A conceptual framework of service quality in healthcare: Perspectives of Indian patients and their...

A conceptual frameworkof service quality in healthcare

Perspectives of Indian patientsand their attendants

Panchapakesan Padma, Chandrasekharan Rajendran andL. Prakash Sai

Department of Management Studies, Indian Institute of Technology Madras,Chennai, India

Abstract

Purpose – The purpose of this paper is to determine the dimensions of service quality in Indianhospitals, from the perspectives of patients and their family members/friends (referred to as“attendants”).

Design/methodology/approach – Based on the existing models and the literature on healthcareservices, a framework is proposed to conceptualize and measure hospital service quality.

Findings – Two instruments for measuring the dimensions of hospital service quality, one each fromthe perspective of patients and attendants, are proposed.

Practical implications – This framework enables hospital managers to understand how patientsand their attendants evaluate the quality of healthcare provided in respect of every dimension.A comparison of perceptions between patients and attendants would aid them to allocate resources tovarious aspects of healthcare, with respect to these two customer groups. Hospital administrators canuse the instruments proposed to obtain feedback on their performance on service quality parametersso that they can benchmark themselves with their competitors.

Originality/value – This paper contributes to research on healthcare services by the developmentof a comprehensive framework for customer (both patient and attendant)-perceived healthcarequality.

Keywords India, Health services, Patients, Customer satisfaction, Customer services quality

Paper type Research paper

1. IntroductionThe abundant literature on research on service quality stands testimony to theuniversal interest in unraveling the minds of service providers and receivers in order togain insights into the dimensions that have a bearing on their respective expectationsand perceptions pertaining to design and delivery of quality services. While theliterature concerning service quality dimensions in the healthcare industry is repletewith studies from the developed world, researchers from developing countrieshave been exploring the applicability of the related models and frameworks in theirspecific context. This work is an effort to comprehend the major stakeholderperspectives germane to the delivery healthcare-related services in India. It attempts tothrow light on the role played by the patients’ family members and friends (referred to

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/1463-5771.htm

The authors are thankful to the referees and the editor for their suggestions and comments toimprove the earlier version of the paper.

Frameworkof service quality

in healthcare

157

Benchmarking: An InternationalJournal

Vol. 16 No. 2, 2009pp. 157-191

q Emerald Group Publishing Limited1463-5771

DOI 10.1108/14635770910948213

as “attendants”) in the healthcare arena. In India, patients, in general, and in-patients inparticular, are always accompanied by their family members or friends (or at least oneof them), by volition provide necessary assistance to the patient for the entire durationof the stay in the hospital by staying in the same premises. Service quality research inthe Indian healthcare context not only needs to take cognizance of the indispensablerole played by attendants, but also examine their influence on patients’ satisfactionwith the services offered by the hospital.

The Indian healthcare industry has been growing at a pace comparable with theIndian sunrise industries such as Telecom and Bio-technology. The developed world isalso waking up to the reality that healthcare industries in developing countries such asIndia have come of age, and they can offer quality service at a competitive price (IndiaBrand Equity Foundation, 2007). A research report by PricewaterhouseCoopers (2007)observed: “Healthcare is one of India’s largest sectors, in terms of revenue andemployment, and the sector is expanding rapidly. Today the total value of the sector ismore than $34 billion. This translates to $34 per capita, or roughly 6 per cent of GDP. By2012, India’s healthcare sector is projected to grow to nearly $40 billion.” Despite thegiant steps taken by the Indian healthcare industry, there is a need for improvement incustomer service. A recent report of Sahay (2008) stated that even though medical careprovided by India’s private hospitals is of a very high standard, the customer serviceleaves a lot to be desired. Jain and Gupta (2004) opined: “Quality has come tobe recognized as a strategic tool for attaining operational efficiency and improvedbusiness performance.” Further, service quality has become the greatest differentiator,the most powerful competitive weapon most service organizations possess (Berry et al.,1988). Guven-Uslu (2005) stated that customers’ feedback was not considered inbenchmarking processes in the UK healthcare services. Arasli et al. (2008) also foundthat patients’ needs were not met with in public and private hospitals in NorthernCyprus. Sahay (2008) added that staff attitudes to patients and their families woulddetermine a fair amount of patient reaction and our hospital services and hospitals havesome way to go on this front. In this context, an understanding of the interplaybetween factors such as quality of healthcare services, its outcome and patientsatisfaction have become invaluable inputs for designing, managing and benchmarkinghealthcare systems. Hence, it is necessary to conceptualize service quality in thehealthcare context.

The specific nature of healthcare services vis-a-vis other service industries such asbanking, hospitality and tourism is duly reflected in terms of the following traits:

. Service strategy. As physical goods contain some elements of service andservices contain some physical components, marketers think of offerings asranging along a good-services continuum. Healthcare is the most intangibleservice because the consumer cannot sample it before purchase and cannotevaluate it after consumption. The medical care provided varies from patient topatient, right from diagnosis to response to the treatment. There are many healthprofessionals involved for treating a single ailment with a great variation of care.Further, the demand for a healthcare service cannot be predicted, but thefacilities (e.g. emergency rooms) have to be staffed and kept ready for patients’use. The consumer is not always the decision maker because it is the physicianwho often recommends specific hospitals and therapists to the patients whomostly follow the advice.

