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QFD application using SERVQUAL for private

hospitals: a case study

Article in Leadership in Health Services · July 2013

DOI: 10.1108/LHS-02-2013-0007

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QFD for private

QFD application using hospitals
SERVQUAL for private hospitals:
a case study
175
Hatice Camgöz-Akdağ
Management Engineering Department, Faculty of Management, Received 7 February 2013
Istanbul Technical University, Istanbul, Turkey Accepted 8 February 2013
Mehveş Tarım
Department of Health Management, Faculty of Health Sciences,
Marmara University, Istanbul, Turkey
Subash Lonial
Department of Marketing, University of Louisville, Louisville, Kentucky, USA, and
Alim Yatkın
Fatih University Hospital, Istanbul, Turkey

Abstract
Purpose – The purpose of this paper is to describe how quality function deployment (QFD)
methodology was employed for translating customer needs and expectations into the quality
characteristics in a private healthcare setting. This case study illustrates how an existing approach of
SERVQUAL and QFD integration can be applied for quality improvement.
Design/methodology/approach – Integrating SERVQUAL into QFD to set the success factors to
improve quality in the healthcare industry is the main aim of this paper. A privately-held university
hospital, within the city of Istanbul in Turkey, was selected as the sampling frame. A
SERVQUAL-type of questionnaire was used and a total of 250 questionnaires were distributed and
210 of them were received. Usable responses were 170, comprising a response rate of 68 percent.
Findings – From the results of the QFD application it is seen that behavior and attitude of staff has
the highest weight score, meaning that when behavior and attitude of staff is improved there will be
almost 25 per cent of improvement in the hospital. Another finding was that there is strong
relationship among skills of physician, behavior and attitude of staff, and having enough modern
equipment.
Research limitations/implications – QFD technique is able to provide hospitals with a better
understanding of customers’ expectations to translate these expectations into appropriate service
specifications and perform existing process assessment.
Originality/value – The case study was a first attempt to apply this integrative approach to a
service sector and thus offers practical and applied information useful to both academicians and
practitioners.
Keywords Health care, Turkey, Private hospitals, Customer requirements, Quality, SERVQUAL,
Quality function deployment
Paper type Case study
Leadership in Health Services
Vol. 26 No. 3, 2013
1. Introduction pp. 175-183
Quality of healthcare has become the latest hot topic everywhere. It is one of the fastest q Emerald Group Publishing Limited
1751-1879
growing industries in the service sector. It is also widely known for its huge concerns DOI 10.1108/LHS-02-2013-0007
LHS about the quality of service. In the healthcare industry, all hospitals provide the same
26,3 type of service, but they do not provide the same level of quality of service (Lim and
Tang, 2000). The quality of services-both technical and functional- is a key ingredient
in the success of service organizations.
With increasing pressure of competition and necessity to deliver satisfaction
demanded or expected by the patients, the elements of quality control, quality
176 assurance and effectiveness of medical treatments have become a vitally necessity. It is
difficult for patients to identify and prioritize their expectations and for management to
include these expectations in the service package (Lim et al., 1999). Quality function
deployment (QFD) technique is available to provide hospitals with a better
understanding of customers’ expectations translate these expectations into
appropriate service specifications and perform existing process assessment.
This study employed Quality Function Deployment methodology for translating
customer needs and expectations into the quality characteristics. The paper suggests
an approach which is integrating SERVQUAL into QFD to set the success factors to
improve quality in the healthcare industry.

