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Hospital Service Quality As
Hospital Service Quality As
Hospital Service Quality As
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Hospital
Hospital service quality as service quality
antecedent of patient satisfaction –
a conceptual framework
Swapnarag Swain
T A Pai Management Institute, Manipal, Karnataka, India, and
Received 1 June 2016
Nirmal Chandra Kar Revised 8 April 2017
28 September 2017
Department of Business Administration, Utkal University, Bhubaneswar, India Accepted 18 February 2018
Downloaded by University of Sussex Library At 05:08 08 July 2018 (PT)
Abstract
Purpose – The purpose of this paper is to explore dimensions of perceived service quality in hospitals and
to develop a conceptual framework showing relationship between hospital service quality, patient satisfaction
and their behavioural intention.
Design/methodology/approach – This paper is based on extensive review of existing literature on
hospital service quality, patient satisfaction and behavioural intention. Critical analysis of these literature
studies has resulted in determining and defining the dimensions of perceived service quality and establishing
relationship between hospital service quality, patient satisfaction and behavioural intention.
Findings – This study has identified six major areas through which patients perceive quality of service in
hospitals. These six areas are technical quality, procedural quality, infrastructural quality, interactional
quality, personnel quality, social support quality. Further 20 dimensions of hospital service quality are
identified under these 6 major areas. These are clinical procedure, quality of outcome, admission, discharge,
waiting time, patient safety, billing and price, follow-up, ambience, availability of resources, accessibility,
food, staff attitude, personalised attention, information availability, staff competency, trustworthiness, staff
diversity, hospital image and social responsibility. The conceptual framework proposes direct relationship
between service quality, patient satisfaction and behavioural intention.
Originality/value – Though many studies have been conducted on hospital service quality, none of them
has been able to project all the possible dimensions to measure the same. The “6-Q framework” developed by
this study explores all the possible dimensions of perceived service quality in hospitals.
Keywords Service quality, Patient satisfaction, Hospital, Behavioural intention
Paper type Research paper
Introduction
Health-care service providers can be categorised in to primary, secondary and tertiary care
institutions. Primary and secondary care institutions generally consist of primary health
centres, community health centres and district hospitals. Tertiary care institutions are
generally equipped with personnel and facilities for advanced investigation and treatment to
offer specialised consultative care usually on referral from primary or secondary medical
care institutions. These days, tertiary health-care institutions like large multispecialty and
super specialty hospitals are giving much importance to be accredited by national or
international health-care accreditation organisations like the United Kingdom Accreditation
Forum (UKAF) in the United Kingdom, Joint Commission International (JCI) in the USA, International Journal of
Australian Council on Healthcare Standards International (ACHSI) in Australia and Pharmaceutical and Healthcare
Marketing
National Accreditation Board for Hospitals & Healthcare Providers (NABH) in India. As a © Emerald Publishing Limited
1750-6123
result, hospitals are required to maintain high standards of care and manage quality of DOI 10.1108/IJPHM-06-2016-0028
IJPHM service delivery. To improve quality of care, health system needs to be effective, efficient,
accessible, patient centred, equitable and safe (World Health Organization, 2006).
Service quality management has both internal and external perspectives (Sachdev and
Verma, 2004). Internal perspective focuses on zero defect and conformance to requirements.
External perspective focuses on customers and their expectation, perception, attitude and
satisfaction. Owing to factors like growing consumer awareness, their expectations and
changing consumer preferences, the external perspective is gaining more importance in case
of services (Sachdev and Verma, 2004). Patients attach highest importance to the
interpersonal aspect of care in case of health services (Padma et al., 2010). Patients’ perceived
value about a hospital is a function of six dimensions such as acquisition value, transaction
value, efficiency value, aesthetic value, social interaction value and self-gratification value
(Chahal and Kumari, 2012). Hospital support functions have significant influence on
patients’ perception about the quality of service in hospitals which in turn influences future
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patient demands and reputation of hospital (Baalbaki et al., 2008). Many researchers have
established a direct relationship between hospital service quality and patient satisfaction
(Zineldin, 2006; Dagger, Sweeney and Johnson, 2007; Duggirala et al., 2008; Vinagre and
Neves, 2008; Padma et al., 2010). Customer satisfaction can lead to competitive advantage for
a firm through repeat buying, higher prices, loyalty in crisis, word-of-mouth, one-stop
shopping and new-product innovation (Seth, 1991). So it has become imperative for hospitals
to create patient satisfaction through effective management of service quality.