BIJ16,2

158

. Experience innovation. Prahalad and Ramaswamy (2003) traced the emergence ofa new business model for providing personalized service in the context of health careindustry. They demonstrated through some case studies that future practices ofinnovation would shift from products and services to experience environments, wherecompanies as well as consumers co-create value unique to individual customers.

. Disruptive technologies and business models. Christensen et al. (2000) assertedthat healthcare sector should allow cheaper, simpler and more convenienttechnologies which focus on low-end customers to disrupt the existing onesaimed at profitable high-end market, in order to be more efficient and providehigher quality care to patients.

. Critical nature of service. The whole focus of healthcare industry is patients’well-being (both physical and mental). Patients are usually in a physical ora psychological discomfort when they consume health services. Further, due tohigh degree of intangibility involved in providing care and high professionalism(e.g. physician specialization, skills, etc.) demanded, healthcare services aredifficult to evaluate.

. Customers inhealthcare. Healthcare has numerous consumers: patients, who actuallyconsume the service provided; physicians, who recommend healthcare providers fortheir patients; third-party payors, who dictate patients’ choice of hospitals by theirsubstantial financial influence. Keeping pace with technological advances, there is afundamental shift in healthcare consumerism – patients are becoming betterinformed, more involved in their own healthcare and more demanding.

. Context of developing nations. In India, patients, particularly in-patients, aremostly accompanied by a family member or a friend (named “attendant” in thecontext of this study). As patients are physically or psychologically ill, attendantsinfluence patients in choosing the hospital service providers (Strasser et al., 1995).Hence, attendants play a crucial role in healthcare.

Our paper focuses on the evolution of service quality and existing models to measureservice quality, and thereafter develops a comprehensive instrument to measureservice quality, considering both attendants and patients in the healthcare system.The treatment on service quality in general is essential to understand service quality inthe context of healthcare. Hence, we devote Sections 2-6 to deliberate on service qualityconceptualization, its measurement, tools and techniques used in this context, etc. andthen move to Sections 7-10 to understand service quality in the context of healthcare.The conceptualization and measurement of service quality enables both internal andexternal benchmarking of services.

2. Conceptualization of service quality: an overviewThe literature on service quality is replete with studies ranging from exploration of itsinherent dimensions to its impact on service outcomes. This section provides anoverview of the existing literature on the definition of service quality, its evolution,conceptualization and measurement and application in various sectors, and itsinfluence on customer satisfaction. As service quality means “perceived servicequality”, the literature on service quality has considered evaluating services fromcustomers’ perspective.


in healthcare

159

2.1 Development of SERVQUALGronroos’ (1984) model of service quality has been recognized as a seminal work inservice quality research. The SERVQUAL instrument formulated by Parasuraman et al.(1985, 1988) is the most widely cited framework in the services marketing literature.According to Gronroos (1984), service quality has two components, namely, technicalquality and functional quality. The technical quality refers to the primary care attributeslike treatment provided, infrastructure, etc. whereas functional quality indicatessecondary care attributes or how the service is delivered like friendliness of servicepersonnel, timely delivery, etc. Gronroos (1990) included “image” of the service provideras the third dimension, in addition to technical and functional quality in serviceevaluation. It acted as a filter in consumers’ perception of quality. Parasuraman et al.(1985) supported the notion that perceived service quality is an overall evaluationsimilar to attitude. They proposed that service quality is a function of the differences orgaps between customers’ expectation and performance along the quality dimensions.Hence, this model is called “Gaps Model”. Gaps Model depicts five gaps in a servicedelivery process, which may lead to unfulfilled needs of the customers. Parasuramanet al. (1988) refined their existing model and came up with a scale to measure servicequality and this scale is named SERQUAL. This scale consisted of five dimensions, viz.,reliability, responsiveness, assurance, empathy and tangibles. The description of thesedimensions is as follows:

. Reliability. Ability to provide services accurately and dependably.

. Responsiveness. Readiness or quickness in responding to customers’ needs.

. Assurance. Courtesy and knowledge of the employees and their ability to conveytrust and confidence.

. Empathy. Caring and individualized attention provided to customers.

. Tangibles. Physical evidence in a service facility (e.g. personnel, equipment, etc).

Several authors (Rohini and Mahadevappa, 2006) listed the advantages of SERVQUALas follows:

. It is accepted as a standard for assessing different dimensions of service quality.

. It has been shown to be valid for a number of service situations.

. It has been known to be reliable.

. The instrument is parsimonious in that it has a limited number of items.This means that customers and employers can fill it out quickly.

. It has a standardized analysis procedure to aid interpretation and results.

However, the instrument also drew several criticisms, which are highlighted inSection 2.3.

2.2 Applications of SERVQUALThe development of SERVQUAL framework marked an important point in servicequality research. Several researchers attempted to apply this framework to myriadindustries and sectors including healthcare services (Rohini and Mahadevappa, 2006;Ramsaran-Fowdar, 2008). An examination of the literature on services similar/relatedto healthcare like banking, hospitality, tourism, etc. would shed light on the various

BIJ16,2

160

factors of service quality, which would impact the customers’ perception of servicequality and their satisfaction.