2. Literature survey
Service quality has received a significant amount of attention by both researchers and
practitioners. The interest in service quality has been influential in contributing
significantly to the growth of the general service marketing field. In business literature,
the customer’s perception of quality has been the major focus in studies completed on
service quality. Hence service quality is often conceptualized as the comparison of
service expectations with actual performance perceptions (Bloemer et al., 1999).
Customers evaluate service quality by comparing the service level they receive, against
both the service level that they would have preferred (or desired) and the service level
they are willing to accept (Tan and Pawitra, 2001).
On an operational level, research done on service quality has been dominated by the
SERVQUAL instrument, which is based on a so-called gap model. Gap model
recognized today as a major contribution to the service management literature
(Parasuraman et al., 1985). SERVQUAL is designed by Parasuraman et al. (1988) to
measure service quality as perceived by the customer. Through an empirical test,
Parasuraman et al. developed SERVQUAL from a modification of ten dimensions
proposed in 1985 to five dimensions in 1988. These are tangibles, reliability,
responsiveness, assurance, and empathy. In their study, the data on the 22 attributes
were factor analyzed and resulted in five dimensions (Parasuraman et al., 1991). After
Parasuraman et al. proposed SERVQUAL, James Carmen adapted the original
SERVQUAL instrument for use in the hospital industry. The original 22 questions
were extended to 34 questions.
As stated by Tan and Pawitra (2001), SERVQUAL is not designed to address the
element of innovation and even though it provides important information on the gaps
between predicted service and perceived service, it is not able to address how the gaps
can be closed. Tan and Pawitra (2001) also added that it would be good if SERVQUAL
can be integrated with other service quality tools that are more focused on reducing the
service gaps.
Quality Function Deployment (QFD) is a literal translation of the Japanese words
hinshitsu kino tenkai, but was initially translated as quality function evolution in 1978
(Mizuno and Akao, 1978). At the first QFD seminar in the USA (Akao et al., 1983), QFD for private
Masaaki Imai felt that the term evolution inappropriately connoted the meaning of hospitals
“change” and that hinshitsu tenkai was better translated as quality deployment (Akao
and Mazur, 2003). QFD is an established and well-known methodology which
translates the “voice of the customer” or customer needs (the “whats”) into its means of
accomplishment within an organization (the “hows”) (Hamilton and Selen, 2004).
In the literature, there have been many examples of combining SERVQUAL. Kano’s 177
model and QFD have been used in different ways and in different industries. Tan and
Pawitra (2001) propose and integrated approach involving SERVQUAL and quality
function deployment for evaluating the image of Singapore from the Indonesian
tourist’s perspective.
The approach aims to help organizations to evaluate customer satisfaction, to guide
improvement efforts in strengthening their week attributes, and to expedite the
development of innovative services through the identification of attractive attributes
embedding them into future services. Franceschini and Terzago (1998) determined the
needs of all actors playing different roles in industrial training courses within the Kano
model and converted these needs into design characteristics using QFD. Matzler and
Hinterhuber (1998) followed a similar methodology for the ski industry.
Literature also includes many examples of integration of SERVQUAL and QFD in
different ways. Lim et al. (1999) adopted SERVQUAL and QFD performance
measurement in Singapore and used the empirical findings as an input for QFD in the
process of designing services based on customer expectations for hospitals. Sahney
et al. (2004) applied SERVQUAL to identify the gap between customer expectations
and perceptions of the actual service received. Afterwards the QFD technique was then
used to identify the set of minimum design characteristics/quality components that
meet the requirements of student as customers of the educational system. In addition
Baki et al. (2009) used SERVQUAL and Kano model to see how well the service quality
attributers are able to satisfy customer needs and findings were transferred to QFD.
As the present case study was held in a private university operating in Istanbul,
Turkey; some valuable information on this industry is given at first, as follows.

3. Healthcare in Turkey
The healthcare delivery system in Turkey faces serious challenges: among them -
improving service quality, being more customer-focused, increasing access and
reducing costs are at top ranks. Since the 1990 s, the healthcare market in Turkey has
been undergoing a gradual change from a seller-oriented to a buyer-oriented market
due to the increasing influence of insurance companies, consumer organizations and
public pressure. The healthcare organizations are public, quasi-public, private and
philanthropic organizations, but relations among them are not well structured or
regulated.
Private hospitals and clinics are mostly collected in major cities and luxury
neighborhoods. About two third of hospitals are located in Istanbul.
Even though there are plenty of rules and regulations for hospitals and clinics it
should be stressed that there is no single standard to audit these systems and evaluate
the quality of healthcare in Turkey. In addition to this neither the state nor the private
hospitals are audited or controlled by real means for their medical applications (Cetik
et al., 2004). According to Cetik et al. (2004), the absence of standards, control, audit and
LHS evaluation results in the reality that the patients’ diagnosis and treatment processes are
26,3 minimized to only the capacity, information, and ethics of the doctor and hospital staff.
Cetik et al. (2004) include that as there is no standard for healthcare in Turkey; success
is perceived as the relative quality of paramedical service.

4. Methodology
178 In order to achieve a proper understanding of the concept and a concrete evaluation of
the previously-mentioned targets, at first a literature review was carried out and a
questionnaire was constructed and used.

4.1 The case study

A privately-held university hospital within the city of Istanbul in Turkey was selected
as the sampling frame of this study to translate the customer expectation and needs.
Participants were selected randomly by using simple random sampling. The
respondents that were eligible to be selected were customers being admitted as
in-patients. There were no diagnostic limitations on patient selection. However,
customers who were in a critical state of health or those who were unable to respond to
the questionnaires and did not have any family members to assist in answering the
questionnaires were excluded. Total of 250 questionnaires were distributed and 210 of
them were received. Usable responses were 170, comprising a response rate of 68
percent at the hospital level. The majority of the respondents completing the
questionnaire were in fact patients present in the hospital.

