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IJPHM
15,4
496
Received 27 February 2020
Revised 26 March 2021
Accepted 27 May 2021
International Journal of
Pharmaceutical and Healthcare
Marketing
Vol. 15 No. 4, 2021
pp. 496-515
© Emerald Publishing Limited
1750-6123
DOI 10.1108/IJPHM-02-2020-0011
Patient satisfaction and loyalty to
the healthcare organization
Thi Le Ha Nguyen
Graduate School of Medical Sciences, Kanazawa University,
Kanazawa, Japan, and
Keisuke Nagase
Department of Corporate Planning, University Hospital, Kanazawa University,
Kanazawa City, Japan and Graduate school of Medical Sciences,
Kanazawa University, Kanazawa City, Japan
Abstract
Purpose – Customer satisfaction is a tool for measuring providers’ service quality and may be evaluated
based on measurement of perceived quality and customer expectations with respect to several aspects of
service. The purpose of this study was to examine the relationships between various factors in the integrated
model, including patient expectation (PE), total quality management (TQM), perceived service quality (PSQ),
patient satisfaction (PS), patient complaint (PC) and patient loyalty (PL).
Design/methodology/approach – A self-administered questionnaire was distributed to inpatients who
were treated in April 2018 at a tertiary-level hospital in Vietnam. The data set was analyzed using the Statistical
Package of Social Sciences version 25.0 for descriptive statistics and AMOS 25.0 for structural equation modeling.
Findings – All hypotheses were supported by the results. TQM and PE positively influence PSQ; PE
influences TQM; PE, PSQ and TQM influence PS; PC and PS influence PL; and PS influences PC.
Practical implications – These findings have implications for management, highlighting the importance
of considering these factors in strategic planning aimed at improving customer satisfaction.
Originality/value – An integrated model was used to measure customer satisfaction and loyalty. The
analyses indicate that TQM, PE and PSQ are the main factors that directly influence PS.
Keywords Loyalty, Satisfaction, Total quality management, Perceived service quality,
Customer expectation
Paper type Research paper
Introduction
In recent decades, service industries worldwide have experienced significant growth and
development (Li and Hilsenrath, 2016). Developed countries’ service sectors are the main
contributors to gross domestic product (Leopold et al., 2012), and the health-care service
sector in particular has attracted considerable attention from both domestic and
international sources (Li and Hilsenrath, 2016). The health-care sector constitutes a service
industry from which customers demand high-quality services (Graffigna et al., 2014;
Consuela-Madalina et al., 2018). This service process entails interaction between patients
and medical staff (Spath, 2009, pp. 5-6), and any misjudgment or error on the part of health-
care staff can have fatal consequences for the patient. One study revealed that, in the USA,
98,000 people die annually as a result of medical errors (Kohn et al., 1999, p. 18), while a
Declaration of conflicting interests: The authors declare that the study has no conflicts of interest.
similar study indicated that errors in medical care constitute a major public health concern Patient
as a leading cause of death in the USA (Oyebode, 2013), prompting these studies’ researchers satisfaction
to suggest a major shift in focus toward health-care quality. Therefore, instruments for
measuring service quality, such as SERVQUAL, have gained recognition in today’s
and loyalty
competitive business world, as service quality is increasingly considered a critical factor in
service organizations’ survival (Dopeykar et al., 2018).
The concept of total quality management (TQM) emerged from quality management
research conducted between 1970 and 1993 (Juran et al., 1998). Various programs and 497
standards are compatible with TQM, including Six Sigma, re-engineering, ISO 9000, ISO
9001 and ISO 10001 (Juran et al., 1998; ISO 9000, 2015; ISO 9001, 2015; ISO 10001, 2007).
Companies applying these standards reported high customer satisfaction (Salter, 1993,
pp. 62-68). TQM emphasizes commitment to continuous quality improvement and customer
satisfaction (Deming, 1986). ISO 9000 (2015) focuses on customer satisfaction, product
quality and service quality. Improving perceived service quality (PSQ) increases customer
satisfaction and behavioral intention (Agyapong et al., 2018).
In the service industry, research has shown that measuring and evaluating satisfaction
levels may also serve to measure the provider’s service quality (Agyapong et al., 2018). TQM
is a strategy for ensuring excellent service quality (Patel, 2015) and thus customer
satisfaction (Almsalam, 2014). Service quality is an antecedent of customer satisfaction and
positively influences behavioral intent (Agyapong et al., 2018). Service quality is evaluated
according to customers’ expectations (Dopeykar et al., 2018). PSQ and customer expectation
are antecedent factors of customer satisfaction (Almsalam, 2014).
In the health-care sector, the patient is a customer who uses the health-care services
provided by the organization that has participated jointly in decision-making regarding
their health care (Salema et al., 2018). Patient satisfaction (PS) functions as a useful tool for
measuring the service quality provided by health-care organizations (Cho et al., 2004).
Accordingly, to increase customer satisfaction, service organizations should endeavor to
improve the quality of services that they provide. Service quality is a determinant factor of
customer satisfaction for the establishment of patient loyalty (PL) (Mosahab et al., 2010).
Most studies focus only on PSQ or customer satisfaction, and few have assessed the
effect of TQM on customer satisfaction (Appendix 1). For greater insight, our study used an
integrated model to assess the effects of TQM, PSQ and customer expectations on satisfaction
and loyalty, and correlations among those factors.

Literature review
Satisfaction is an emotion or feeling that is experienced in relation to a completed task. By
contrast, loyalty concerns the action that the customer will take in the future (Spiridon et al.,
2018). Spiridon et al. (2018) suggested that satisfaction should be considered based on
various psychological elements, including cognitive thinking/evaluation, affective to present
emotional/feeling and behavioral intention, where perceived quality is a precursor of the
customer’s behavioral intentions. The aspects of PSQ have reciprocally influenced one
another to determine overall satisfaction (Jung et al., 2009). This study aimed to examine an
integrated model of customer satisfaction and loyalty based on the following six factors:
TQM, PSQ, patient expectation (PE), PS, patient complaint (PC) and PL.