2.2.1 Applications of SERVQUAL in hospitality and tourism. One of the earliestworks in the hotel industry was an exploratory study by Akan (1995) that examinedthe relevance of SERVQUAL (Parasuraman et al., 1985) in Turkey hotels. The studyidentified new dimensions (such as accuracy of speed of service, solutions to problems,communication and transactions), and determined their importance to the customers.Alexandris et al. (2002) also applied SERVQUAL framework in Greece hotels, andfound that tangibles received the highest mean value followed by theassurance-dimension. Akama and Kieti (2003) measured tourist satisfaction inKenya. They used SERVQUAL instrument to operationalize service quality, and theyconsidered two addtional dimensions, namely, price and perceived value, apart fromthe five SERVQUAL dimensions. Lau et al. (2005) in their study on luxury hotels inMalaysia used SERVQUAL scale to evaluate the hotel services, and found that thetangibility factor was of at most importance in hospitality services. The study of Nadiriand Hussain (2005) in North Cyprus revealed a two dimensional structure of servicequality consisting of tangibles and intangibles, instead of five dimensions.

2.2.2 Applications of SERVQUAL to banking. Tamimi and Amiri (2003) appliedSERVQUAL framework to UAE banks in Dubai and Abu Dhabi to determine that allthe dimensions had a significant impact on overall service quality. Gan et al. (2006)used only three dimensions of the SERVQUAL model, namely, reliability, assuranceand responsiveness, in their study on customers’ choice in electronic and non-electronicbanking organizations. Several authors (Sureshchandar et al., 2002a) developed theirown instrument to measure service quality.

2.2.3 Applications of SERVQUAL in other service sectors. Natalisa and Subroto(1998) employed SERVQUAL dimensions in their study on airline service quality inIndonesia, and determined that assurance had the strongest effect on customer’ssatisfaction. Mai (2005) examined the differences in student satisfaction in highereducation between UK and the USA. The students in UK rated most of the servicequality attributes significantly less than their US counterparts. Chen and Lee (2006) usedimportance-performance analysis to determine the quality attributes leading tostudents’ satisfaction in dormitory services. They found that dormitory could increaseits students’ satisfaction if it provided television programmes and lowered its fee.Tsoukatos and Rand (2006) customized SERVQUAL and applied to Greek insuranceindustry, and found that dimensionality of service quality was different from thatproposed by Parasuraman et al. (1988). All the non-tangible factors merged together toform a single dimension whereas tangibles form another dimension. Even thoughSERVQUAL has been the most popular framework in services literature, it is widelycriticized by many researchers.

2.3 Criticisms on SERVQUALThe SERVQUAL scale, a milestone in service quality research and though popular,was severely criticized by numerous researchers. Babakus and Boller (1991) performedconfirmatory factor analysis on SERVQUAL dimensions and arrived at a poor modelfit. They suggested a two-dimensional structure, one with positively worded itemsand the other with negatively worded items. Parasuraman et al. (1991) addressedthe issues raised by vindicating the use of gap scores for measuring service quality.


in healthcare

161

They modified the negatively worded items in their instrument to improve the overallreliability values of the scale. Cronin and Taylor (1992) disagreed with the gaps-scoremeasurement, and proposed that measuring service quality in terms of performancealone would suffice; they developed performance-only measurement scale, which theytermed “SERVPERF”. Parasuraman et al. (1994) responded to these concerns andrevised their original instrument but disagreed on replacing their model entirely with theones proposed by these authors. Further criticism pertaining to SERVQUAL is that itfails to capture the dynamics of changing expectations. Parasuraman et al. (1985, 1988)asserted that SERVQUAL had five sound and psychometrically strong dimensions.They also claimed that the structure and dimensionality was consistent across thechosen five independent samples from different industries. However, Carman (1990)arrived at a different dimensional structure while using SERVQUAL scale in a studypertaining to hospitals. Nine dimensions were found: admission service, tangibleaccommodations, tangible food, tangible privacy, nursing care, explanation oftreatment, access and courtesy afforded visitors, discharge planning and patientaccounting, and these dimensions explained 71 per cent of variation in service quality.

According to Babakus et al. (1993), service quality was a single-factor modelexplaining 66.3 per cent of overall service-quality variance, and they concluded thatempirical evidence did not support a five-dimensional concept. SERVQUAL scale wasalso criticized for not considering the technical aspect of a service and its outcomes.Even though the developers of SERVQUAL scale claimed that it consisted of both theprocess (functional) and the outcome (technical) dimensions, it is devoid of anymeasure of technical quality (Gronroos, 1990). Teas (1993) believed that expectationsbattery of SERVQUAL lacked discriminant validity. The use of seven-point Likertscales has been criticized on several grounds. Rust et al. (1995) supported the notion ofusing gap score but they asserted measuring the gap directly by asking therespondents to provide a score for each performance item in relation their expectations.This could make the scale more reliable and reduce the length of the instrument. Someauthors (Caruana et al., 2000) demonstrated that prior items could influence therespondents’ evaluation of subsequent items. For SERVQUAL, in which respondentscomplete the expectations- and perceptions-battery on the same Likert scale, sucheffects are more likely to occur. Further, the variance extracted by SERVQUAL scaleaccounted for very low proportion of item variances (Buttle, 1996). Table I provides asummary of critique on SERVQUAL. The varied comments on SERVQUAL mandatedfurther investigation of dimensions of service quality and led some researchers todevelop their own scale for measuring service quality. A number of authors (Lee et al.,2000) demonstrated that performance-only model of Cronin and Taylor (SERVPERF)to be better than SERVQUAL. Despite these developments, SERVQUAL is still themost widely used model in the field of service quality (Coulthard, 2004).

