnaire that we have created, we use Dramaturgical Theory to demonstrate our points. Taking The Japanese consumer as an example, we use Grey Relational Analysis (GRA) to determine the Key Success Factor (KSF) of Medical Tourism in Taiwan. ln conclusion, we utilize TRlZ to draft a plan of Medical Tourism for Taiwan in the fuωre.

2. Literature Review

In this section, we review literature about Medical Tourism, Consumer Decision Process, Dramaturgical Theory and Grey Relational Analysis in order to further understand current conditions of Medical Tourism.

2.1. Medical Tourism

Medical Tourism, according to the definition of World Tourism Organization (ECCP, 2005), is separated into medical attendance, therapy and recovery, including screening health, plastic surgery, SPA, and other treatments in hospitals. Arnit Sen Gupta (2004) considers that taking treatment in public or private health system (e.g. hospitals, clinics) or public and private services (e.g. government facilities, hotels) is Medical Tourism. Some researchers use also the term Health Tourism (e.g., GarCÍa-Alt位, 2005).

We divided medical treatment into five categories: critical care, chronic disease treatment, health care, health preserving and plastic surgery by medical instiωtions. ln tourism, traveling, food and beverage industry, accommodations,

entertainment and traffic system are all included. Furthermore, indoor activities such as hot springs, local CU1sme and shopping, outdoor activities such as

mountain climbing, hiking, snorkeling, whitewater rafting and are all involved in Medical Tourism. For Medical Tourism, the schedule of the trip can be arranged based on customer individual needs, and surely the medical treatment is the main focus while arranging the schedule of a trip.


150 To Deve/op the Strategies 0/ the Medica/ Tot;rism Industry in Taiwan by Using GRA and TRlZ: the Japanese Consumer Vìewpoint

defined that Medical Tourism is an outsourcing service, composed of medical services and expensive surgeries. But countries such as India and Thailand can provide this type of medical care in lower cost than most of the developed countries. Another definition, from vertical integration point of view, illustrates medical service as integrator of tourism and medical service according to supply and demand (Lu and Wang, 2007). Lunt and Carrerab (2010) mentioned that customers could make different choices for Medical Tourism services if the information was easily accessible by media. Customers in different ages or of different social statuses would make their choices differently.

In sum, we define Medical Tourism as a medical treatment combined with sightseeing activities. Taiwan Medical Tourism can provide lower cost on medical treatment for the Westerners, sparing a lot of time that otherwise would be wasted in the long waiting lists. Examples would be dentistry and double eyelid surgery. With Medical Tourism, medical treatment can be a pleasant activity for customers.

Medical Tourism is growing in importance all around the world, inc1uding Thailand, Malaysia and other Asian countries, Costa Rica, Argentina and other Latin American countries, Dubai, Israel and other middle-east countries, Hungary and other eastern European countries, Aus仕alia and South Africa. Among these countries, Asian countries such as India, Thailand, Malaysia and Singapore are making great effort to develop this industry (García-Alt缸, 2005, Connell, 2006).

It can observed that South-East Asian countries hold majority in developing Medical Tourism industry. Taiwan, as one of them, has to develop its own strategy on Medical Tourism in the future by learning 企om other South-Eastern Asian neighbor countries.

In Taiwan, the projects of Medical Tourism were derived by the Science and Technology Advisory Group of Executive Yuan in 2003. These projects inc1uded telehealth, international Medical Tourism, and health insurance and hospi tal authority ( _ 003.htrn, accessed 30/3/08). The Taiwanese High Technology industry is wOrld-famous, therefore,

Wuang (2007) proposed that we should combine our superior health care system with experience in health insurance. AIso, Taiwan should combine exquisite service with Medical Tourism to make the medical service more internationa


Chiao Da Management ReνiewVol. 30 No. 2. 2010 151

making Taiwan a famous location for medical services.


Consumer Decision Process (CDP)

Consumer Decision Process (CDP) is a decision-making process conducted by the consumers before a purchase (Mowen, 1988). When consumers purchase products or services, their decision may be affected by situations, such as searching for the products or services that can satisfy their needs. So, when consumers first identif扯 a certain, they start searching for information and evaluate alternatives to choose the best option for purchase to fulfill the need, and make an evaluation ofthe process afterwards (Blackwell et a/., 2006).

The idea of CDP, shown in Figure 1, was presented by Blackwell, Miniard, and Engel (2006). We use the theory as a framework for designing the questionnaire used in our study.

Figure 1

Consumer Decision Process

Need recognition

Infonnation Search

Altemative Evaluation

Purchase Decision


Post Purchase Decision



152 To Develop the Slralegies ollhe Medical Tourism Induslry in Taiwan by Using GRA and TRIZ: Ihe Japanese Consumer Viewpoint

At the first phase, needs are triggered by intemal and extemal stimuli. Then,

to meet their needs, consumers actively search for information about the way to fulfill them. After the search, they evaluate accordingly to their sense of value,

lifestyle, and living condition to decide whether they will make the purchase or not. During the purchase, consumers are going to decide where to purchase first;

their attitude could be affected by media, salespeople or exhibition of the product.

After the purchase, post-purchase decisions are made. Delighted consumers are satisfied with those products that meet their needs. On the contra哼, people who feel unsatisfied with the products, will dispose, recyc1e or resale their products.

Gurley et al. (2005) suggested managers can apply CDP to motivate consumers during making their decisions. ln business management, managers can distribute resources effectively to promote products in the market. To know more about relation between CDP and Medical Tourism, we will conduct further exploration through CDP model application in this sωdy.