Total quality management

The International Standard Organization (ISO) suggests that “TQM is quality management
that requires that the process approach enables an organization to plan its processes and its
interactions” (ISO 9001, 2015, pp. vi, vii). Therefore, TQM is a leadership tool that allows
IJPHM companies to develop competitive strategies (Consuela-Madalina et al., 2018). Measurement and
15,4 evaluation of customer satisfaction are crucial steps in optimizing the quality system and closely
related to the notion that customers are key to improving service quality (ISO 10001, 2007). ISO
10001 (2007) pertains to general customer satisfaction. ISO 9000 (2015) concerns customer
satisfaction with products and services. ISO 9001 (2015) covers customer satisfaction and
expectations of product, process and service quality, as well as organization and operating
498 systems. Research has identified process quality, interaction quality, environmental quality,
price and trust as the five key factors in PS (Zarei et al., 2015a; Zarei et al., 2015b). Our research
assesses the process quality, interaction quality and environmental quality of a research
hospital using structural equation modeling (SEM). Five-point Likert scales (1 = strongly
disagree, 5 = strongly agree) were used to obtain data from the respondents.
According to Arab et al. (2012), process quality refers to the provision of prompt, “error-
free” service, and a willingness to help customers. Other researchers also pointed to the need
to foster trust in customers (Zarei et al., 2015a; Zarei et al., 2015b).
Interaction quality refers to the politeness and friendliness of staff, sensitivity to
customers’ beliefs, emotions, needs and interests, and 24-h availability of services (Zarei
et al., 2015a; Arab et al., 2012).
Environmental quality is evaluated based on social, psychological and physical factors (ISO
9001, 2015). Well-dressed personnel, a clean environment, state-of-the-art equipment and
visually appealing facilities promote environmental quality (Zarei et al., 2015a; Arab et al., 2012).

Perceived service quality

PSQ and customer expectations are antecedents of customer satisfaction (Almsalam, 2014).
Service quality depends on the extent to which customer expectations align with the
perceived quality of the service received (Dopeykar et al., 2018). Thus, perceived quality and
customer expectations of service quality are closely related (Marimon et al., 2019). Moreover,
PSQ directly affects customer satisfaction and behavioral intentions (Agyapong et al., 2018)
and indirectly affects customer loyalty (where this relationship is mediated by customer
satisfaction; Mosahab et al., 2010).
PSQ encompasses various aspects of service quality, including tangibility, reliability,
assurance and empathy (Nadi et al., 2016). Tangibility denotes the sense of physical space in
relation to services, facilities, equipment, personnel and communication channels; reliability
denotes the service’s ability to consistently function in a way that is safe and dependable;
responsiveness refers to employees’ willingness to cooperate with and assist clients; empathy
denotes an approach to the client that is adjusted based on their mood; finally, assurance
refers to a firm’s ability to instill a sense of confidence in their customers with respect to the
competence of the services provided (Zarei et al., 2012). Measuring and evaluating customer
satisfaction in terms of these aspects of service is a crucial step in assessing PSQ and customer
expectations (Nadi et al., 2016). Our model conceives of PSQ in terms of tangibility, reliability
and responsiveness. In the research hospital context, tangibility refers to conveniently located,
signposted services, easily accessible wards, professional staff and the availability of free
treatments. Reliability pertains to the admission process, staff responsiveness, staff interest in
patients, staff reliability and error-free treatment. Responsiveness pertains to the friendliness
and courtesy of the staff, promptness of their response to customer request, adequacy of their
knowledge of patient health and the affordability of prescribed medicines.

Patient expectation
Kotler and Keller (2016) showed that customer expectations are based on past experiences,
word of mouth and advertising. If the perceived service does not meet the expectations,
customers are disappointed. Customer expectations and PSQ predict customer satisfaction Patient
(Marimon et al., 2019; Almsalam, 2014). Evaluation of service quality is based on the satisfaction
measurement of customer expectations and perceived quality with respect to various
aspects of service, such as tangibility, reliability, responsiveness, assurance and empathy
and loyalty
(Nadi et al., 2016; Dopeykar et al., 2018). Therefore, perceived quality is closely related to
consumer expectations (Marimon et al., 2019). Customers’ expectations and satisfaction
must be fulfilled to improve perceived quality (Marimon et al., 2019). Moreover, fulfilment of
consumers’ satisfaction and expectations noticeably influences service outcomes (Ruiz- 499
Moral et al., 2007). We define PE similarly to PSQ.

Patient satisfaction
Service quality is a core factor in the competitive environment of the service industry
(Dopeykar et al., 2018). Therefore, measuring customer satisfaction is used to evaluate and
assess the service quality of service organizations (ISO 10001, 2007). The ISO defines
customer satisfaction as “the customer’s perception of the degree to which the customer’s
stated or implied needs or expectations have been fulfilled” (ISO 9000, 2015, p. 25). In
particular, the measurement of satisfaction focuses on perceived quality and customer
expectations with respect to various aspects of service (Almsalam, 2014). PSQ directly
affects client satisfaction (Agyapong et al., 2018) and indirectly affects customer loyalty
through the mediating role of satisfaction (Mosahab et al., 2010). Mosahab et al. (2010)
demonstrated that satisfaction mediates between service quality and loyalty. Customer
satisfaction has been shown to be the customer’s receipt of the expected result from the
service provider (Marimon et al., 2019). Therefore, customer satisfaction is an indispensable
factor when assessing service organizations’ service processes (ISO 10001, 2007). In addition,
complaint management may be used as a tool to improve quality (Aris-Brosou et al., 2018) and
enhance customer satisfaction and loyalty (Filip, 2013). We define customer satisfaction based
on patient outcomes and fulfillment of expectations.

Patient complaints
Complaints provide valuable insight into customer needs and can help customer-centric
organizations identify areas where they need to improve (Chen et al., 2014). Complaints can
therefore help organizations to ultimately improve customer satisfaction and trust (Morgeson
et al., 2020). Loss of customers decreases profits and damages reputation through negative
word of mouth (East et al., 2007). Complaint management functions as a tool with which
product and service quality may be improved (Aris-Brosou et al., 2018), with the aim of
increasing satisfaction and customer loyalty (Filip, 2013). Osarenkhoe and Komunda (2013)
suggested that customer complaints have a positive effect on satisfaction and loyalty. This
study considers the time taken to respond to a customer’s complaint and whether any
subsequent action met the customer’s expectations.

Patient loyalty
Customer loyalty is a crucial factor for consideration when assessing a provider’s service
quality, as perceived quality has a close relationship with client satisfaction and loyalty
(Agyapong et al., 2018). A study by Spiridon et al. (2018) indicated that relationship quality
has a significant effect on emotional satisfaction and loyalty. Customer satisfaction with a
provider’s service quality predicts behavioral intention (Agyapong et al., 2018) and plays a
mediating role between perceived quality and loyalty (Mosahab et al., 2010). In addition,
Astuti and Nagase (2014) demonstrated that customer satisfaction mediates relationship
marketing and loyalty. Furthermore, complaints should be considered as a factor of loyalty
IJPHM when building an integrated conceptual model that includes brand image, behavior, quality,
15,4 value, satisfaction, trust, commitment and customer complaints (Zhou et al., 2017), and they
are also a factor in the service quality model, which includes perceived quality, expectation,
satisfaction and customer complaints (Angelova and Zekiri, 2011). We define customer
loyalty as the customer’s willingness to use the services of a health-care service provider
again, and the likelihood of them recommending it to others and using it exclusively in
500 preference to other organizations.