2.4 SERVPERF and its applicationsThe wide acceptance of performance-only model (SERVPERF – discussed in Section 2.3)of Cronin and Taylor (1992), resulted in the application of the model in a variety of sectorslike travel, tourism, hospitality, etc.

Cunningham et al. (2002) used SERVPERF model to find the link between servicequality and customer satisfaction in airline industry. They compared the servicequality perceptions of the USA and Korean travellers, and found that US passengers

BIJ16,2

162

were more satisfied with the airline service than their Korean counterparts.US travellers perceived higher risk in airline service, and hence, service firms shouldaim to promote less risk in their marketing strategies. Jain and Gupta (2004) conducteda study on Delhi restaurants to compare SERVQUAL and SERVPERF scales in Indiancontext. They concluded that SERVPERF should be employed for assessing overallservice quality of a firm and in undertaking service quality comparisons across serviceindustries because of its psychometric soundness and greater instrument parsimony.On the other hand, in order to identify areas relating to service quality shortfalls forpossible intervention by the managers, the SERVQUAL scale needed to be preferredbecause of its superior diagnostic power. Johns et al. (2004) also showed thatSERVPERF scores predicted overall satisfaction better, and they had higher validityand reliability than SERVQUAL scores.

3. Measurement of service qualityThe area of service quality is well-researched. There are some researchers whoemployed/applied SERVQUAL framework in their study (this has been already discussedin Section 2.2.3). Others developed their own scale for measuring service quality (thiswould be discussed in this section). Several authors like Kano et al. (1984) and Silvestroand Johnston (1990) pointed out that the determinants of service quality which causedsatisfaction and dissatisfaction were different. Further, measuring service quality andobtaining customer feedback on services enable the service providers to benchmarkthemselves with their competitors and thereby add value to their own processes.Hence, it becomes necessary to explore the various factors/dimensions of service

Criticism Literature

Use of attitudinal model in place ofdisconfirmation model

Cronin and Taylor (1992, 1994) and Oliver (1993)

Conceptualization of service quality as gapbetween perceptions and expectations

Cronin and Taylor (1992) and Boulding et al.(1993)

Psychometric validity of gap scores Teas (1993)Focus only on functional quality rather thantechnical quality

Cronin and Taylor (1992) and Richard andAllaway (1993)

Use of Likert scale for measuring service qualityand failure of the model to draw from theories ofstatistics, psychology and economics

Babakus and Mangold (1992)

Exclusion of crucial factors such as core service,image, value, physical ambience, serviceencounter, etc.

Sureshchandar et al. (2001)

Number and structure of dimensions Babakus and Boller (1991) and Carman (1990)Ambiguity and usage of expectations battery Carman (1990) and Teas (1993)Item compositions Carman (1990)Moments of truth Carman (1990)Polarity of scale Babakus and Boller (1991) and Babakus and

Mangold (1992)Two administrations, one each for performanceand expectation

Babakus et al. (1993)

Order effects of expectations and perceptions Caruana et al. (2000)Variance extracted in explaining service quality Babakus and Boller (1991)

Table I.Criticisms onSERVQUAL


in healthcare

163

quality, as perceived by customers and other stakeholders and also based on modelsother than SERVQUAL so as to satisfy the individual objectives of the study.

3.1 Measurement of service quality in banksOppewal and Vriens (2000) determined that accessibility to the bank, competence of thepersonnel, accuracy and friendliness of the service offered and tangibles were thecomponents of bank service quality. Sureshchandar et al. (2002a) found that core service,human element of service delivery, systemization of service delivery, tangibles of serviceand social responsibility as the determinants of service quality in Indian banks. Jabnounand Khalifa (2005) conducted factor analysis to find that personal skills, reliability,values and image formed the dimensions of service quality in UAE banks. Glaveli et al.(2006) found that effectiveness, price, assurance, reliability, access and tangibles to bethe dimensions of retail banking service quality in Balkan countries. Olorunniwo andHsu (2006), in their study on mass services in retail banking industry, found thatresponsiveness, tangibility, reliability, knowledge and accessibility formed thedimensions of service quality.

3.2 Measurement of service quality in hospitalityKo and Pastore (2005) developed a reliable and valid measure of service quality inrecreational sports industry. They operationalized service quality in terms of fourconstructs, namely, program quality, interaction quality, outcome quality andenvironment quality. Poon and Low (2005) utilized exploratory factory analysis toobtain the factors – hospitality, accommodation, food and beverages, recreation andentertainment, supplementary services, transportation, location, security and safety,innovation and value added services, appearance, pricing and payment. Olorunniwoet al. (2006) conducted a second-order factor analysis to find that tangibles, recovery,responsiveness and knowledge were the dimensions of service quality in lodgingindustry. Narayan et al. (2009) proposed dimensions of service quality in Indian tourismindustry. They were: core tourism experience, information, hospitality, fairness of price,hygiene, amenities, value for money, logistics, food and security.