Service quality is one of the vastly researched areas in business and many studies have
been conducted on hospital service quality. Review of literature shows gaps with respect to
the dimensions of hospital service quality as each of the studies has missed one or more
dimensions that are important constituents of service quality. This study focuses on
identifying all the possible dimensions through which patients evaluate or perceive quality
of service in a tertiary health-care institution, especially large hospital. It has also tried to
develop a conceptual framework (the 6-Q framework) to show the relationship between
perceived service quality, patient satisfaction and behavioural intention. The findings of this
study are based on extensive review of existing literature on hospital service quality, patient
satisfaction and their behavioural intention.
Literature review
Service quality is an area of research in which a large number of researchers have made
their contribution in terms of development and testing of theoretical models, development of
service quality scales, implementation of service quality scale to measure quality of service
in various sectors such as retail, banking, hospitality and health care. Service gaps model is
one of the most famous models of service quality that was developed by Parasuraman,
Zeithamal and Berry (1985). According to this model, perceived service quality is a result of
difference in consumers’ perception and expectation out of a service that can be observed
through five service gaps, which led to development of the most famous SERVQUAL scale.
Thereafter, this scale or its modified versions have been implemented to measure service
quality in health-care setting. The present study is based on review of literature comprising
two broad sections – the first section includes literature with respect to the dimensions of
service quality especially in health-care setting, and the second section includes literature
with respect to the relationship between service quality, patient satisfaction and behavioural
intention. The first section further consists of three sub sections – the first sub section deals
with studies that are based on SERVQUAL approach, the second sub section deals with
studies based on modifications of SERVQUAL and the third sub section deals with studies
that are not based on SERVQUAL approach. The set of literature for this analysis was
obtained using the search terms “hospital/health-care service quality” and/or “patient Hospital
satisfaction” in databases like Emerald Insight, EBSCOhost and Google Scholar. Finally a service quality
total of 40 literature pieces in 15 journals were considered based on the following criteria:
availability of full access by the researcher;
appearance of the terms hospital/health-care service quality and/or patient
satisfaction in the title, abstract and keywords; and
relevance to the present study.
Table I represents the extensive framework of literature review conducted for this study.
Many researchers have used these five dimensions to measure service quality in health-care
organisations including public and private hospitals (Anderson and Zwelling, 1996; Wong,
2002; Sohail, 2003; Doran and Smith, 2004; Wisniewski and Wisniewski, 2005; Moghadam
and Amiresmaili, 2009; John et al., 2011; Ramanujam, 2011; Alborie and Damanhouri, 2013).
Though this scale has been used extensively to measure hospital service quality, it remains
silent about dimensions like clinical procedures and their outcome, process of admission,
discharge, billing, follow up, information dissemination, patient safety, food and social
image or responsibility.
Owing to these limitations, some researchers have modified the SERVQUAL scale by
adding some dimensions, especially for health-care organisations. Roshnee and Fowder
(2008) measured service expectations and perceptions in private clinics of general
practitioners. They developed PRIVHEALTHQUAL scale, which is an extension of
SERVQUAL scale. This instrument includes seven dimensions of health-care service quality
such as tangibility or image, reliability or fair and equitable treatment, responsiveness,
assurance or empathy, core medical services or skill or competence, equipment and records
and information dissemination. Arasli et al. (2008) developed a modified SERVQUAL scale
to evaluate service quality in both public and private hospitals. This study identified six
dimensions of hospital service quality such as empathy, relationship, giving priority to
inpatients’ needs, professionalism of staff, food and physical environment. Rashid and Jusoff
(2009) proposed a conceptual model of hospital service quality in which they added five
more dimensions to the SERVQUAL scale to make a total of ten dimensions that contribute
to service quality. These ten dimensions of hospital service quality are reliability, tangibles,
responsiveness, assurance, empathy, access, choice, information, redress and representation.