4.2 Survey instrument

A survey was conducted to measure service quality in the private healthcare setting in
Istanbul Turkey. To enable this study to be conducted, the survey instrument used is
the SERVQUAL 5 dimensions model, adapted as recommended by Parasuraman et al.
(1985). The SERVQUAL-type of questionnaire for use in the private healthcare sector is
constructed by retaining some items from the updated SERVQUAL dimensions.
Selected items are refined and paraphrased in both wording and contextual
applications as appropriate for this research.
The questionnaires were designed in a Likert scale five-point format ranging from
“completely disagree” (1) to “completely agree” (5). This instrument includes 25 items
for the expectations scale and the same 25 items for the perceptions scale.
The results of the questionnaire were then used to integrate the findings from the
SERVQUAL instrument into QFD to set the success factors to improve quality in the
healthcare industry.

5. Analysis and results

Application of QFD to healthcare satisfaction is described step by step as follows:
(1) This step focuses on understanding the customer. This information is refined
and then a second subset of the information becomes the input for the second
step. For this paper, customer (patient) expectations were determined by 170
patients with survey.
(2) This step involves gathering the voice of the customer and understanding the
context in which customer makes statements. The purpose of this activity is to
establish a clear understanding of all customers’ needs and expectations,
 particularly the subjective performance. After understanding all customers’ QFD for private
needs and expectations, these customer needs, expectations and weights must
be rated over 9.
hospitals
(3) In this step, technical requirements related to customer expectation were
determined and explained. Technical requirements are very important for QFD
analysis because engineers and experts consider these requirements when they
struggle to meet the customer expectations (Kurtay, 2005). To determine the 179
requirements, experts from different departments should work together.
(4) After determining the technical requirements, experts constructed the
relationships between customer expectations and technical requirements
keeping in mind the importance of ratings and direction of improvement that
were crucial points for QFD analysis. This information was evaluated and
determined by experts.
(5) Physicians and experts of the hospital defined which customer expectations
were related with which technical requirement. The resulting relationships,
direction of improvement and importance degrees are shown in Figure 1.
(6) In the sixth step, experts calculated the technical importance degree of each
requirement. These values are calculated for each technical requirement
as summation of the importance degree of customer expectation which has
relationship with the technical requirement multiplied with the weight of
relationship.
The formula is as follows:
S Technical Importance Degree ¼
S ðImportance degree of customer satisfaction
£ Weight of customer expectationÞ
As the questionnaire was formed with seven Likert scale, the response to each
question was giving the important degree for each related customer expectations.
The relative weight of customer expectations were the percentage explained for
each importance degree response.
(7) Maximum relationship degree is the degree of relationship between the
customer expectation(s) and technical requirement(s). If no relationship is found
between customer expectation and technical requirements, the components of
customer expectations are deleted from the matrix to save space. Direction of
improvement for technical requirements are symbolized with an upward
triangle, downward triangle and an X. Upward triangle means needs
improvement by increasing the relationship. While a downward triangle
means for improvement one should decrease for example the waiting time of
patient. If it is decided that there is no need for improvement then that
requirement direction of improvement is shown with an X. Also provided are
the calculated degrees of importance, relative weights and maximum
relationship degree and matrix and direction of improvement.
(8) In addition to the information given in the house of quality matrix, it should
be realized that there can be a relationship between each technical
requirements in itself. Improvement for one technical requirement can also
LHS
26,3

180

Figure 1.
House of quality for a
private hospital

indirectly or directly affect another technical requirement positively or

negatively or vice versa. These correlations among technical requirements are
described in Figure 1, using a correlation matrix which also forms the roof of the
quality house. Four different symbols are used in the correlation matrix to
illustrate the relationship. For a strong positive correlation a double positive
symbol (þ þ ), for a positive correlation a single positive symbol (þ ), for a strong
negative correlation two negative symbols (2 ) and for a negative correlation a
downward triangle symbol is used. After the relationship is figured out among
technical requirements the symbols are placed on the roof of the house of quality.
The house of quality matrix illustrates which technical characteristic has
positive or negative relationship with other technical requirements.