3.3 Measurement of service quality in educationJoseph and Joseph (1997) examined the New Zealand students’ perceptions of servicequality in education. Seven dimensions, namely, programme issues, academicreputation, physical aspects/cost, career opportunities, location, time and other factorswere identified. Sohail and Shaik (2004) determined that contact personnel, physicalevidence, reputation, responsiveness, access to facilities and curriculum provided werethe factors influencing students’ evaluation of educational service in a business schoolin Saudi Arabia.

3.4 Measurement of service quality in other servicesSome researchers attempted to study the customer perceptions of service quality inonline service environments. Jun and Cai (2001) conceptualized internet bankingservice quality based on three quality perspectives:

(1) Banking service product quality.

(2) Customer service quality.

(3) Online systems quality.

BIJ16,2

164

They also identified 17 underlying dimensions of electronic banking service qualityincluding product variety/diversity features, reliability, responsiveness, competence,courtesy, credibility, access, communication, understanding the customer,collaboration, continuous improvement, contents, accuracy, ease of use, timelines,aesthetics and security. Issac et al. (2003) proposed a framework to evaluate softwarequality from customers’ perspective. Their model included the following factors:product quality, client focus, infrastructure and facilities, operational effectiveness,process quality and employee competence. Li et al. (2006) explored the service qualitydimensions of US parcel services and came up with five dimensions, namely,access/availability, readiness to provide service, consistency/reliability, completenessof service and professionalism.

Service quality research has made use of a variety of statistical like factor analysis,multiple regression, etc. to arrive at the dimensional structure of service quality and tofind the impact of service quality dimensions on outcome variables such as customersatisfaction. Analytical tools like critical incident method, importance-performanceanalysis, etc. have been made use of in the literature to make strategic decisions. Thenext section gives a detailed description of such tools and techniques used in thiscontext.

4. Tools and techniques used in the research on service qualityService is a bundle of service encounters. A failure in service encounter may lead to theperception of “bad service”. Bitner (1990) employed critical incident method todistinguish between events causing satisfactory encounters and those that causedissatisfactory experience to customers. The results showed that employee’sresponse to service delivery failure and employee’s ability to accommodate customerneeds were sources of customer satisfaction. On the contrary, inappropriate handlingof service failure, unsolicited employee behaviours were causes of dissatisfaction.Oppewal and Vriens (2000) used conjoint analysis to measure service quality in banks.They found that the delivery of a customer-perceived high-quality service is not achance event; only through proper service delivery design and ongoing conformancechecks can a service firm hope to be successful. Min et al. (2002) made use of analytichierarchy process (AHP) to benchmark service quality in Korean hotels and suggestedthat cleanliness was the most important indicator of guest room values, and courtesy ofthe employees was the most important front-office service indicator for hotel visitors.The study also recommended various guest retention strategies. Jones (2004) describedhow Gulf Bank used balanced score card method to grow and retain its customers,increase profitability and improve service delivery and efficiency. The scorecard washelpful in identification of key drivers of customer satisfaction, consolidation of servicequality information and linking this information to the service delivery channels.Gonzalez et al. (2005) integrated benchmarking and quality function deployment (QFD)and activity based costing (ABC) to analyze the customer needs in Spanish healthindustry. They proposed an ABC model, which has the customer expectations andrequirements, as an outcome of their analysis.

Duffy et al. (2006) applied data envelopment analysis (DEA) to benchmarklong-term care services. They compared various models of DEA and showed that forprofit nursing homes were significantly more efficient than non-profit nursing homesbecause the for-profit nursing homes seemed to be motivated for a more efficient


in healthcare

165

resource utilization than their non-profit counterparts. Galguera et al. (2006) appliedchi-squared automatic interaction detector (CHAID) and logistic regression to segmentcustomers based on their loyalty for using credit cards. Logistic regression was used toidentify the significant predictors and then these predictors were used in CHAID toarrive at mutually exclusive segments to predict the target behaviour. The authorsconcluded that age, education and dwelling in urban/suburban area were the variablesdefining people with loyalty cards. Kumar et al. (2006) integrated QFD andbenchmarking methodologies to obtain strategic and financial synergies in theservices. They asserted that while QFD aided in developing the best product, whichsatisfied customer needs, benchmarking would help to develop the most efficientprocesses at the expense of the least amount of resources. The output obtained wouldhave the best value in terms of customer satisfaction. Blanchard et al. (2008) explainedhow to adopt best practices of Wal-Mart in healthcare industry. The best practicesfrom Wal-Mart’s strategy, logistics and distribution, information technology andsupplier collaboration could be implemented in healthcare services to expediteinsurance processing, make the billing procedure efficient, etc.

In this age customers are aware of various options available to them. Serviceproviders and practitioners employ various multi-variate statistical tools in order togain more insights about customer preferences. Thus, the use of various statistical andanalytical tools and techniques is much warranted.