Research Methodology



Dramaturgical Theory

Dramaturgical Theory is a theory that presents the interaction~ of entire society in dramaturgical way (Goffm恤, 1959). Grove and Fisk (1983) applied Dramaturgical Theory in their research in service industry. He developed the Dramaturgical Theory for service marketing. It is the interaction in “Performance" between Personal Front (“Actor" in Dramaturgical Theory), and Customers

(“Audience" in Dramaturgical Theory) in the same environment (“Setting" in Dramaturgical Theory).

We can tell that interaction between different elements in Dramaturgical Theory from customer viewpoint is important. Solomon et al. (1985) uses similar approach, as in Figure 2, as well. ln the next section, we combine Dramaturgical Theory with the first phase (“Need Recognition") from CDP to present its m句 or effects on Medical Tourism from customers' perspective.


Chiao Da Management ReviewVol. 30 No. 2. 2010 Figure 2 Dramaturgical Theory Actors Perfonnance Setting

Source: Grove et al. (1992)


Grey Relational Analysis


Grey Relational Analysis (GRA) is an analysis of the correlation between different discrete sequences within the Grey System Theory (Wu et al., 1996;

Zhang and Li, 2006; Kunga, and Wen, 2007; Zhai, Khoo, and Zhong, 2009; Tseng,

2010). In the research, we use GRA to find out the Key Success Factors that affect the behavior of The Japanese consumers in Medical Tourism services. Because Medical Tourism is not widespread in Taiwan yet, consumers in Taiwan are not familiar with its services. Relevant statistics and infonnation are limited.

Because of the lack of statistics, we cannot present a particular distribution pattern as we usually do in mathematical statistics. However


using GRA


statistics with non-typical distribution pattern is allowed (Wu et al., 1996; Zhang and Li, 2006; Lin, Lu, and Lewis, 2007; Zhai, Khoo, and Zhong, 2009; Tseng, 2010). Therefore,

we use GRA as a tool to identify critical factors that influence the way how The Japanese consumers participate in Medical Tourism in Taiwan.


Questionnaire Design and Sampling Methods

To conclude, we used CDP and Dramaturgical Theory to systematize our research. Then, we used questionnaires and GRA to identify the Key Success Factor in Medical Tourism in Taiw阻, and applied TRIZ theory to our conclusions in order to find the solution to the problems in Medical Tourism.


154 To Deve/op the Strategies 01 the Medica/ Tourism Industry in Taiwan by Using

GRA and TRIZ: the Japanese Consumer Viewpoint



Questionnaire Design

The questionnaire was designed based on the CDP theory proposed by Blackwell, Miniard and Engel (2006). Meanwhile, we combined it with Dramaturgical Theory (Grove et al.,(l992) to understand the interactions among the four elements - setting, actors, audience and performance - during the first CDP stage (“needs recognition"). Concerning that the Medical Tourism emphasizes human interactions


Dramaturgical Theory is to explain the interactions between purchase process and service. In this case


everyone in the

service has to play their part to make the process work smoothly and to make their customers satisfied. Figure 3 is the theoretical 企amework of the consumer questionnaire used in this study, and it consists of seven steps. The items developed in the questionnaire are shown in Appendix A.

4.2. Sampling

In our sωdy we have used convenience sampling. The questionnaires were

sent out to The Japanese citizens and The Japanese business travelers in Taiwan to get our samples. In total, we sent out 300 questionnaires, and received 225 back,

but only 212 of them being valid, including 146 企om The Japanese citizens and 66 from The Japanese businessmen in Taiwan. That gives us the response rate of 70.67%.

4.2.1. Distribution in Japan: Cooperate with The Japanese Local Academic Research Team to Distribute the Questionnaires

To make our research credible, we cooperated with professors and researchers ofKobe University, Chuo University, Yamagata University, Rakuno Gakuen University, Wakayama University, Tokyo University of Marine Science and Technology, Agricultural Research Center, and other educational institutions for assistance to distribute questionnaires to enhance the credibility of the quest\Onnmre.


Chiao Da Managemenl ReviewVol. 30 No. 2, 2010

Figure 3

Theoretical Framework of the Questionnaire Needs recognition

Information search

Evaluate the a1ternat凹的

Purchase Consume No good Rejection Rejection Add Dramaturgica1 Theory 1. setting 3.audience 2. actors 4.performance Satisfy the productlservice 155 Use the productlservice

4.2.2. Distribution in Taiwan: the Japanese Business Travelers in Taiwan We focused on over thirty of the Japanese business travelers staying in Taiwan for 1 to 3 years. To distribute 0叮 questionnaires among them, we have visited business hotels and The Japanese noodle shops in Taiwan to invite them to fil1 our questionnaires.


156 To Develop the Strategi臼 01 the Medical Tourism Jndustry in Taiwan by Using GRA and TR1Z: the Japanese Consumer Vìewpoint

5. Research Analysis

Firstly, we analyzed the Reliability and Validity of our questionnaires, and

then we carried the survey to investigate our samples and analyze their

characteristics. Afterwards, we used descriptive Statistics Analysis to better

understand consumer behavior, and used GRA to deterrnine the Key Success

Factor for Medical Tourism industry.

nE aE




- m-SSE



-m-M 叫叫一 -a-ME TEAU-ρLE M-S 且­ OE








R-CDP aspect Taiwan and Japan Taiwan Japan

Need Recognition Setting .89 .84 .85 .88 .70 82 .83 .85 64 .91 .88 84 .80 .84 .71 .75 .76 75 .74 .62 .45 .81 .76 70 Actor Audience Performance Information Search Alternative Evaluation Purchase Post-purchase Evaluation



Reliability and Validity Analysis

In our sample analysis, our reliability coefficient, based on Nunnally's

theory (1978), is considered high. Whenαis more than 0.7, it means high

reliability coefficient; when αlies between 0.7 to 0.35, it means reliability

coefficient is fair; when αis lower than 0.35, it means low reliability coefficient.