Research hypotheses
Service quality is customer-focused and aims to provide the best possible quality of service
for customer satisfaction (ISO 9001, 2015). Client expectations and perceived quality with
respect to aspects of services are antecedent factors in evaluating client satisfaction
(Almsalam, 2014). A gap exists between expectations and PSQ with respect to service
quality (Nadi et al., 2016; Marimon et al., 2019). Specifically, customer expectations are met
through the improvement of service quality (ISO 9001, 2015). A study by Ruiz-Moral et al.
(2007) indicated that customers’ expectations are related to service outcomes. Based on these
discussions, we propose the following hypothesis:

H1. PE has a positive influence on TQM.

Service organizations have acknowledged the importance of focusing on service quality in a
bid to enhance customer satisfaction and loyalty and to develop their core competence (ISO
10001, 2007). Several studies have discussed service users’ expectations and perceived
quality in situations where the perceived quality falls short of expectations (Dopeykar et al.,
2018; Nadi et al., 2016). PSQ is measured with respect to various aspects (Mosahab et al.,
2010). Almsalam (2014) demonstrated that PSQ is a key predictor of satisfaction. The service
firm develops perceived quality to increase clients’ expectations (Marimon et al., 2019).
However, health-care competition has a positive effect on perceived quality and consumer
satisfaction (Consuela-Madalina et al., 2018). Therefore, the following hypothesis is
proposed:

H2. TQM has a positive influence on PSQ.

Client satisfaction is a useful metric with which to measure service quality in service
organizations (Mosahab et al., 2010). Studies have demonstrated that customer satisfaction
is determined by perceived quality and expectations of service quality (Marimon et al., 2019;
Almsalam, 2014). Consuela-Madalina et al. (2018) indicated that perceived quality plays a
mediating role between service quality and user satisfaction. Furthermore, client
expectations are a mediating factor in perceived quality and customer satisfaction (Marimon
et al., 2019). Therefore, PSQ and expectation on parts of service are the necessary factors in
determining customer satisfaction (Almsalam, 2014). Thus, this study proposes the
following hypothesis:

H3. TQM has a positive influence on PS.

Measurement and evaluation of expectations and PSQ have attracted increased attention in
recent years, owing to their specific contributions to business competitiveness and the
cultivation of satisfied and loyal customers (Consuela-Madalina et al., 2018; Marimon et al.,
2019). Research has shown that service quality does not meet customer expectations when
the expectation is higher than the PSQ (Nadi et al., 2016; Dopeykar et al., 2018). Mosahab
et al. (2010) demonstrated that measuring the perceived quality of various aspects of
services is a necessary step in assessing consumer satisfaction. The relationship between Patient
perceived quality and expectations in terms of customer satisfaction must also be considered satisfaction
in assessments of service quality (Marimon et al., 2019; Nadi et al., 2016). Consumers evaluate
service quality by measuring the gap between perceived quality and expectations (Dopeykar
and loyalty
et al., 2018). Considering this, this study offers the following hypothesis:

H4. PE has a positive influence on PSQ.

501
Customer satisfaction is determined by the relationship between perceived quality and
expectations of service quality (Dopeykar et al., 2018; Almsalam, 2014). As such, PSQ is a
necessary factor in determining customer satisfaction (Marimon et al., 2019; Jamaluddin and
Ruswanti, 2017), relating to both customer satisfaction and repurchase intentions (Spiridon et al.,
2018; Mosahab et al., 2010) and playing a mediating role between service quality and user
satisfaction (Consuela-Madalina et al., 2018). It has a close relationship with expectations of
service quality (Marimon et al., 2019). Both PSQ and customer expectations are predictive
elements of customer satisfaction (Almsalam, 2014). Thus, the following hypothesis is proposed:

H5. PSQ has a positive influence on PS.

Expectations affect satisfaction (Almsalam, 2014). The fulfillment of expectations directly
impacts consumers’ satisfaction levels (Marimon et al., 2019). A significant relationship has
been identified between customer expectations and PSQ and satisfaction (Marimon et al.,
2019). Service quality is measured based on customer expectations and the perceived quality
of service aspects (Dopeykar et al., 2018; Nadi et al., 2016). Improved perceived quality
results from the fulfillment of expectations and customer satisfaction (Marimon et al., 2019).
Additionally, the fulfillment of consumers’ satisfaction and expectations has a significant
influence on service outcomes (Ruiz-Moral et al., 2007). Perceived quality and expectations
directly influence consumer satisfaction and indirectly influence consumer loyalty through
satisfaction’s mediating role (Rahman et al., 2017). Therefore, the following hypothesis is
proposed:

H6. PE has a positive influence on PS.

In the service industry, in which businesses invariably focus on the consumer, customer
satisfaction and loyalty are regarded as key elements of business strategy (Mosahab et al.,
2010; Consuela-Madalina et al., 2018). As such, customer satisfaction serves as a tool with
which to measure and evaluate the provider’s service quality by assessing the gap between
perceived quality and expectation with respect to various aspects of the service (Almsalam,
2014; Consuela-Madalina et al., 2018). Improved perceived quality is expected to lead to
greater satisfaction and repurchase (Rahman et al., 2017; Marimon et al., 2019). Thus, service
quality is related to consumer satisfaction and loyalty (Rahman et al., 2017). Based on these
observations, this study offers the following hypothesis:

H7. PS has a positive influence on PL.

Customer complaints initiate processes of improvement for service companies whose
primary focus is on customer satisfaction (Uusitalo et al., 2008). Complaints constitute an
important feedback factor in the improvement of products and service quality with the aim
of increasing satisfaction (Paraschivescu, 2012). Bark et al. (1994) demonstrated that
complaints significantly influence service quality and customer satisfaction. Based on this
consideration, the following hypothesis is proposed:
IJPHM H8. PS has a positive influence on PC.
15,4 Complaints are considered a factor of loyalty when building an integrated conceptual model
that includes brand image, behavior, quality, value, satisfaction, trust, commitment and
customer complaints (Zhou et al., 2017). They are also a factor of the integrated model that
consists of perceived quality, expectations, satisfaction and customer complaints (Angelova
and Zekiri, 2011). Meanwhile, customer complaints are related to satisfaction and loyalty
502 (Osarenkhoe and Komunda, 2013). Based on these observations, the following hypothesis is
proposed:

H9. PC has a positive influence on PL.

Research methods
Sample size and data collection
According to Wolf et al. (2013), a research model’s sample should consist of at least 500
cases, based on the numbers of indicators and factors, the magnitude of factor loadings and
the path coefficients of SEM. Participants were randomly selected from inpatient lists of 39
clinical departments treating around 2,500 inpatients per day in cancer specialist medical
fields. A sample size of 20% of the total number of inpatients was set at 500 respondents. In
total, 550 participants were recruited to this survey to compensate for incomplete questionnaires.