5. Service-quality research: other aspectsSome researchers attempted to find the return on quality, the financial gains for a firmproviding quality service, customer dissatisfaction, link between service quality andbusiness performance, etc. These are explained in this section. Rust et al. (1995) felt thatquality efforts should be financially accountable and proposed the “return-on-quality”approach. The framework would act as a guide to managers on the areas whereadditional investment would be worthwhile, since spending too much on quality mightnot be valid equally in areas. Wisner and Corney (2001) benchmarked traditional andinternet banking companies and found that customer feedback was not utilized inimproving operations in these firms. van der Wiele et al. (2002) studied the linkbetween customer satisfaction and business performance. The study providedempirical evidence to the relationship, even though it was not very strong. Wait andNolte (2005) reported that there was target fatigue among managers and practitionersas they faced increasing checklists of indicators with little information on how thesedata would help in improving the health system.

Hence, benchmarking results must be viewed cautiously with full awareness of thecontext of use and limitations in their interpretation. Verhoeven et al. (2006) studied theeffect of interior colours of hospital walls on perceived service quality of patients inmedical care. They confirmed that the interior colour of the walls could enhance serviceevaluation by improving patients’ affective state and by increasing their evaluation ofthe physical environment.

Thus, the research on service quality from various aspects has yielded interestinginsights. The next section deals with the relationship between the perceived servicequality affecting customers’ satisfaction and their behavioural intentions.

BIJ16,2

166

6. Service quality, customer satisfaction and behavioural intentionsThis section deals with the comparison between service quality and customersatisfaction terminologies. The conceptual differences between the two constructs havebeen much debated. Hence, in this section the similarities and contrasts between thetwo constructs have been listed.

6.1 Service quality and customer satisfaction – a comparisonIn the literature, service quality and customer satisfaction have been considered as twosides of the same coin. Oliver (1980) proposed that satisfaction is a function of thedisconfirmation of performance from expectation. Gronroos (1982) suggests that theconsumers’ expectations of service provided are also influenced by marketingactivities, external influences and word-of-mouth. Parasuraman et al. (1985)conceptualized service quality based on this disconfirmation paradigm, andproposed that quality is a result of the difference between perceived and expectedservice. Oliver (1989) defined satisfaction as an evaluative, affective or emotionalresponse. So customers can evaluate the object only after they interpret the object.Hence, satisfaction is the post-purchase evaluation of products or services given theexpectations before purchase (Kotler, 1991). Satisfaction is dependent on the ability ofthe supplier to meet the customer’s norms and expectations, and no matter how goodthe services are, customers will continually expect better services. While customersatisfaction could be related to values and prices, service quality generally does notdepend on prices. Service quality judgments are quite specific to the service deliveredbut satisfaction can be determined by a broader set of factors including those which areoutside the immediate service delivery experience (e.g. his/her mood is good on thatparticular day). Perceptions on service quality do not depend on experiences with theservice environment or service providers, while judgments for satisfaction depend onpast experiences (Oliver, 1993).

Researchers are divided in their views on service quality and satisfaction. Someresearchers (Bitner and Hubbert, 1994; Sureshchandar et al., 2002b) attempted tooperationalize satisfaction in the same lines as service quality as both are forms ofattitudes. They debated that although items to measure service quality indicated thelevel of service offered by the firms, they could also act as measures of overall servicesatisfaction with respect to the multiple experiences the customers have with the firm.But, some researchers (Cronin and Taylor, 1992; Shemwell et al., 1998) stated that bothwere different. According to them, service quality perceptions reflected a customer’sevaluative perceptions of a service encounter at a specific point in time whereascustomer satisfaction was experiential in nature involving both a process and an endstate, comprising both cognitive and emotional elements. Table II provides a summaryof contrasts between service quality and customer satisfaction. Though service qualityand customer satisfaction are attitudes, and interchangeably used in the literature, it isevident from Table II that these two constructs are different.

6.2 Link between service quality, customer satisfaction and behavioural intentionsThe service quality research has largely gained focus because of the notion that highservice quality results in customers’ satisfaction and their behavioral intentionsincluding positive word of mouth, recommendation to others, revisit the provider, etc.Zeithaml et al. (1996) provided empirical evidence for the positive link between service


in healthcare

167

quality and behavioral intentions. However, not all the aspects of service quality mayimpact the satisfaction of customers and hence, it is vital to focus on the dimensions ofservice quality which are important to the customers. Even though there are otherantecedents to customer satisfaction, namely, price, situation, personality of the buyer(Natalisa and Subroto, 1998), service quality receives special attention from the servicemarketers because it is within the control of the service provider, and by improvingservice quality, its consequence, customer satisfaction could be improved, which mayin turn influence the buyer’s intention to purchase the service. Caruana et al. (2000), intheir study on audit firms in Malta, confirmed the moderating role of “perceived value”in the link between service quality and customer satisfaction. Lee et al. (2000) alsocorroborated with the finding that service quality is an antecedent of customersatisfaction. They found that SERVPERF performed better than SERVQUAL inexplaining customer satisfaction. Alexandris et al. (2002) showed that service qualitypredicted significant amount of variation in all the behavioral intentions, namely, wordof mouth communication, intention to purchase and price sensitivity. Caruana (2002)tested a model where customer satisfaction mediated between service quality andcustomer loyalty. The model was validated with respect to retail banking customers inMalta. Sureshchandar et al. (2002a) operationalized customer satisfaction along thesame factors as service quality in the context of Indian banks and found that the twowere highly correlated but significantly different constructs.