Chiao Da Management Review 的l. 30 No. 2. 2010 157

recognition" phases are fair


others are all high reliability coefficients

We have also high reliability coefficients. We have used Content Validity, which refers to the extent to which a measure represents all facts of a given social construct, and in addition, we took former researches as references, and we also interviewed experts and scholars to make our questionnaire more valid.

5.2. Sample Characteristics

We analyze sample population to realize the relation between consumers and Medical Tourism. Among both the Japanese in Japan and the Japanese businessmen in Taiwan, middle age and elder people spend more on real estate,

medical services and education expenses. From family's perspective, single parent families spend less money than traditional families do, while the purchase decisions in single parent families are mostly made by children (Etzel et al, 2006). Be\ow we summarize the profile ofthe both researched groups.

A. The Japanese in Japan: 64.4% of our samples are women; 54.8% of them owns bachelor degree; 27.4% of them are housewife; 25.3% of them are professionals; 19.9% ofthem are in the age between 30 to 34; 17.1% of them are between 55 to 59; 45.9% ofthem eam around 200,000 yen (about

1,800 U.S. dollars) 74.7% ofthem are married; 52.1% ofthem have 3 to 4 family members and 43.2% ofthem have 1 to 2 family members.

B. The Japanese business travelers in Taiwan: 78.8% of them are male; 54.5% of them owns bachelor degree; 40.9% of them do manufacturing as a job; 42.4% of them are between the age of 30 to 34; 28.8% of them eam 200,000 to 300,000 yen per month (about 1,800 to 2,700 U.S. dollars); 25.8% of them eams 400,000 to 500,000 yen per month (about 3,500 to 4,500 U.S. dollars.). 51.5% of them are not married yet; 63.6% of them have 1 to 2 family members.

5.3. Descriptive Statistics Analysis

In this part we analyze the “purchase" phase in CDP to better understand the Japanese consumer behavior. We looked into when they purchase, where they


158 To De闊的'p the Strategies 0/ the Medical Tourism lndustry in Taiwan by Using GRA and TRlZ: the Japanese Consumer Viewpoint

purchase, how they purchase, and how much do they purchase.

A. When they purchase: Statistics show that The Japanese consumers in both Japan and Taiwan attend to Medical Tourism mostly on weekends in succession or after their retirement. 33.6% of the Japanese in Japan suggested that they would like to take Medical Tourism on weekends in succession; 31.5% of them would take it after their retirement. In Taiwan,

40.9% of the Japanese would like to take Medical Tourism on weekends in succession; 40.9% ofthem would take it after their retirement

B. Where they purchase: Statistics show that 76% of the Japanese in Japan and 84.4% of Japanese in Taiwan prefer to take Medical Tourism service in medical institutes. As a human oriented industry, Medical service in medical institutes seems to have better care for customers with less danger or difficulties.

C. How do they purchase: Both the Japanese in Japan and the Japanese in Taiwan are aware of health insurance and organic food importance. The difference between them is the way to travel. 45.2% of the Japanese in Japan prefer to go on a tour, while 33.3% of the Japanese in Taiwan prefer to arrange trip themselves. We consider the difference depending on the oversea working experience, inc1uding the familiarity with local culture and formality for departing and arriving.

D. How much do they purchase: Since most ofthe Japanese respondents in our research are housewives, averagely, they do health examination once or twice a year. On the contrary, the Japanese in Taiwan are mostly business travelers, who do health examination half to once a year. Normally, The Japanese enterprises emphasize on health oftheir employees.


.4. Grey Relational Analysis

In this pa哎, we use GRA to determine the Key Success Factors (KSF) in the five phases of the CDP. The KSF theory was referred to by Daniel(l961), who indicated that the organization should take note of these factors, attempt to contribute to them. By implementing company's KSF seriously, there is a better chance to succeed. If not, there is a great chance of failure.


Chiao Da Management ReviewVol. 30 No. 2, 2010 159

We can find the gender difference in our samples analyzis above - 64.4% of the Japanese in Japan are female, while 78.8% ofthe Japanese in Taiwan are male. To avoid the deviation, we do the GRA separately. The difference shows in two aspects: “need-recognition and actors" dimension and “lnformation Research" dimensions. Other results are all more consistent. We are going to explain the differences in each CDP phase using GRA below.

A. Need recognition - Actors dimension

ln Table 2, Grey Relational Grade and Grey order show that the Japanese in Japan put more emphasis on tour leader's attitude than The Japanese in Taiwan. lt suggests that people in the latter group are familiar with Taiwanese culture than the former.

To put their grey relational order on line and group the factors with

c10se numbers, we get Grey Relational Grade figure (Figure 4). The black dots represent the Grey Relational Grade for each factor. There are five groups (named 1, 2, 3,4, 5) in Figure 4. According to the Daniel (1961) the optimum number of KSFs is 4 to 6, s叩o we can see the Japanese in Japan

regar吋d “M臼edica叫1 Profes鈞SIωoIn1,",:,

“Attiωd由e oftωou叮I汀r leaders'正,",, and “Attitude ofhealth care personnel" as KSFs. Therefore, we chose “Medical profession",“Commitment from health care personnel" ,“Attitude of tour leaders",“Attitude of health care personnel" and

“Appearance of tour leader" to be representative KSFs for the both surveyed groups.

B. lnformation research dimension

ln Table 3, samples of Grey Relational Grade and Grey Relational Order show that the Japanese in Japan acquire information of new products from

Books, newspapers and magazines." However, the Japanese in Taiwan rank it the second-last. We draw the inference that The Japanese in Taiwan are mostly business travelers who acquire latest information 仕om the lntemet.