Instruments
The survey instrument was a structured questionnaire consisting of 54 questions in two
main parts. First, the socio-demographic factors comprised six questions concerning age,
sex, marital status, educational level, occupation and method of paying hospital fees.
Second, 48 questions addressed TQM factors, PSQ, PE, PS, PC and PL. In particular, 12
questions concerned TQM factors that included four relating to process (TQM1–TQM4),
five concerning interaction (TQM5–TQM9) and three concerning environment (TQM10–
TQM12). These questions were based on the SERVPERF questionnaire developed by Zarei
et al. (2015a, 2015b) and modified for compatibility with the research hospital context.
Furthermore, the PSQ factor was addressed by 14 questions comprising five concerning
tangibility (PSQ13–PSQ17), five concerning reliability (PSQ18–PSQ22) and four concerning
responsiveness (PSQ23–PSQ26). The content of these questions was based on previous
research (Aman and Abbas, 2016). Similarly, the PE factor was evaluated by 14 questions,
including five pertaining to tangibility (PE27–PE31), five pertaining to reliability (PE32–
PE36) and four pertaining to responsiveness (PE37–PE40). Next, the PS factor was
addressed by three questions (PS41–PS43), followed by two questions related to the PC
factor (PC44, PC45). Finally, three questions addressed the PL factor (PL46–PL48).
Responses were recorded using a Likert scale ranging from 1 to 5.

Data analysis
The questionnaire in the present study was based on prior research (Zarei et al., 2015a;
Aman and Abbas, 2016), with items tailored to the aims of the study, and for compatibility
with SEM. In accordance with Hair et al. (2014), Cronbach’s alpha was used to measure
reliability and internal consistency. Confirmatory factor analysis (CFA) was performed to
analyze dimensionality, and convergent and discriminant validity.
The data were analyzed using Statistical Package of Social Sciences (SPSS) software
(version 25.0; IBM Corp., Armonk, NY) software. AMOS 25.0 software (IBM Corp.) was used
to analyze the validity of the proposed SEM model and the hypotheses.
Results and discussion Patient
Scales’ reliability satisfaction
A Likert scale was used for all questions in this study, ranging from “very strongly agree”
(5) to “very strongly disagree” (1). Cronbach’s alpha coefficient was used to assess the
and loyalty
construct reliability and validity of the scale using SPSS version 25.0, considering the extent
to which a set of indicators consistently and stably reflects a given construct.
In particular, the Cronbach’s alpha value of the TQM factor was 0.823–0.896, that of PSQ
was 0.845–0.873, that of PE was from 0.939 to 0.955, that of PS was 0.792, that of PC was
503
0.807 and that of PL was 0.800 (Table 1). All Cronbach’s alpha values were over 0.70 for all
latent variables, indicating that the scales were adequately internally consistent.
Additionally, of the 48 original items, 45 were retained, with three items omitted to ensure
sufficient reliability of the scales.

Confirmatory factor analysis

CFA was used to evaluate the fit of the SEM model (Hair et al., 2014, p. 602).
The study’s model was assessed in terms of standardized regression weights, the
composite reliabilities (CR) and the average variance extracted (AVE) (Hair et al., 2014,
p. 605), as shown in Table 2.
As Table 2 illustrates, the standardized coefficients of all items were around 0.68–0.93,
thus exceeding the required threshold of 0.5. The CR values for all constructs were between
0.80 and 0.97, thus exceeding the cut-off value of 0.70 for adequate internal consistency. The
AVE values were approximately 0.55–0.71, thus exceeding the cut-off of 0.50 and thereby
indicating that a large proportion of the variances were explained by our constructs. The
AVEs exceeded the squared correlations between any pair of constructs, implying high
discriminant validity (Hair et al., 2014, p. 605). The findings show that the model was
acceptable.

Model goodness-of-fit
The fit indices of the model are presented in Table 3. Specifically, the ratio of x 2 to the
degrees of freedom was 2.492 (P = 0.000). The x 2 test was known to be sensitive to sample
size, and several widely used goodness-of-fit (GFI) indices demonstrated that the confirmatory

Constructs Items Cronbach’s alpha

Total quality management

Process quality 4 0.896
Interaction quality 5 0.890
Environment quality 3 0.823
Perceived service quality
Tangibility 5 0.873
Reliability 5 0.854
Responsiveness 4 0.845
Patient expectation
Tangibility 5 0.942
Reliability 3 0.955
Responsiveness 4 0.939
Patient satisfaction 3 0.792
Patient complaint 2 0.807 Table 1.
Patient loyalty 2 0.800 Reliability statistics
IJPHM Average variance extracted Composite reliability
15,4 Construct measures Standardized coefficients (AVE) (CR)

Total quality management 0.611 0.934

(TQM)
TQM1 / TQM 0.828
TQM2 / TQM 0.742
504 TQM3 / TQM 0.799
TQM4 / TQM 0.840
TQM5 / TQM 0.833
TQM6 / TQM 0.799
TQM7 / TQM 0.775
TQM10 / TQM 0.722
TQM12 / TQM 0.682
Perceived service quality 0.549 0.916
(PSQ)
PSQ15 / PSQ 0.684
PSQ16 / PSQ 0.729
PSQ18 / PSQ 0.705
PSQ19 / PSQ 0.741
PSQ20 / PSQ 0.729
PSQ21 / PSQ 0.760
PSQ23 / PSQ 0.804
PSQ24 / PSQ 0.756
PSQ25 / PSQ 0.756
Patient expectation (PE) 0.706 0.966
PE27 / PE 0.707
PE28 / PE 0.764
PE29 / PE 0.780
PE30 / PE 0.781
PE31 / PE 0.803
PE34 / PE 0.891
PE35 / PE 0.919
PE36 / PE 0.929
PE37 / PE 0.857
PE38 / PE 0.881
PE39 / PE 0.865
PE40 / PE 0.876
Patient satisfaction (PS) 0.569 0.798
PS41 / PS 0.769
PS42 / PS 0.791
PS43 / PS 0.700
Patient complaint (PC) 0.681 0.810
PC44 / PC 0.856
PC45 / PC 0.793
Table 2. Patient loyalty (PL) 0.667 0.800
Confirmatory factor PL46 / PL 0.836
analysis results PL47 / PL 0.797