Hong and Goo (2004) found the path “service quality ! customersatisfaction ! loyalty” to be significant in Taiwanese service firms. Otani and Kurz(2004) concluded that nursing was more important in improving customer satisfactionand behavioral intentions than other factors, in the US healthcare sector. Tam (2004)found that in Chinese restaurants, as customers’ perceptions of the quality of the

Service quality Customer satisfaction

Definition “The consumer’s overall impressionof the relative inferiority/superiorityof the organization and its services”(Bitner and Hubbert, 1994)

“It is a summary cognitive andaffective reaction resulting fromexperiencing a service qualityencounter and comparing it withwhat was expected” (Oliver, 1980)

Experience with theprovider

Quality perceptions do not requireexperience with the service provider

Satisfaction judgments do need priorexperience with the provider

Nature of underlyingdimensions

The dimensions underlying qualityjudgments are very specific todelivering quality

Satisfaction can result from qualityor non-quality related dimensions

Expectation Expectations for quality are based onperceptions of excellence

Non-quality issues like needs,“fairness”, etc. could formsatisfaction judgments

Dependence ontransaction

Service quality judgments need notbe transaction-specific

The satisfaction, which is theemotional reaction following adisconfirmation experience with theservice is consumption-specific(Oliver, 1981)

Consequence Superior quality is supposed to resultin customer satisfaction

Satisfied customers would engage inpositive word of mouth, recommendto others and re-patronize

Table II.Comparison betweenservice quality andcustomer satisfaction

BIJ16,2

168

service increased, they felt more satisfied with the service and in turn perceived highervalue. Ting (2004) found that “ownership of banks’ moderated the relationship betweenservice quality and customer satisfaction in Malaysian banks. Lin and Ding (2005)looked into the moderating effect of prior Information Technology experience on thelink between network quality and satisfaction. The effect was not found to besignificant, while it significantly affected the link between and service recovery andsatisfaction. Nadiri and Hussain (2005) found that only some dimensions of servicequality, namely, physical appearance and facilities as well as the behavior ofemployees, significantly influenced the satisfaction of hotel visitors in NorthernCyprus. Olorunniwo and Hsu (2006) found that satisfaction fully mediated the directlinkage from service quality to behavioural intentions in the retail banking industry.Olorunniwo et al. (2006) in their study on the link among service quality, customersatisfaction and purchase intentions, determined that service quality influencedbehavioural intentions both directly and indirectly in the lodging industry. Tsoukatosand Rand (2006) recommended that insurance service firms had to improve onintangibles rather than tangibles, in their study on customer loyalty in Greek InsuranceIndustry. So far, service quality literature has been reviewed, in general. The nextsection discusses service quality in the context of healthcare services. Wei-Shong andKuo-Chung (2006) proposed an internal benchmarking process to monitor and improvethe operational qualities of employees in the lending department. They developed ananalytical framework to analyze borrowers’ capacity.

7. Service quality in the context of healthcareHealthcare services, being credence in nature, are difficult to evaluate. Hence,understanding the perceptions of customers gains prominence and significance, in theabsence of availability of an objective measurement of medical care. This section dealswith the literature on service quality in healthcare context, viz., application ofSERVQUAL and other scales, relationship among service quality, patient satisfactionand behavioural intentions, and effect of demographics with respect to healthcareservice quality.

7.1 Applications of SERVQUAL to healthcareBrown and Swartz (1989) evaluated medical services from both the provider andcustomer perspectives by conducting a gap analysis and revealed that physicianinteraction was the most significant independent variable influencing customersatisfaction. Tucker and Adams (2001) used caring, empathy, reliability andresponsiveness as service quality dimensions of the US hospital services in their study.Curry and Sinclair (2002) tested the applicability of SERVQUAL model to healthcareservices. They found that the patients appreciated the services even though the gapscores were slightly negative which indicated that negative score was because ofhigher expectation and not due to lower perception. Jabnoun and Chaker (2003)compared the service quality perceptions of patients between private and publichospitals in the UAE. They found reliability, responsiveness, supporting skills,empathy and tangibles to be the dimensions of the service offered and also discoveredthat private and public hospitals significantly differed in terms of all these dimensionsexcept supporting skills. Sohail (2003) measured the quality of services provided byMalaysian private hospitals. It was found that perceptions exceeded expectations for


in healthcare

169

all the dimensions of service. Boshoff and Gray (2004), in their study on South Africanhospital, operationalized service quality by the dimensions, communication, tangibles,empathy of nursing staff, assurance, responsiveness of administrative staff, securityand physician responsiveness.