Eleuch (2011) conducted an empirical study in Japan to measure patients’ perception about
quality of service in health care. According to this study, health-care service quality consists
of both functional and technical quality. The items in SERVQUAL scale represent functional
quality. The technical quality consists of doctor’s service, performance of adequate
diagnostic tests and appropriateness of treatment. This study revealed three major
dimensions that contribute to health-care service quality such as staff behaviour, technical
quality and physical appearance. Murti et al. (2013) conducted an empirical study in India to
measure hospital service quality and its influence on patient satisfaction. This study
identified eight dimensions of hospital service quality, namely, tangibles, reliability,
responsiveness, assurance, empathy, discharge, safety measures and medicine quality
management. Mahapatra (2013) developed a logistic regression model to predict patients’
preference for private or public hospital based on gaps between their expectation and
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Table I.
IJPHM
Framework of
Table I.
service quality
Hospital
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Table I.
IJPHM
impression and staff diversity. Rose et al. (2004) conducted an empirical study in Malaysia
for predicting hospital service quality. This study identified eight quality dimensions such
as technical, interpersonal, amenities or environment, access or waiting time, cost, outcomes,
social support and patient education. Zineldin (2006) developed the 5Q multidimensional
model of health-care quality and patient satisfaction. According to this model health-care
quality is a function of five quality dimensions such as quality of object, quality of process,
quality of infrastructure, quality of interaction and quality of atmosphere.
Dagger et al. (2007) conducted an empirical study in Australia to develop a
multidimensional hierarchical scale for measuring health-care service quality. This study
identified four major dimensions of hospital service quality such as interpersonal quality,
technical quality, environment quality and administrative quality. Tam (2007) evaluated
hospital service quality in Hong Kong by using seven dimensions of medical encounter that
represent quality of service delivery. These seven dimensions are doctors’ consultation,
support staffs’ performance, nurses’ performance, physical environment, dispensers’
performance, length of wait for consultation and doctors’ proactive attitude. Mejabi and
Olujide (2008) developed a scale for measuring hospital service quality in Nigeria. This scale
included eight dimensions of hospital service quality such as resource availability, quality of
care, condition of clinic or ward, condition of facility, quality of food, attitude of doctors or
nurses, attitude of non-medical staff and waiting time for service. Duggirala et al. (2008)
identified seven dimensions of hospital service quality in Indian conditions, namely,
infrastructure, personnel quality, process of clinical care, administrative procedures, safety
indicators, social responsibility and overall experience of medical care received. Padma et al.
(2009) developed a conceptual framework to measure hospital service quality from the
perspective of patients as well as their attendants. This framework proposed eight
dimensions of service quality such as infrastructure, personnel quality, process of clinical
care, administrative procedures, safety indicators, corporate image, social responsibility and
trustworthiness of the hospital. Padma et al. (2010) conducted an empirical study to measure
hospital service quality perceptions of both patients and their attendants. For this purpose,
they used an instrument with the above mentioned eight dimensions of hospital service
quality.