160 To De間的'P the Stra但'gl臼 01 the Medical 加rism Industry in Taiwan by Using

GRA and TRIZ. the Japanese Consumer Vìewpoint

Figure 4

Grey Relational Line from The Japanese in Japan in Need Recognition-Actor





0.52 0.54 0.56 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76

Table 2

Grey Relational Grade and Order in Two Samples in Need Recognition

The Japanese in Japan The Japanese in Taiwan

Jterns Grey Grey Grey

Relational Re1ational Relational Grey Relational Grade Order Grade Order

卸ledicalProfession 0.7550 0.6490 2

Cornrnitrnent frorn health care

。 7528 2 0.7179


Anitude of tour leaders 0.7458 3 0.5417 8

Anitude of health care personnel 。 7458 4 0.6439 3

Tour leader 's skill 0.7366 5 0.5997 5

Tour leader's cornrnitrnent to travelers 0.7359 6 0.5615 6

Appearance of health care personnel 0.6582 7 0.5586 7

Appearance of tour leader 。.5560 8 0.6031 4

On the other hand, after our analysis, we found that The Japanese people in Taiwan regard

Medical profession"


Attitude of health care personnel" and


Chiao Da Management ReviewVol. 30 No. 2, 2010 161

Figure 5

Grey Relational Line ofThe Japanese People in Taiwan in Need

Recognition-Actor Dimension





0.52 0.54 0.56 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76 Table 3

Compare GRA Result Between The Japanese in Japan and The Japanese in Taiwan

the Japanese in Japan the Japanese in Taiwan

Items Grey Grey Grey Grey

Relational Relational Relational Relational

Grade Order Grade Order

Newspaper and magazines 0.6282 0.4949 11

Experts 0.6263 2 0.6263 4

Intemet 0.6092 3 0.6894

Experience 0.5986 4 0.6089 5

Media(Ex: news report) 0.5947 5 。 4924 12

Television 0.5816 6 。 6424 2

Relatives and 企iends 。.5734 7 0.6318 3

Packages or product exhibition 。 5708 8 0.5949 7

Advertisement 0.5676 9 0.6030 6

Public relations(Ex : workshop) 0.5278 10 0.5778 9

Consumer protection commissions(Ex

0.5226 11 0.5768 10 Consumers' Foundation)

Sales promotion 0.4979 12 0.5808 8

We put Grey Relational Grades out of the two samples on a line and group

the c10se numbers in groups. The data was divided into seven groups as shown in

Figure 6. According to Daniel's (1961) rule about the number ofKSFs, we choose


162 日 Develop the Strategies 01 the Medical Tourism Industry in Taiwan by Using

GRA and TRIZ: the Japanese Consumer Vìewpoint

Table 4

KSF From Two Samples on Medical Tourism in Taiwan

CDP dimension KSF Factor number

Need Recognition 一-settmgs Need Recognition 一-actors Need Recognition audience Need Recognition -performance Information Research Altemative evaluation Purchase Post-purchase Evaluation Medical equipment

Environment of medical institutions Decoration in tourist spots

Medical Profession

Commitment from health care personnel Attitude of tour leaders

Attitude ofhealth c訂官 personnel

Appearance of tour leader

Cooperation with health care personnel

Cooperation with travelers in the tour gro叫P

Cooperation with tour leaders

Service quality of medical institutions Sufficient medical service

A well-arranged travel group On newspaper and magβzmes

From experts On the intemet On television

From relatives and 仕iends After 甘它atrnentfollow-up


Operations or treatments work with日叫tmedical failure

In medical institution Through travel agency In representative 。但ce

Never join Medical Tourism again Tell others about the bad experien吋

Complain to ∞nsumer prote氾tioncommissions in Taiwan --AV'l-勻 , 包司且 A 斗-'、 JZO 弓,'。。 ny-AU--弓,必一句 3A 峙,、, -LU 弓,'。。 l23-45678-9ll-1All--Ill--222-222-222 FFF-FFFFF-FFF-FFF-FFFFF-FFF-FFF-FFF


Chiao Da Management ReviewVol. 30 No. 2, 2010 163

Figure 6

Information Research from The Japanese in Japan in Grey Relational



808 色


0.48 0.5 0.54 0.56 0.58 0.6 0.62 0.64

The "infonnation search" results of the Japanese in Taiwan in Grey Relational line are presented below. Data is divided into six groups. From Figure 7, we can tell t血ha剖t "可the Int健ermIn1edt'"':,

"Rela剖ti仰ves" are the



Figure 7

Information Research" from The Japanese in Taiwan in Grey Relational



S~主, 80


0.48 0.50 0.52 0.54 0.56 0.58 0.60 0.62 0.64 0.66 0.68 0.70

The Japanese in Japan share the same opinion with The Japanese in Taiwan.

The results for other phases (except the above two) prove this point. We draw the

inference that the Japanese in both Taiwan and Japan are no different in the

evaluation aspect because they grow up and live in the same environment.

Therefore, we combine samples from Japan and Taiwan to make the second GRA

and put the Grey Relational grade on a line. We group the data with close

numerical result in groups. According to KSF from Daniel (1961), we come to the

conclusion by finding 28 KSFs for all the CDP phases, presented in Table 4.