factor model was a good fit to the data. In detail, GFI = 0.86 [cut-off = 0.80]; normalized fit
index [NFI] = 0.91 [requirement = value of 0–1]; root mean squared error of approximation
[RMSEA] = 0.05 [requirement = value from 0.05–0.08]; comparative fit index [CFI] = 0.95;
adjusted goodness-of-fit index [AGFI] = 0.84 [cut-off = 0.80]; and Tucker-Lewis index [TLI] =
0.94 [cut-off = 0.9] (Hair et al., 2014). Thus, the model fit was satisfactory, and all scales met the
reliability and validity requirements.
Hypotheses testing Patient
The study’s hypotheses are presented in Table 4. satisfaction
Patient expectation on total quality management (H1). This relationship is represented
by the coefficient of the path (PE ! TQM); the coefficient was statistically significant (0.443;
and loyalty
p = 0.001), indicating that PE has a positive influence on TQM, which is consistent with
previous findings (Marimon et al., 2019). Client expectation factors were measured via a
questionnaire with a focus on aspects of service quality that included tangibility, reliability
and responsiveness. Customers’ expectations affect several aspects of service quality by 505
virtue of the gap between expectation and PSQ (Dopeykar et al., 2018). This implies that
health-care organizations may develop total service quality by consistently meeting
customers’ needs and expectations. This finding is supported by an earlier study that
demonstrated that fulfillment of customers’ expectations contributes to improved care
outcomes and customer satisfaction (Ruiz-Moral et al., 2007).
Total quality management on perceived service quality (H2). The path coefficient
(TQM ! PSQ) for H2 was statistically significant (0.849; p = 0.001), i.e. TQM had a positive
influence on PSQ. Customers’ PSQ was measured with respect to aspects including
tangibility, reliability and responsiveness. Similarly, previous scholars have suggested that
PSQ should be considered from the perspective of the client (Marimon et al., 2019). Consuela-
Madalina et al. (2018) indicated that the development of quality should improve perceived
quality to ultimately increase customer satisfaction. Moreover, scholarship has highlighted
the importance of measuring aspects of service quality based on the gap between client
expectations and perceptions (Nadi et al., 2016).
Total quality management on patient satisfaction (H3). This relationship is described by
the path coefficient (TQM ! PS), which was statistically significant (0.272; p = 0.003), i.e.
TQM had a positive influence on PS. Similarly, Agyapong et al. (2018) found that PSQ is an
important factor in maintaining customer satisfaction. Perceived quality among users has
been used to measure the overall service quality offered by the service organization
(Dopeykar et al., 2018) and has been found to be directly affected by customer satisfaction
and loyalty (Cho et al., 2004; Arab et al., 2012).
Patient expectation on perceived service quality (H4). The path coefficient (PE ! PSQ)
for H4 was statistically significant (0.064; p = 0.040) and thus showed that PE had a positive
influence on PSQ. Also, earlier studies have demonstrated a significant relationship between
perceived quality and expectations with respect to various aspects of service quality
(Dopeykar et al., 2018). Marimon et al. (2019) found that perceived quality directly affects
expectations and satisfaction, with expectations functioning as a mediating factor between
perceived quality and satisfaction.

Goodness-of-fit Index Value Range Accepted

Absolute fit Chi-square 1,512.809

df 607
Chi-square/df 2.492 Less than 5 Accepted
GFI 0.861 >0.85 Accepted
RMSEA 0.054 0.05–0.08 Accepted
RMR 0.029 Close to zero Accepted
Incremental fit NFI 0.911 Between 0 and 1 Accepted Table 3.
TLI 0.939 > 0.90 Accepted Goodness-of-fit
CFI 0.945 > 090 Accepted measures of the
Parsimony fit AGFI 0.839 > 0.80 Accepted model
IJPHM Hypotheses Path Standardized coefficients Sig. Results
15,4
H1 PE ! TQM 0.443 *** Accepted
H2 TQM ! PSQ 0.849 *** Accepted
H3 TQM ! PS 0.272 0.003 Accepted
H4 PE ! PSQ 0.064 0.040 Accepted
H5 PSQ ! PS 0.516 *** Accepted
506 H6 PE ! PS 0.112 0.004 Accepted
H7 PS ! PL 0.289 0.003 Accepted
H8 PS ! PC 0.809 *** Accepted
H9 PC ! PL 0.463 *** Accepted

Notes: This table shows the hypotheses test results. The hypotheses were evaluated by standardized
Table 4. coefficients and path coefficients with significance (sig. < 0.05). The symbol *** (sig. = 0.001). The
Hypotheses test acronyms were included in total quality management (TQM), patient expectation (PE), perceived service
results quality (PSQ), patient satisfaction (PS), patient complaint (PC) and patient loyalty (PL)

Perceived service quality on patient satisfaction (H5). The coefficient of the path (PSQ ! PS)
was statistically significant (0.516; p = 0.001), supporting the hypothesis that PSQ has a
positive influence on PS. This finding also supports the results of studies by Mosahab et al.
(2010) and Almsalam (2014). The present study’s findings imply that health-care organizations
can improve service quality and maintain customer satisfaction by enhancing the management
of perceived quality. Perceived quality’s effect on loyalty is mediated through customer
satisfaction (Jung et al., 2009; Spiridon et al., 2018). Therefore, service facilities should develop
strategic plans aimed at improving perceived quality to maintain customer satisfaction and
loyalty.
Patient expectation on patient satisfaction (H6). The path coefficient (PE ! PS) for H6
was statistically significant (0.112; p = 0.004), i.e. PE had a positive influence on PS.
Similarly, studies by Marimon et al. (2019) and Almsalam (2014) supported the assertion
that customer expectations regarding aspects of service quality have a positive effect on
customer satisfaction or mediate in the relationship between perceived quality and
satisfaction (Marimon et al., 2019).
Patient satisfaction on patient loyalty (H7). This hypothesis was confirmed by the
statistically significant (0.289; p = 0.003) path coefficient of (PS ! PL), i.e. PS had a positive
influence on PL, consistent with Mosahab et al. (2010) who found that satisfaction plays a
mediating role between service quality and loyalty, while satisfaction mediates between
perceived quality and repurchase intention (Jung et al., 2009; Spiridon et al., 2018).
Patient satisfaction on patient complaint (H8). The direct path of PS ! PC was
supported by a standardized coefficient of 0.809 at a p-value of 0.001. This indicates that PS
had a positive influence on PC, which is consistent with previous research (Osarenkhoe and
Komunda, 2013). Bark et al. (1994) considered complaints to correlate with care quality
and customer satisfaction. A study by Paraschivescu (2012) suggested that service firms
should consider complaint management as a tool with which to increase customer
satisfaction and improve service quality. Thus, service organizations can increase customer
satisfaction by managing customer complaints.
Patient complaint on patient loyalty (H9). This hypothesis was supported by the
statistically significant (0.469; p = 0.001) path coefficient for (PC ! PL), i.e. PC had a positive
influence on PL, corroborating the findings of Osarenkhoe and Komunda (2013). Filip (2013)
recommended that service organizations establish integrated complaint management
systems that draw on customer feedback to improve customer satisfaction and loyalty. Our Patient
findings indicate that PC is a key factor in cultivating customer satisfaction and loyalty. satisfaction
and loyalty
Implications for research, practice and society
Our study has several implications for service management, verifying that high client
satisfaction leads to client loyalty. In particular, our findings may assist managers to
develop policies aimed at improving service quality. The study also enhances our 507
understanding of the various factors of service quality that influence consumer satisfaction.
In addition, our research, based on a doctoral thesis on health-care management, has
significant theoretical and practical implications for strategic planning to improve customer
satisfaction and loyalty. Our findings should be considered when modeling service quality.
A comprehensive analysis was conducted in this study, as opposed to evaluating factors
in isolation. The findings should be of interest to both researchers and students engaged in
social science, health-care/medical sciences and service industries; it should also be of value
to service/health-care organizations.