Chahal and Kumari (2010) developed and empirically validated HCSQ scale to measure
health-care service quality in Indian context. This study categorised hospital service quality
in to five broad components such as physical environment quality, interaction quality,
outcome quality, service quality and image. Three sub-dimensions, namely ambient
conditions, tangibles and social factor constitute the component physical environment
quality. Four sub-dimensions like attitude and behaviour, expertise, process quality and
IJPHM service quality constitute the component interaction quality. Similarly four sub-dimensions
such as waiting time, patient satisfaction, patient loyalty and service quality constitute the
component outcome quality. Three sub-dimensions like physical environment, staff
competence and trust constitute the component service quality. Finally three sub-
dimensions like technical image, modern equipment and technical facilities constitute the
component image. Narang (2010) considered four major dimensions of hospital service
quality such as health personnel practices and conduct, adequacy of resources and services,
health-care delivery and access to service to measure patients’ perception towards tertiary
health-care services in India. Aagja and Garg (2010) developed and validated PubHosQual
scale to measure perceived service quality for public hospitals in the Indian context. This
scale consists of five dimensions of hospital service quality, namely, admission, medical
service, discharge process, overall service and social responsibility. Mehta (2011) empirically
evaluated service quality and patient satisfaction in Indian health-care context in which he
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identified three dimensions of hospital service quality such as promptness, medical aids and
patient interest. Results of this study also found promptness to be the most important
determinant of service quality followed by medical aids and patient interest.
Zineldin et al. (2011) used 5Q model to empirically evaluate health-care service quality in
Kazakhstan. This study measured service quality through eight dimensions such as
infrastructure, atmosphere, interaction, process, staff skills, waiting time, object and
adequacy. Atinga et al. (2011) empirically measured hospital service quality in Ghana
through four dimensions such as communication, patient–provider relationship,
environment and waiting time. Amin and Nasharuddin (2013) empirically investigated
service quality in Malaysian health-care setting in which they considered five dimensions,
namely admission, medical service, discharge, overall service and social responsibility to
measure service quality of both private and public hospitals. Mosadeghrad (2013) conducted
a qualitative study to propose a broad definition of hospital service quality in Iranian health-
care setting based on expectations of nine different stakeholders such as patients, patients’
relatives, providers, managers, policymakers, suppliers, payers, accreditation staffs and
quality managers. This study defined hospital service quality through eight quality rights:
“right care in the right way for the right individual in the right place at the right time by the
right person and for the right price to achieve the right results”. Voon and Abdullah (2014)
conducted an empirical study and developed HospiSE scale to measure service quality of
both public and private hospitals in Malaysia. This measurement scale included three broad
dimensions, namely, employee orientation, patient orientation and competitor orientation
that represent service excellence environment in hospitals. Employee orientation includes
parameters like internal coordination and communication, employee motivation and
competency along with innovative approach in delivering service. Patient orientation
includes parameters like hospital’s commitment to provide service, understanding patients’
needs and resolving their problems along with provision for measurement of patient
satisfaction at regular intervals. Itumalla et al. (2014) developed HospitalQual scale to
measure service quality for in-patient services in hospitals. This scale consists of seven
dimensions such as medical service, nursing services, supportive services, administrative
services, patient safety, patient communication and hospital infrastructure. This study also
established these seven dimensions as significant determinants of inpatient service quality.
suggest both direct and indirect impact of service quality on behavioural intention. This
study confirms that the indirect impact of service quality on behavioural intention mediated
through customer satisfaction is greater than that of the direct impact. Li et al. (2011)
empirically investigated moderating effect of customer satisfaction on the relationship
between service quality and behavioural intention in hospital setting. Findings suggest
positive moderating effect for service quality dimensions like reliability and empathy
whereas negative moderating effect for dimensions like responsiveness and assurance.
Mohamed and Azizan (2015) proposed and empirically tested a model that confirms
significant association between perceived service quality, patient satisfaction and
behavioural compliance in health-care organisation. This study establishes patient
satisfaction as the dominant and significant determinant of behavioural compliance. It also
establishes direct as well as indirect influence of perceived service quality on behavioural
compliance mediated through patient satisfaction. Sadeh (2017) validated direct linkage
between service quality and patient satisfaction, service quality and patient loyalty as well
as patient satisfaction and patient loyalty.