6. Apply TRIZ to Medical Tourism Development

ln this part, we will introduce TRIZ fir仗, and explain how to apply TRIZ to


164 To Deve/op the Strategies 01 the Medical Tourism lndustη in Taiwan by Using GRA and TRIZ: the Japanese Consumer Vìewpoint




"TRlZ" is the acronym for phrase in Russian. It means "The theory of inventive problem solving (Rantanen and Domb, 2002). It was first1y developed by a Soviet engineer and researcher Gemich Altshuller in 1946. In a problem formulation, TRlZ generates innovative ideas to solve the contradiction to make the whole system works smoothly. Contradiction refers to positive and negative contradictory results of an action (Zhang et al., 2005).

In our research, by using GRA, we have medical profession as our KSF in Medical Tourism. However, even the organization recognizes this factor as a KSF; health care personnel should take time to gain experience. In this case, it is a contradiction. That is, when we increase more medical profession in medical care for health care personnel need, they need more time. We can utilize TRlZ to solve the contradiction and make a new strategy

Researchers use Contradiction Matrix (see Appendix B) and F。此y

Inventive Principles (see Appendix C) in solving contradictions by using TRlZ. The Contradiction Matrix is a matrix composed of 39 improving parameters and 39 worsening parameters. (see Appendix D) According to Contradiction Matrix, users can find out the solution of contradiction in it.

Forty Inventive principles are conc1usions from four hundred thousand patents. It is widely used in other fields such as business, service industry, quality control, education (Marsh et al., 2004). Other experts like Teminko (2001) in social science, Belski et al. (2003) in public health, Dourson (2004)in finance, and Retseptor (2005) in marketing and advertisement use this as well. According to their professions and background, they develop different strategies to solve the problems they faced.

6.2. Apply TRIZ Theory to Medical Tourism

After determining KSFs for Medical Tourism in Taiwan, we are going to tum these factors into key problems. We do it because when people are promoting Medical Tourism through KSF, there are problems and difficulties on the way. Therefore, it would definitely be helpful to find and solve them beforehand. These


Chiao Da Management ReviewVol. 30 No. 2, 2010 165

problems and difficulties are named key problems, and we are going to

systematically find out solutions to them. There are two ways to transfer the KSF to key questions. One is one-to-one mapping approach. Take medical equipment (Fl) 的 an example: Though it might be helpful to offer patients a better diagnosis

and treatment, medical personnel might also need time to get accustomed to these

equipment, the whole medical room needs to be rearranged as well. These

changes could make the whole medical service unstable for a period of time. In

this case, we transfer Fl to Pl (Problem 1), where Pl means to

“upgrade the

facilities of medical institution" (Pl). The other approach is to combine factors with similar contradictions, such as "the environment of medical institute" (F7),

"the quality of health care personnel" (F8), and "provide the medical service with no medical failure" (F9). These factors can be presented as to improve

service quality of medical treatment, which is our key problem (P7). Finally, we

conc1ude 15 key problems out of28 KSFs (see Table 5).

Next, we are going to apply TRlZ theory to fínd out solutions to 15 key

problems, and we take the

“upgrading the facilities of medical institution" (Pl)

and “Emphasis on appearance oftour leaders" (P4) as examples.

6.2.1. Upgrade the Facilities of Medical Institution (Pl).

A. Description of the problem: upgrading the facilities of medical institution (Pl)

In Table 5, KSF

“Upgrading the facilities of medical institution (F 1)" is to

improve the quality and quantity of Taiwan's medical facilities; however,

before reaching this goal, we need to upgrade Taiwanese medical facilities.

So, the key problem is

“Upgrading the facilities of medical institution (P 1)'\

With the advanced technology and sophisticated medical facilities, we can

provide a better diagnosis and treatment for patients. On other hand, when

the facilities of medical institutions are not advanced enough, it will be hard


166 To Deve/op the Strategies 01 the Medica/ Tourism Indl叫ry in Taiwan by UsingGRA and TRlZ: the Japanese Consumer 的 KSF F1 F3 F4 F8 F10 F16 F2 F12 F22 F5 F6 F7 KSF Key prob1emss Table 5

Key Questions


Strategies and Performance Phases

lmprovmg parameters

worsenmg parameters

U sab1e inventive Chosen inventive

prob1em solvin略 prob1em solving

princip1es princip1es



Upgrading the According to the need of customers

faci1ities of medica1 39 13 35, 3, 22, 39 3 and take Japan as a referen必 ω

lnstitution (P 1 ) improve medical 閃uipments(S1 )

Arrangement in

tourist spots (P2) 12 17 22, 14, 19,32 14

Combine Japanese and Taiwanese C祖 lture in the spot and provide interactive services with tourists (S2)

Medical Profession ..,,, ..,c ~.., ..,,, ..,0 10 ..,,, Deve10p knowledge management

29 25 32, 26, 28, 18 26

(P3) --, --, --, -- system (S3)

Appearance oftour

世坐監立企 12 33 32,15,26 15 Design comfo前able uniforrns(S4)

Characteristics of 1 " ~ 1 1 ~ ~ ~" .., A .., A Deve10p customer re1ationship

10 31 13, 3, 36, 24 24

customers (P5) --, -, --, _. management system (S5)

Professionals' Influence (P6) Improve service quality of medical treatment (P7) Service attitude (P8) Key prob1emss 14 28 17 lmprovmg parameters 11 35 19 worsemng parameters 13, 17,35 35 13,35,2 13 19, 15, 17,3 17

Usab1e inventive Cho唱 en inventive

prob1em solving prob1em solving

principles princip1es

Deve10p focus service target based on Taiwanese and The Japanese


Make abstract service concrete(S7)

Apply total appraisal to improve the attitude of servers(S8) strategy phases medium medium short short 10ng 10ng short short phases


Chiao Da Managemenl ReviewVol, 30 No, 2, 2010 167 F9 Fll F13 FI4 F20 FI5 FI8 FI7 F21 F23 F24 F25 F28 FI9 F26 F27