Conclusion and recommendation

This study examined aspects of service quality from the consumer’s perspective, measuring
the relationship between TQM, perceived quality and expectations with respect to several
dimensions of service offered by organizations in terms of satisfaction, complaint
management and loyalty. All hypotheses were supported by the findings. Customer
satisfaction was shown to depend on TQM, PSQ and PE, while customer loyalty depends on
PS and PC.
Managers should consider TQM, PSQ, PE and customer expectations when aiming to
improve customer satisfaction, loyalty and aspects of service quality including tangibility,
reliability and responsiveness. Furthermore, the study has indicated the key factors that
should be considered to improve quality by service organizations, including processes,
interactions and environmental quality.
As a limitation, we only collected data from one public facility and focused exclusively on
inpatients. Future research should consider the private sector and the experiences of both
outpatients and inpatients.
The GFI of the model was high. However, the model should be validated in larger
samples. The relationships between the identified factors and customer loyalty, as opposed
to only customer satisfaction, should also be analyzed.

References
Agyapong, A., Afi, J.D. and Kwateng, K.O. (2018), “Examining the effect of perceived service quality of
health care delivery in Ghana on behavioral intentions of patients: the mediating role of
customer satisfaction”, International Journal of Healthcare Management, Vol. 11 No. 4,
pp. 276-288.
Almsalam, S. (2014), “The effects of customer expectation and perceived service quality on customer
satisfaction”, International Journal of Business and Management Invention, Vol. 3 No. 8,
pp. 79-84.
Aman, B. and Abbas, F. (2016), “Patients’ perceptions about the service quality of public hospitals
located in district Kohat”, Journal Pakistan Medical Association, Vol. 66 No. 1, pp. 72-75.
Angelova, B. and Zekiri, J. (2011), “Measuring customer satisfaction with service quality using
American customer satisfaction model (ACSI model)”, International Journal of Academic
Research in Business and Social Sciences, Vol. 1 No. 3, pp. 232-258.
IJPHM Arab, M., Tabatabaei, S.M.G., Rashidian, A., Forushani, A.R. and Zarei, E. (2012), “The effect of service
quality on patient loyalty: a study of private hospitals in Tehran, Iran”, Iranian Journal Public
15,4 Health, Vol. 41 No. 9, pp. 71-77.
Aris-Brosou, S., Kim, J., Li, L. and Liu, H. (2018), “Predicting the reasons of customer complaints: a first
step toward anticipating quality issues of in vitro diagnostics assays with machine learning”,
JMIR Medical Informatics, Vol. 6 No. 2, pp. 1-13.
508 Astuti, H.J. and Nagase, K. (2014), “Patient loyalty to healthcare organizations: relationship marketing
and satisfaction”, International Journal of Management and Marketing Research, Vol. 7 No. 2,
pp. 39-56.
Bark, P., Vincent, C., Jones, A. and Savory, J. (1994), “Clinical complaints: a means of improving quality
of care”, Quality and Safety in Health Care, Vol. 3 No. 3, pp. 123-132.
Chen, Y., Liu, J., Xiao, S., Liu, X., Xinhui, T. and Zhou, Y. (2014), “Model construction of nursing
service satisfaction in hospitalized tumor patients”, Int J Clin Exp Med, Vol. 7 No. 100,
pp. 3621-3629.
Cho, W.H., Lee, H., Kim, C., Lee, S. and Choi, K. (2004), “The impact of visit frequency on the
relationship between service quality and outpatient satisfaction: a South Korean study”, Health
Services Research, Vol. 39 No. 1, pp. 13-33.
Consuela-Madalina, G., Lorin, P.V. and Iuliana-Raluca, G. (2018), “A marketing perspective on
consumer perceived competition in private ophthalmology services”, Romanian Journal of
Ophthalmology, Vol. 62 No. 2, pp. 123-134.
Deming, W.E. (1986), Out of the Crisis, MA Institute of Technology Center for Advanced Engineering
Study, Cambridge, MA, pp. 21-24.
Dopeykar, N., Bahadori, M., Mehdizadeh, P., Ravangard, R., Salesi, M. and Hosseini, S.M. (2018),
“Assessing the quality of dental services using SERVQUAL model”, Dental Research Journal,
Vol. 15 No. 6, pp. 430-436.
East, R., Hammond, K. and Wright, M. (2007), “The relative incidence of positive and negative word of mouth:
a multi-category study”, International Journal of Research in Marketing, Vol. 24 No. 2, pp. 175-184.
Filip, A. (2013), “Complaint management: a customer satisfaction learning process”, Procedia - Social
and Behavioral Sciences, Vol. 93, pp. 271-275.
Graffigna, G., Barello, S., Riva, G. and Bosio, A.C. (2014), “Patient engagement: the key to redesign the
exchange between the demand and supply for healthcare in the era of active ageing”, Active
Ageing and Healthy Living, pp. 85-95.
Hair, J.F., Jr, Black, W.C., Babin, B.J. and Anderson, R.E. (2014), “Confirmatory factor analysis”,
Multivariate Data Analysis (7th ed.), Prentice Hall, London, pp. 599-638.
ISO 10001 (2007), International Standard: Quality Management – Customer Satisfaction – Guidelines
for Codes of Conduct for Organizations (1st ed.), Geneva, Switzerland: ISO.
ISO 9000 (2015), International Standard: Quality Management Systems – Fundamentals and
Vocabulary (4th ed.), Geneva, Switzerland: ISO, p. 25.
ISO 9001 (2015), International Standard: Quality Management Systems – Requirements (5th ed.),
Geneva, Switzerland: ISO.
Jamaluddin and Ruswanti, E. (2017), “Impact of service quality and customer satisfaction on customer
loyalty: a case study in a private hospital in Indonesia”, Journal of Business and Management,
Vol. 19 No. 5, pp. 23-33.
Jung, M., Lee, K. and Choi, M. (2009), “Perceived service quality among outpatients visiting hospitals
and clinics and their willingness to re-utilize the same medical institutions”, Journal of Preventive
Medicine and Public Health, Vol. 42 No. 3, pp. 151-159.
Juran, J.M., Godfrey, A.B., Hoogstoel, R.E. and Schilling, E.G. (1998), “Section 14: Total quality
management”, Juran’s Quality Handbook (5th ed.), New York, McGraw-Hill, pp. 14.1-14.35.
Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (1999), To Err is Human: building a Safer Health Patient
System, Washington, DC, National Academy Press, p. 18.
satisfaction
Kotler, P. and Keller, K.L. (2016), Marketing Management (15th ed.), New York, Prentice Hall, 2016, p. 440.
and loyalty
Leopold, C., Mantel-Teeuwisse, A.K., Seyfang, L., Vogler, S., Joncheere, K., Laing, R.O. and Leufkens, H.
(2012), “Impact of external price referencing on medicine prices–a price comparison among 14
European countries”, Southern Medical Review, Vol. 5 No. 2, pp. 34-41.
Li, H. and Hilsenrath, P. (2016), “Organization and finance of China’s health sector: historical 509
antecedents for macroeconomic structural adjustment”, Journal of Health Care Organization,
Provision, and Financing, pp. 1-8.
Marimon, F., Gil-Domenech, D. and Bastida, R. (2019), “Fulfilment of expectations mediating quality
and satisfaction: the case of hospital service”, Total Quality Management and Business
Excellence, Vol. 30 Nos 1/2, pp. 201-220.
Morgeson, F.V., Mithas, S., Hult, G.T.M. and Keiningham, T.L. (2020), “Turning complaining customers
into loyalty customers: moderators of the complaint handling-customer loyalty relationship”,
Journal of Marketing, Vol. 84 No. 5, pp. 1-55.
Mosahab, R., Mahamad, O. and Ramayah, T. (2010), “Service quality, customer satisfaction and loyalty:
a test of mediation”, International Business Research, Vol. 3 No. 4, pp. 72-80.
Nadi, A., Shojaee, J., Abedi, G., Siamian, H., Abedini, E. and Rostami, F. (2016), “Patients’ expectations
and perceptions of service quality in the selected hospitals”, Medical Archives, Vol. 70 No. 2,
pp. 135-139.
Osarenkhoe, A. and Komunda, M.B. (2013), “Redress for customer dissatisfaction and its impact on
customer satisfaction and customer loyalty”, Journal of Marketing Development and
Competitiveness, Vol. 7 No. 2, pp. 102-114.
Oyebode, F. (2013), “Clinical errors and medical negligence”, Medical Principles and Practice, Vol. 22
No. 4, pp. 323-333.
Paraschivescu, A.O. (2012), “Complaints management”, Economy Transdisciplinarity Cognition, Vol. 15
No. 2, pp. 108-115.
Patel, G. (2015), “Total quality management in healthcare”, The MIDAS Journal -Medical Imaging and
Computing, pp. 1-5.
Rahman, M., Hossain, I., Mustafi, M.A.A. and Miah, M. (2017), “An examination of the effects of
customer expectation, perceived quality, and customer satisfaction on customer loyalty: a case
study on KFC restaurant”, International Journal of Engineering and Applied Sciences (IJEAS),
Vol. 4 No. 12, pp. 58-64.
Ruiz-Moral, R., Torres, L.A.P. and Jaramillo-Martin, I. (2007), “The effect of patients’ expectations on
consultation outcomes. A study with family medicine residents”, Journal of General Internal
Medicine, Vol. 22 No. 1, pp. 86-91.
Salema, D., Townsend, A. and Austin, J. (2018), “Patient decision-making and the role of the prenatal
genetic counselor: an exploratory study”, Journal Genetic Counselors, pp. 1-9.
Salter, J.M. (1993), Total Quality Management and Applications to the Construction Industry,
Gainesville, FL, America: University of FL, pp. 62-68.
Spath, P. (2009), Introduction to Healthcare Quality Management, Chicago: Health Administration
Press, pp. 5-6.
Spiridon, S., Gheorghe, C.M., Gheorghe, I.R. and Purcarea, V.L. (2018), “Removing the barriers in health
care services: the importance of emotional satisfaction”, Journal of Medicine and Life, Vol. 11
No. 2, pp. 168-174.
Uusitalo, K., Hakala, H. and Ketone, T. (2008), “Customer complaints as a source of customer-focused
process improvement: a constructive case study”, International Journal of Business Science and
Applied Management, Vol. 3 No. 1, pp. 1-13.
IJPHM Wolf, E.J., Harrington, K.M., Clark, S.L. and Miller, M.W. (2013), “Sample size requirements for
structural equation models: an evaluation of power, bias, and solution propriety”, Educational
15,4 and Psychological Measurement, Vol. 73 No. 6, pp. 913-934.
Zarei, A., Arab, M., Froushani, A.R., Rashidian, A. and Tabatabaei, S.M.G. (2012), “Service quality of
private hospitals: the Iranian patients’ perspective”, BMC Health Services Research, Vol. 12
No. 1, pp. 1-7.
Zarei, E., Daneshkohan, A., Khabiri, R. and Arab, M. (2015a), “The effect of hospital service quality on
510 patients’ trust”, Iranian Red Crescent Medicine, Vol. 17 No. 1, pp. 1-5.
Zarei, E., Daneshkohan, A., Pouragha, B., Marzban, S. and Arab, M. (2015b), “An empirical study of the
impact of service quality on patient satisfaction in private hospitals, Iran”, Global Journal of
Health Science, Vol. 7 No. 1, pp. 1-9.
Zhou, W., Wan, Q., Liu, C., Feng, X. and Shang, S. (2017), “Determinants of patient loyalty to healthcare
providers: an integrative review”, International Journal for Quality in Health Care, Vol. 29 No. 4,
pp. 442-449.
Appendix 1 Patient
satisfaction
and loyalty
Hypotheses of the present
Reference Purpose/objective Hypotheses/findings study