Wong (2002) found the five dimensions of service quality considered in SERVQUAL
scale as significant predictors of overall satisfaction of ambulatory patients in a bone
densitometry unit. Dagger et al. (2007) empirically validated a model, which shows patients’
perception of service quality has significant impact on their level of satisfaction towards
health-care service delivery, which in turn influences their behavioural intention. Zineldin
(2006) developed a multidimensional model of health-care quality and patient satisfaction,
according to which five quality dimensions constitute total quality in health care which
influences patient satisfaction that results in positive behavioural intention of patients to
recommend a health service provider. Tam (2007) conducted a longitudinal study which
shows improvement in quality of health service delivery improves patient satisfaction
which in turn, encourages patients’ behavioural intention to revisit a specific health-care
service provider. Duggirala et al. (2008) found seven dimensions of patient perceived total
quality service in health-care as significant predictors of overall patient satisfaction. Vinagre
and Neves (2008) developed a model to establish direct impact of service quality, patient’s
emotion, involvement and expectations on patient satisfaction. Padma et al. (2009) proposed
a conceptual framework which shows the eight dimensions of hospital service quality
influence customer satisfaction which in turn, influences their behavioural intention.
Naidu (2009) proposed a conceptual model, which shows health service quality perception as
antecedent of patient satisfaction and their behavioural intention in terms of the level of
loyalty towards a health-care service provider. Chaniotakis and Lymperopoulos (2009)
developed a model based on empirical study, which shows direct influence of service quality
IJPHM dimensions like tangibles, assurance and responsiveness on patient satisfaction and their
behavioural intention to spread the word-of-mouth. Padma et al. (2010) explored the impact
of hospital service quality dimensions on patients’ and their attendants’ satisfaction. This
study found service quality dimensions like personnel quality, clinical care, image and
trustworthiness having statistically significant impact on patients’ satisfaction. Service
quality dimensions like infrastructure, personnel quality, process of clinical care and
administrative procedure were found to have statistically significant impact on attendants’
satisfaction. Mehta (2011) established the cause and effect relationship between hospital
service quality and patient satisfaction. Atinga et al. (2011) found service quality dimensions
like communication, provider–patient relationship, environment and waiting time as
significant predictors of patients’ satisfaction with quality of health service delivery.
Amin and Nasharuddin (2013) developed a model establishing positive relationship between
dimensions of hospital service quality, patients’ satisfaction and their behavioural intention.
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Murti et al. (2013) developed a model, which suggests the seven dimensions of hospital
service quality as significant predictors of patient satisfaction as well as their behavioural
intention. Voon and Abdullah (2014) suggested dimensions of hospital service quality
having positive and significant influence on employee perceived overall quality, patient
satisfaction and their repurchase intention.
Admission
Discharge
Waiting time
Procedural Quality
Patient safety/privacy
Follow up
Ambience
Overall
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Behavioural
Staff attitude
Intention
Personalized attention Interactional Quality
Information availability
Staff competency
further proposes a direct relationship between patients’ overall perceived service quality and
their level of satisfaction with the service delivery. This direct relationship represents the 20
dimensions of hospital service quality as antecedents of patients’ satisfaction, which, in turn,
influences their behavioural intention. Patients’ behavioural intention reflects their tendency
to spread word of mouth about the hospital, recommend a hospital to their friends and
relatives to avail services and consider repeat visit in case of illness in future.