Make the service procedure flexible (P9) 8uild a sound workflow (PIO) 35 33 37 12 15,34,29,28 28

Make customers part ofthe procedure(S9) Build a Taiwan-Japan e-communication platform to

Improve workflow (S 1 0) Improve the The story marketing shωId base on

甘adit的nal chaIHEEls l S 5 l 9,3 2 2 6 3 2 t h e culture ofTa1wan and Japmjnd

for information O J, J _ , -~ launch a series of contents of medical

Search (P II ) tourism services (S 11)

The use of internet 38 36 15. 24. 10 10 Build a good environment for online

tm加101010'(PI2) "-, - " 甘組saction(SI2)

Expand the local " ~~ " ,~ ~~ ~O , , Develop th晦 relationshipwith 27 11,35,27,28 11

channels (PI3) ""' J J , -', -~ partners to work together (S 13)

Build direct __ "_ __ "_ Build a customer service center with 30 37 22, 19,29,40 22

channels (PI4)





, "


functions ofthe channel (SI4) Effect of human

networki月 (PI5) 21 24 10, 19 19

Develop customer relationship management system (SI5)

long medium long medium medium medium long


168 To Develop the Strategies 01 the Medical Tourism Industry in Taiwan by Using GRA and TRlZ: the Japanese Consumer Vìewpoint

B. Definition of contradictory attribute of a question

(A) Improving parameters : Parameter 39 (productivity)

Upgrade the facilities of the medical institute wil\ not only provide an accurate diagnosis but also a better treatment. This wiU improve the whole medical system by obtaining customers satisfaction with the treatment.

(B) Worsening parameter : Parameter 13( Stability ofthe facilities.)

Health care personnel have to be familiar with those upgrading facilities and devices in order to improve diagnosis and treatment. Thus, it is essential for healthcare personne\ to keep leaming to get accustomed to those facilities and devices. Furthermore, purchasing new facilities might change the whole environmental layout, or even effect on the stability of the whole medical system.

C. From the contradiction matrix to obtain principles out of 40 innovation principles.

According to the worsening parameter and the improving parameter above,

the counterparts are in Table 6 below. Other key questions and their worsening parameters, improving parameters and innovation principles are in Table 5.

D. Apply the principles found in 40 innovation principles

(A) Principle 35: Changing parameter, this is to distinguish changes in each phase according to the result. From management viewpoint, it is sa\es promotion with special discount (Retseptor, 2005)

(B) Principle 3: Partial quality, this is to make partial instruments and systems work more efficiency. From management viewpoint, it is to use differentiated market tactic to different markets (Retseptor, 2005).

(c) Principle 22: To tum worsening factors improving ones, it is to take advantage of the inferior factors, and make it effect positively. From management viewpoint, it is to change customers' compliant into the improvement of the organization (Retseptor, 2005).

(D) Principle 39: Inert environment: To replace regular environment by inert environment. For example, in market research, use anonymous questionnaires to enhance the recovery and make them less nervous or


Chiao Da Managemenl ReνiewVo/. 30 No. 2. 2010

insecure. From management viewpoint, it is to use anonymous questionnaire or interviews to know the solutions to problems (Retsepor, 2005).

E. To deve\op strategies based on the principles found in 40 innovation principles


According to Table 6, we understand that key problem can be corresponded to 4 innovation principles. However, considering of the viability when it is applied on Medical Tourism, we choose one of the principles as a solution to solve the key prob\em. So, we adopt innovation principle 3

\oca\ quality." That is,

to make each part of the object or system become easier to be operated, making each part of the 0句 ect or system perforrns di位erent and providing diverse functions. We suggest that when it is applied on the strategy development of Taiwan's Medical Tourism services, it should meet the target consumers' needs. For example, for middle-aged consumers, cancer screening test can be added to the health check. To have better detection of cell mutation, rnedical instruments with high detection rates should be purchased such as ultrasound, blood test apparatus etc. This will provide better detection for patients. In this field of detection technology and cure, the Japanese have superior techno\ogy than Taiwan because of their average life expectancy is longer. As a result, the strategy that we should deve\op is to "meet the need of customers, \eam the Japanese technology, and introduce new medical facilities (Sl). Other core problems and their strategies are presented in Table 5.

6.2.2. Emphasis 00 Appearaoce ofTour Leaders (P4)

A. Description ofthe question: Emphasis 00 appearance oftour leaders (P4) In Table 7, with neat and tidy uniforrns, emphasis on appearance of tour leaders (P4) can not only make good impression among customers but also make tour leaders look more professional. In general, Taiwanese tour leaders are more passionate and outgoing. Norrnally, they just put on casual c10thes on duty. Compared to Taiwanese tour leaders, most of the The Japanese are wearing uniforrns in service industry, like The Japanese taxi drivers. For us, Taiwanese should make their customers a professional


170 To Develop the Strategies 01 the Medical Tourism Industry in Taiwan by Using GRA and TRIZ: the Japanese Consumer Viewpoint

lmpresslOn on tounsm,

B. Definition of contradictory attribute of the question (A) Improving parameter: Parameter 12, shapes.

Charming packages attract people. Similarly


how to make us charming is the first step of making a good impression. Appearance of tour leaders shows their profession and reliability to tourists. Therefore,

improving their appearance makes a positive impression for tourism service in Taiwan,

(B) Worsening parameter: Parameter 33(easy to work)

Tour leaders play important roles during the journey. They should be capable of dealing with emergencies and taking charge of complicated assignments. Therefore, light and casual clothes may be suitable for them to work outside. Relatively, travelers may be doubtful of their profession of tour leaders or even about other services when they dressed light and casual clothes.