Consuela- To assess the H1: Influence of health-care competition H1: Influence of patient
Madalina et al. knowledge of on perceived quality expectation (PE) on total 511
(2018) customers making quality management
decisions pertaining (TQM)
to the use of a private H2: Influence of health-care competition H2: Influence of TQM on
ophthalmology on consumer satisfaction perceived service quality
service, with a focus (PSQ)
on health-care H3: Influence of health-care competition H3: Influence of TQM on
competition. on price satisfaction patient satisfaction (PS)
H4: Influence of perceived quality on H4: Influence of PE on
price satisfaction PSQ
H5: Influence of price satisfaction on H5: Influence of PSQ on
consumer satisfaction PS
H6: Influence of perceived quality on H6: Influence of PE on PS
consumer satisfaction
Findings: all hypotheses were supported. H7: Influence of PS on
patient loyalty (PL)
Relevant to the present study: H6. H8: Influence of PS on
patient complaints (PC)
H9: Influence of PC on PL
Agyapong To examine the H1: Influence of PSQ on PS
et al. (2018) mediating role of H2: Influence of PSQ on behavioral
customer satisfaction intention
(CS) in the H3: Influence of PS on behavioral
relationship between intention (BI)
perceived service H4: PS mediates the relationship
quality (PSQ) and between PSQ and BI
behavioral intentions. Findings: all hypotheses were supported.
Relevant to the present study: H1 and
H4
Almsalam To assess the H1: Influence of CE on CS
(2014) relationships of H2: Influence of PSQ on CS
customer expectations Findings: both hypotheses were
(CE) and PSQ with supported.
CS. Relevant to the present study: H1 and
H2
Mosahab et al. To determine the H1: Influence of PSQ on CS
(2010) quality of services H2: Influence of PSQ on customer
offered by the service loyalty (CL)
organization, and to H3: Influence of CS on CL
examine the H4: CS mediates the relationship Table A1.
relationships among between PSQ and CL Related studies on
PSQ, CS and CL. Findings: all hypotheses were supported. the effect of service
Relevant to the present study: H1, H3
quality on customer
and H4
satisfaction and
(continued) loyalty
IJPHM
Hypotheses of the present
15,4 Reference Purpose/objective Hypotheses/findings study