Conclusion
Extensive review of literature on hospital service quality strongly indicates that the
dimensions discussed under SERVQUAL and modified SERVQUAL instruments are not
adequate to cover the holistic perspective of perceived service quality in a health-care
setting. Thus, understanding and measurement of hospital service quality needs a non-
SERVQUAL or different approach to address all the concerned areas, as it is adapted by
many researchers that are discussed earlier in the literature review section. With reference to
all the literature considered for the present study, this article has tried to develop an
exhaustive framework (The 6-Q framework for hospital service quality and patient
satisfaction) to provide a holistic impression about hospitals service quality through 6 broad Hospital
quality areas consisting of 20 dimensions. service quality
This “6-Q framework for hospital service quality and patient satisfaction” also supports
earlier researchers’ view about the direct relationship between hospital service quality and
patient satisfaction, as well as the mediating role of patient satisfaction while linking
hospital service quality with behavioural intention. This “6-Q framework” clearly suggests
that patients evaluate quality of service delivery in a hospital through the 20 dimensions
which results in patients’ overall perception about the service quality of a hospital. This
overall perception about service quality directly influences the level of patients’ satisfaction
with health-care service provider. Depending on the level of satisfaction, patients show
either positive or negative behavioural intention with respect to spreading word of mouth,
future usage and recommending a particular health service provider to others.
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Managerial implications
The conceptual framework projects all the possible dimensions through which patients
evaluate or perceive quality of service delivery in hospitals. Health-care managers/
administrators should take all possible measures to take feedback from patients and/or their
attendants at regular interval to evaluate quality of service, identify gaps across these
dimensions and fix issues accordingly. All health-care organisations should attach highest
importance to technical quality, as it addresses management of the core medical service that
comprises treatment and its outcome for which patients basically visit to hospitals. Without
proper management of technical quality, a hospital can never be rated higher for its service
delivery. The second most important area that should be managed by hospitals is the
procedural quality, which addresses essential administrative functions like admission,
discharge, waiting time, billing and follow-up that are associated with medical treatment.
Thus, health-care managers need to understand that technical quality and procedural
quality are the basic expected level of service associated with hospitals. All the other four
areas such as infrastructural quality, interactional quality, personnel quality and social
support quality can be considered as elements of augmentation to the basic health service.
Thus, depending on the availability of physical/financial/manpower resources, health-care
managers can prioritise their focus on these four areas to improve patients’ experience
during hospital stay. This will help improve patient satisfaction and spread positive word-
of-mouth, thereby improving hospital’s image as well as profitability.
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Frimpong, N.O., Nwankwo, S. and Dason, B. (2010), “Measuring service quality and patient satisfaction
with access to public and private healthcare delivery”, International Journal of Public Sector
Management, Vol. 23 No. 3, pp. 203-220.
Appendix
It represents the items that can be used to measure each of the 20 dimensions of perceived
service quality in a hospital, patients’ satisfaction level with the service delivery and their
behavioural intention.
(1) Clinical procedure:
thorough investigation or examination of illness by doctors;
performance of adequate number of clinical or diagnostic tests;
efficient handling of critical incidents during the course of medical treatment;
pre-operative advice given by doctors; and
efficient management of post-operative treatment.
(2) Quality of outcome:
complications owing to inadequate or negligent care;
deterioration in health after treatment;
incidence and severity of nosocomial infections; and
effectiveness of treatment in curing illness.
(3) Admission:
convenience in getting appointment with doctors;
prompt and simple admission process;
ease of availing emergency service of the hospital;
short and simple process of allocation of beds or wards; and
smooth transition from OPD to wards.
(4) Discharge: Hospital
prompt and simple discharge process; service quality
proper explanation about the discharge process; and
explanation about precautions and medicines to be taken post discharge.
(5) Waiting time:
time required to meet doctors in the OPD;
time required to receive first care by doctors in wards;
time required to get diagnostic test reports; and
time required to receive emergency care when needed.
(6) Patient safety and privacy:
adequate hygienic care and procedures to prevent infections;
presence of safety measures like ramps, hand rails, elevators to prevent fall;
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stay.
(22) Behavioural intention:
extent to which patients spread positive word of mouth about the hospital;
patient’s willingness to come back for treatment at the same hospital in case of any
illness in future; and
patient’s willingness to refer this hospital to friends or relatives for treatment in
case of any illness.
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