C. Find corresponding 40 innovation principles from contradiction matrix

According to the results of improving parameters and worsening parameters above


other key questions and their coηesponded improving parameters


worsening parameters and innovation principles are listed in Table 7. D. Develop strategies according to 40 innovation principles.

E. Develop comfortable uniform designing strategy for appearance of tour leaders

We take innovation principle 15, movement, to balance both the tour system and the service. While applying this theory to develop strategies of Medical Tourism in Taiwan, we suggest that uniform should be designed comfortable for employees to wear. Due to the connection of employees' appearance and image of enterprises


uniforms could be designed with special marks of their brands According to employees' departments, uniforms could be designed differently as well. For instance, enterprises can use same marks or images on polo shirts for tour leaders and t-shirts for administers. Consistent uniforms make customers impressed by the brand of the enterprise.


Chiao Da Management ReviewVol. 30 No. 2. 2010

Table 6

The Contradiction Matrix of

Upgrade the Facilities of Medical Institution (Pl)"

The worsening parameter

Parameter 13 : Stability of object


( Stability of healthcare workers ωadaptωthe The improving parameter

Parameter 39 : Productivity

( Improvement of medicalservices )

mw facilities)

Prin叫ple 35: Transfonnation of the physical and ch叫nicalstates of an object

Principle 3 : Local Quality

Principle 22 Convert hann into benefit Principle 39 : Inert environment

Table 7

Contradiction Matrix of Emphasis on Appearance of Tour Leaders (P4) wOrsening parameter

Improving parameter

Parameter 12 : Shape

(Professional image make tour leaders reliable)

Parameter 33, easy to work

( Appearance can make difference about how ωur leaders work)

Principle 32 : Change the color Principle 15 : movement Principle 26 : Duplication

7. Develop Short


Medium and Long-Term Strategic

Implementation Goals.

In order to implement the 15 strategies in Table 5 effectively, we establish goals for the short, medium and long-term phases based on the experience in Taiwan. The method to differentiate the three phases is in the paragraph below:


172 To Develop the Strategies



the Medical Tourism lndustry in Taiwan by Using GRA and TR1Z: the Japanese Consumer Vìewpoint

requires to be notified because it's in initial phase. The medium-tenn phase inherits the past and lead to the future. In the medium-tenn phase, it takes over constructions in the short-tenn phase and strengthens for the long-tenn development in the future. The main point of long-tenn stage is to help Taiwanese promote the development in the future in this industry. Therefore, the implementation strategies are as follows:

A. The short-tenn goal: To cultivate people in Medical Tourism in Taiwan for serving the overseas Chinese in Japan, the strategies that we suggest are S3,

S4, S7 and S8.

Since Medical Tourism service in Taiwan is in initial phase in global market, domestic healthcare personnel are not ready to serve international patients yet. Therefor巴, the short-tenn goal can focus on the overseas Chinese in Japan as our target customers and encourage them to take Medical Tourism services. We are promoting the strategy,“making intangible service tangible" and present the profession in Taiwan's Medical Tourism service to patients all over the globe. Meanwhile, to make our healthcare personnel accumulate their experiences in intemational service, we should

develop knowledge management system" and

applying total appraisal to improve the attitude of servers". By these two strategies, members learn and grow through knowledge management system; moreover, we encourage them by diverse perfonnance evaluation. In addition, taking employees' welfare and consumers' need into account, we can meet the both demands by

“designing comfortable unifonns".

B. The medium-tenn goal: Establish the hardware and channel network in Taiwan's Medical Tourism services, so the strategies we suggest are Sl, S2,

SlO, S12, S13 and S16.

When the market of the overseas Chinese is progressing step by step,

the market of the non-overseas-Chinese can be further developed (ex: developed countries such as EU countries and Japan). In order to make Taiwan's Medical Tourism more competitive, basic construction is highly valued before accessing to the market of the non overseas Chinese:


Chiao Da Management Review Vl划'. 30No. 2, 2010 173

Taiwan's Medical Tourism; improving current quality in service to develop long-term marketing strate斟酌. We take the

need of target customers" and

introducing The Japanese technology with new facilities" as our reference, aiming at The Japanese market because of their rapid pace of living and the great number of hypertensive patients. Seeing The Japanese as our target customers, we purchase precision instruments to detect or treat hypertension. This will improve health care of The Japanese tourists in Taiwan, enhancing the current quality of medical services.

C. The long-term goal: In order to serve non-overseas-Chinese customers in Taiwan's Medical Tourism, the strategies that we suggest are S5, S6, S9,

SII and S15.

In order to gain competitive advantages in global market of Medical Tourism, domestic medical institutions need to find more target customers who are non-overseas-Chinese. Hence, in this phase, we develop the long-term plan aJmmg at intemational customers. Take the strategy of

building customer database system" as an example, medical institutions can develop or enhance intemational customers' intention to visit Taiwan for another Medical Tourism service by analyzing customers' characteristics, preference or attitude from the customer database system, and then they can develop new Medical Tourism services. Take The Japanese market as an example, statistics shows that most ofthe families in Japan are small families. When Taiwan's Medical Tourism designs the whole set of services for adults, we could also design services for children. For instance, weight loss camps can solve the problems such as obesity and overweight among current children for loving to eat fast food.

8. Conclusions

Medical Tourism has been a new 句pe of innovative industry around the globe in 21st century. In our research, we take the consumer's perspective ofthe Japanese consumers as to develop the strategies for Medical Tourism in Taiwan. To prove our point and make it both valid and credible, we apply the CDP to


174 To Develop the Strategies 01 the Medical Tourism Industry in Taiwan by Using

GRA and TRlZ: the Japan自e Consumer Vìewpoint

design the questionnaire distributed among the Japanese. Using the GRA we have determined KSFs for Medical Tourism in Taiwan and turned them into the key problems. Finally, we used TRIZ theory to make short-, medium- and long-term strategies to systematically promote its development.