Zarei et al. To examine the effect H1: Aspects of service quality, including
(2015b) of aspects of service costs, processes, interactions and the
quality including environment may influence patient
processes, satisfaction (PS)
512 interactions, the Findings: costs, process quality and
environment and interaction quality had a positive
costs on CS. influence on PS, but environment quality
did not.
Relevant to the present study: H1

Marimon et al. To devise a scale for H1: Influence of PSQ on PS

(2019) measuring service H2: Influence of PSQ on PE
PSQ by analyzing the H3: Influence of PE on PS
effect of PSQ on PS, Findings: all hypotheses were supported.
and the mediating role Relevant to the present study: H1–H3.
of PE in the
relationship between
quality and
satisfaction.
Osarenkhoe To examine the H1: Influence of demographic factors on
and Komunda relationship between CS
(2013) the handling of H2: Influence of customer complaint
customer complaints, behavior (CCB) on CL
CS and loyalty. H3: Influence of CCB on CS
H4: Influence of CS on CL
Findings: all hypotheses were supported.
Relevant to the present study: H2–H4
Astuti and To examine the H1: Influence of relationship marketing
Nagase (2014) influence of on loyalty
relationship H2: Influence of relationship marketing
marketing on CS and on satisfaction
loyalty. H3: Influence of PS on PL
H4: PS mediates the relationship
between marketing and loyalty
Findings: most hypotheses were
supported, but PS did not mediate the
relationship between marketing and
loyalty.
Relevant to the present study: H3
Rahman et al. To explore the H1: Influence of PSQ on CS
(2017) influence of customer H2: Influence of PSQ on CL
expectation, PSQ, and H3: Influence of customer expectation
CS on customer (CE) on CS
loyalty. H4: Influence of CE on CL
H5: Influence of CS on CL
Findings: most hypotheses were
supported, but PSQ did not influence CS.
Relevant to the present study: H1, H3
Table A1. and H5
Appendix 2. Questionnaire Patient
Patient satisfaction and loyalty to the healthcare organization satisfaction
Your responses will be used solely for research purposes. The information that you provide and loyalty
will help to improve the quality of healthcare services.
Serial No: …………………………………………………………………………………..
Date of completion………………………………………………………………………
Please write your response in the blank column or mark the box provided. 513
1. What is your age? ……………………………………years
2. What is your sex?
1. Male 2. Female
3. What is your marital status?
1. Single 2. Married
3. Divorced 4. Widowed
4. What is your educational level?
1. No school 2. Primary school
3. Secondary school 4. High school
5. Bachelor’s degree 6. Postgraduate degree
5. What is your occupation?
1. Govt. employee 2. Non-govt. employee
3. Unemployed 4. Agriculture
5. General labor 6. Retired
6. Method of paying hospital fees
1. Insurance 2. Personal payment
Please place a cross in the box corresponding to the level of your agreement/disagreement
with each of the following statements.
1. Very strongly disagree, 2. Strongly disagree, 3. Agree, 4. Strongly agree, 5. Very
strongly agree
Total Quality Management (TQM)
Statement/Item 1 2 3 4 5
TQM1 Services were provided on time
TQM2 I was informed when services would be performed
TQM3 Staff were available when needed
TQM4 Medical and non-medical services were provided
promptly
TQM5 Round-the-clock services were available
TQM6 Staff were polite and friendly
TQM7 Staff had my best interests at heart
TQM8 Staff understood my specific needs
TQM9 Staff were knowledgeable when answering my
questions
TQM10 Hospital environment was clean and comfortable
TQM11 Employees were well dressed and neatly presented
TQM12 Equipment was up-to-date

(continued)
IJPHM Perceived service quality (PSQ)

15,4 PSQ1
Statement/Item
Hospital was conveniently located
1 2 3 4 5

3
PSQ1 Direction signs were clear
4
PSQ1 Wards were designed with easy access and were
514 5 comfortable
PSQ1 Staff were professional
6
PSQ1 Free medicine was available
7
PSQ1 The admission process was fast and straightforward
8
PSQ1 Staff responded immediately when called
9
PSQ2 Staff showed genuine interest in attending to my
0 problems
PSQ2 Staff were reliable in handling my problems
1
PSQ2 Hospital treatment was error-free
2
PSQ2 Admissions staff were friendly and courteous
3
PSQ2 Staff responded promptly to my requests
4
PSQ2 I was provided with adequate information about my
5 health condition
PSQ2 I was prescribed affordable medicines
6

Patient Expectation (PE)

Statement/Item 1 2 3 4 5
PE27 I expect the hospital to have a convenient location
PE28 I expect direction signs to be clear
PE29 I expect the wards to be well-designed for easy access
and comfort
PE30 I expect staff to be professional
PE31 I expect free medicine to be available
PE32 I expect the admission process to be fast and
straightforward
PE33 I expect staff to respond immediately when called
PE34 I expect staff to show a sincere interest in attending to
my problems
PE35 I expect staff to be reliable in handling my problems
PE36 I expect the hospital to provide treatment that is error-
free
PE37 I expect admissions staff to be friendly and courteous
PE38 I expect staff to respond promptly to patient requests
PE39 I expect to be provided with adequate information about
my health condition
PE40 I expect affordable medicine to be prescribed

(continued)
 Patient Satisfaction (PS) Patient
Statement/Item 1 2 3 4 5 satisfaction
PS41
PS42
I am satisfied with the results of my recovery
The quality of service I received met my expectations
and loyalty
PS43 I am satisfied with my selection of this hospital to
provide me with healthcare

Patient Complaint (PC) 515

Statement/Item 1 2 3 4 5
PC44 The time taken to respond to my complaint was
satisfactory
PC45 The feedback provided met my expectations

Patient Loyalty (PL)

Statement/Item 1 2 3 4 5
PL46 I would return to this hospital if I required healthcare in
the future
PL47 I would recommend this hospital to others
PL48 I do not want to use other healthcare service providers

The English in this document has been checked by at least two professional editors, both
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About the authors

Thi Le Ha Nguyen has been a Medical Doctor for 18 years in Vietnam. She graduated from the
Mahidol University, Thailand, and was awarded Master of Primary Healthcare Management. Now,
she is pursuing a doctoral program in Healthcare Management at Kanazawa University, Japan. Thi
Le Ha Nguyen is the corresponding author and can be contacted at: ng.leha72@yahoo.com
Prof Keisuke Nagase has been conducting research and teaching in hospital management, medical
IT (including AI application) and pulmonary medicine for 20 years in medical schools. Keisuke
Nagase provides service as Deputy Director of the University Hospital for Finance, Budget and IT.

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