This approach helps identify the minimum set of technical requirements of hospitals to
meet the various customer requirements, in turn leading to a cost-effective means of
improving quality – quality as perceived by the customers.
 Application of QFD to healthcare satisfaction is shown in the house of quality QFD for private
(HOQ) illustrated in Figure 1. hospitals
Figure 1 shows the customer requirements, technical requirements, maximum
relationship degree, relative weight of relationships, improvement direction and
correlation among technical requirements. For example; it is obvious that there is
strong relationship among skills of physician, behavior and attitude of staff, and
having the modern equipment available have impacts in the final results. There is a 181
lower relationship between doctor attitudes and modern equipment used in hospital,
but still it must be realized that there is a relationship, which means the modernization
of equipment has a slight effect on doctor attitude.
When the relative weight of column is analyzed, it is seen that behavior and attitude
of staff has the highest weight score; meaning that when behavior and attitude of staff
is improved there will be almost 25 percent of improvement in the hospital. The second
highest relative weight score is calculated to be the attitude of nurses towards patients
which states that an improvement in nurse attitude will improve the hospital by 18
percent. And finally the third highest relative weight score is given to the doctor
attitude towards patient as it has a score of 15 percent. All three are related to behavior
and attitude toward patients. When all three are combined, the hospital will realize
improvement and customer satisfaction by total 58 percent.
The correlation among technical requirements indicate that doctor attitudes
towards patients has a strong positive relationship with attitude and behavior of
nurses, attitude and behavior of other staff and modern and enough number of
equipment used. Skills of doctors have a strong positive relationship with skills of
nurses. Attitudes and behavior of nurses has a strong positive relationship with other
staff attitude, modern and enough number of equipment and also with attitudes of
doctors.
The general atmosphere of hospital also has a strong positive relationship with
hygiene and cleanliness of hospital. This is logical since waiting time will decrease if
atmosphere is positive, nice and helpful. Waiting time also has strong negative
relationships which are related to attitude and behavior of other staff and with
modernization and availability of enough number of equipment.

6. Conclusion
This case study illustrates how an existing approach of SERVQUAL and QFD
integration can be applied to a private university hospital. As a first attempt to
applying this integrative approach to a different sector and thus offering practical and
applied information, it will be useful for both academicians and practitioners.
The authors have experienced that the integrated usage of two methods gives a
systematic and efficient approach in translating customer needs into technical
requirements in the present case study of a private hospital. Although such integration,
service quality position of the hospital was evaluated by SERVQUAL, service quality
attributes of analyzed factors show which attributes of service quality have a strategic
significance on customer satisfaction and expertise of qualified professionals and how
they are linked to these strategic service needs of patients.
From a methodological perspective, it can be concluded that the ability of
correlating technical requirements with customer satisfaction makes this approach a
powerful tool for healthcare sector just like other manufacturing sectors.
LHS In order to stay competitive, designing the technical services in according with
26,3 customers expectations has become an increasingly important necessity for hospitals.
In this context, the approach provides hospitals a deep understanding of their service
quality levels from customer satisfaction perspective. Also, highlighting the most
important customer requirements (service attributes) which are highly attractive for
their patients, the approach helps hospitals to develop innovative ideas in both
182 strategic and tactical point-of-views.
Furthermore, using two methods in a complementary way creates some
methodological and practical advantages. Integrating QFD to SERVQUAL
successfully identifies and optimizes internal capabilities and addresses specific
customer opportunities by improving hospitals’ services design in parallel with the
customer needs (Killen et al., 2005). Even though using these two methods has benefits of
their own, it should be mentioned that there are limitations involved in each method. For
SERVQUAL, limitations such as measuring the expectations of excellence which might
not exist, weak discrimination between the dimensions can result, and the results of gap
analysis which cannot be easily generalized to the other areas can become somewhat
tedious (Alves and Vieira, 2006). Since QFD is sensitive to the measurement of customer
needs and expectations, the success of the method largely depends on the power of data
collections on each level. Also, the procedure of aggregating customer demands and
identifying their relative importance can be problematic in some situations (Poel, 2007).
The limitations, however, have not affected the use of the integrative model since its
advantages are far greater than its limitations. In summary, since none of the methods
separately can achieve total benefits of this integrative approach, a minimal amount of
adaptation is required for either method (Tan and Pawitra, 2001). This methodology
can be evaluated as being sufficient in response to the main goal of this study. The ease
of applying this methodology to different sectors constitutes a very practical benefit
and makes it desirable for use in all healthcare sectors.

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Corresponding author
Hatice Camgöz-Akdağ can be contacted at: haticeakdag2002@yahoo.com

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