According to the strategies presented in the paper, we suggest that the size and features of the Taiwanese medical institutions, such as medical centers,

regional hospitals, district hospitals, clinics and all other medical institutions,

would be categorized to develop their own strategies. Due to their differences in levels and scales, these medical institutions' resources would be different. We recommend that when discussing a strategic problem of Medical Tourism,

researchers assist the Taiwanese medical institutions to do market segmentation and benefit the whole medical industry in Taiwan.

Secondly, we suggest that researchers can in future apply supply chain theory to satisfy supply and demand of Medical Tourism. For example,

post-purchase activities is an interesting research direction. Because Medical Tourism is related to medical service, it can lead to malpractice lawsuit caused by careless medical care, which rnight influence the whole Medical Tourism industry. Hence, it is advisable to use supply chain to realize customers' attitudes and lifestyles after their returning to their own countries.

At last, from supply aspects, post-purchase activities can let us realize the relation between supplier and the Taiwanese Medical Tourism service providers. For the Taiwanese organizations in this indust哼" to open the local channels, it is very important to choose suppliers carefully. To seize commercial potential,

choosing a channel is one of the most crucial matters. For those companions who offer medical service for homecoming consumers, both them and their suppliers should offer consistent quality of medical services. From the consumers point of view, all the follow-up services are also related to the Taiwanese Medical Tourism. Accordingly, services of the suppliers and retailers should be well integrated to make it more efficient. This can make the Taiwanese Medical Tourism play an important role in the medical services ofthe world.


Chiao Da Management R仰的Ii Vol. 30 No. 2, 2010 175


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Aspects Need recogmtlOn

To Deνelop the Strategies


the Medical Tourism Jndustry in Taiwan by Using GRA and TRlZ: the Japanese Consumer Viewpoint

V盯iables Dependency References

Devices in medical institute such as high-tech medical equipment Devices

Facilities in tourist spots such as toilets,

chairs and tourist center.

Decoration of medical institute in the environment


Arrangement in the tourist spots such as

Eroglu and Machleit(l993),

controlling the number of people Arnould and Price(l993), settmg John(l996),

A sanitary enviromnent of medical Wakefield and Blodgett( 1999), mstItute Lockyer(2005)


Prcscrvation of thc tourist spot.

Distance between one tourist spot and another


Arrangement of medical institute in the environment like the distance between treatment room and waiting room

Actors Clothing of the healthcare personnel. Grove el al. (1992),



Clothing of the tour leaders

Attitude of the medical personnel


A仕itudeof the tour leaders

Profession of the healthcare personnel.



Chiao Da Management Review 制 30No. 2, 2010 181

Aspects Variables Dependency References

Commitment from health care personnel Commitment to


Commitment from the tour leaders

Reasons for For health promotion. joining Medical


For travel

Cooperation with the health care personnel Parasuraman et al. (1985),

Audi- Actions during Grove et al. (1992),

ence Medical Tourism JohnGarbarino (l996)an, dJonson( 1999),

Cooperation with the tour leaders Wu(2007)

Whether patients like social interaction Interactions during Medical Touris肌


customers Whether travelers like social interaction during Medical Tourism

Schedule of medical treatment works smoothly or not

Time arrangement

Grove et al. (1992),

Perfor- Schedule of tourist spots works smoothly John( 1996),

rnance or not Bitner et al. (1997),

Blackwell et al. (2∞6)

Service quality in tourist spots. (Ex Service quality Famous ancient monuments or


182 To Develop the Strategies of the Medical Tourism Indust砂 in Taiwan by Using GRA and TRlZ: the Japanese Consumer Viewpoint

Appendix A Items Developed in the Questionnaire (continued 1

Aspects Variables Dependency References

Service quality in medical institutions. (Ex. Service quality Secure Socket Layer or certification of


Well-arranged medical service

Need Perfor- Processing

recogmhon mance Well-arranged travel service

Overall atmosphere during medical Synthetic treatment


Overall atmosphere during the travel

Personal I used to make a guess about the new experience and product depending on my personal

knowledge experience and knowledge

Relati ves and 仕iends are the main resource Interpersonal of my new inforrnation.

relationship Experts are the main resource of my new inforrnation

Mass media are the main resource of my new inforrnation

(Ex: News Report)

Public relation like school or inforrnal Public media discussion meetings are the main reSQurce

of my new infol1l祖hon

Larson(200 1),

Consumer protection commissions (Ex

Inforrnation Consumers' Foundation) are the main Blackwell et a/. (2006), Kotler and Kelle呵2006),

Research resource of my new inforrn-"tion Translated from English by Lou I receive the info口nationof the new product and Fang

from advertisement

I receive the inforrnation of the new product

on television

Business 1 in newspaper receive the inforrnation and magazines. of the new product Inforrnation

resource 1 receive the inforrnation ofthe new product on mtemet

1 receive the inforrnation ofthe new product

from packaging or product e沿libition. I receive the inforrnation of the new product from sales promotion

Purchase evaluation Location Convenience to purchase at the store. ( Ex: Park and Snlith (1989), (distance) easy to find a parking space) Blackwell et a/. (2006),


Chiao Da Management ReviewVol. 30 No. 2, 2010 183

Aspects Variables Depend個cy Refer電配es

Convenience 10 purchase on Ihe inlemel Kotler and Keller(2∞6) (Ex: simple 10 place an order on line) Translated from English by Lou

and Fang, Parasuraman el al. * Security 10 purchase online (Ex: Make sure (1988),




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