Iyer and Muncy (2004) employed SERVQUAL dimensions to compare the servicequality perceptions among different groups patients classified based on trust. It wasrevealed that for the high trust groups, reliability and responsiveness were the mostimportant attributes, whereas, for the low trust groups, empathy and tangibles werecrucial. Wu et al. (2004) argued that traditional methods to measure the dimensions ofservice quality were inadequate. They employed Fuzzy AHP to compare the servicesprovided by different hospitals based on the dimensions of SERVQUAL model. Hersteinand Gamliel (2006) dealt with the service quality perceptions in health maintenanceorganization. The study showed that in addition to the five dimensions of SERVQUALmodel, private branding emerged as the sixth dimension of service quality. Rohini andMahadevappa (2006) applied SERVQUAL framework and applied SERVQUAL factorsin their study on Bangalore (Indian) hospitals. They obtained the perceptions of both thepatients and the hospital management. The study concluded that there existed anoverall gap between patient’s perceptions and expectations and also betweenmanagement’s perception of patients’ expectations and patient’s expectations. Theauthors provided recommendations to fill those gaps. Ramsaran-Fowdar (2008), in astudy on private hospitals, found that “reliability, and fair and equitable treatment” wasthe most important service quality dimension in Mauritius healthcare services. Theyhad used modified SERVQUAL scale for this purpose.

In spite of SERVQUAL’s popularity, some authors developed their own instrumentto measure service quality, which would tailor to their research objectives.

7.2 Non-SERVQUAL studies in healthcareSeveral authors developed their own framework to conceptualize and measure servicequality in hospital services. Reidenbach and Smallwood (1990) conducted factoranalysis and operationalized service quality in terms of patient confidence, businesscompetence, treatment quality, support services, physical appearance, waiting timeand empathy. Andaleeb (1998) found that communication, cost, facility, competenceand demeanour were the important determinants of patient satisfaction in hospitalservices. Carman (2000) identified that hospital service had two components, viz.,technical and interpersonal aspect. Nursing care, outcome and physician careconstituted technical care whereas, food, noise, room temperature, privacy, cleanlinessand parking were parts of interpersonal care. According to the study conducted byHasin et al. (2001) in Thailand, communication, responsiveness, courtesy, cost andcleanliness were the component dimensions of service quality in hospitals. O’Connoret al. (2001) analyzed the perceptual gap in understanding patient expectations amonghealthcare stakeholders. The authors concluded that health administrators were mostlikely to estimate patient expectations while medical and nursing students were mostlikely to underestimate them. Baldwin and Sohal (2003), in examining the relationshipbetween service quality practices and service quality outcomes in dental care, foundthat patient fear and anxiety, patient’s appreciation of convenient and punctual service,involvement of patients in treatment were found to significantly influence the patient’sperceptions of dental care.

BIJ16,2

170

Otani and Kurz (2004), in their study on hospital services in the USA, foundadmission process, physician care, nursing care, compassion to family/friends,pleasantness of surroundings and discharge process to be the key dimensions ofservice quality. Rose et al. (2004) found that interpersonal aspect, patient education,cost, technical aspect, outcome of the care, access time, amenities and social support asthe dimensions of service quality in Malaysian hospitals. The study also revealed thattechnical quality was the most important factor, consistent with other studies in theliterature (Parasuraman et al., 1998; Carman, 2000, etc.) in both private and publichospitals. Secondly, interpersonal aspect and amenities were determined to be the mostimportant for private and public hospitals, respectively. Pakdil and Harwood (2005)studied patient satisfaction in a pre-operative assessment clinic. They showed thatpatients were most dissatisfied with the waiting time and positive physician-patientinteraction increased patient satisfaction more than any other provider-customerrelationship. Arasli et al. (2008) suggested that in-patients’ needs had to be gatheredsystematically in order to manage their complaints effectively. Duggirala et al. (2008)proposed that healthcare service quality consisted of seven dimensions, namely,infrastructure, personnel quality, process of clinical care, administrative processes,safety indicators, overall experience of medical care and social responsibility. Theyfound that all the dimensions were significant predictors of patient satisfaction.

It can be seen that in the context of healthcare services, some dimensions of servicequality that are specific to healthcare services have emerged. It would be worthwhile toexamine if service quality has positive relationship with customer satisfaction andbehavioural intentions in the context of healthcare services.

7.3 Service quality, customer satisfaction and behavioural intentions in healthcareservicesIn healthcare literature, some studies have established the link between hospitalservice quality and patient satisfaction. Reidenbach and Smallwood (1990) found thatoverall service quality perceptions of patients, their satisfaction and their willingnessto recommend to others were strongly correlated to each other in different hospitalsettings, namely, in-patients, out-patients and emergency care patients. Taylor andBaker (1994) showed that the moderating effect of customer satisfaction betweenservice quality and purchase intentions was significant in a variety of services such ascommunication, travel, recreation except healthcare. de Ruyter et al. (1998) concludedfrom their study that the relationship between service quality and service loyaltydiffered based on industry type; in an industry characterized by heavy switching costs(e.g. healthcare setting), customers would be loyal. Tucker and Adams (2001), in theirstudy on patient satisfaction in public hospitals, determined that provider performancetogether with access explained almost 74 per cent of variance in satisfaction. It wasfound that service quality had positive relationship with customer satisfaction andbehavioural intentions in the context of healthcare services as well. The next sectiondeals with the impact of demographics on service-quality perceptions and satisfaction.Choi et al. (2005), in their study on South Korean healthcare, revealed that therelationship between service quality and patient satisfaction did not vary acrosspatient groups based on gender, age and types of services received. Rhodes et al. (2008)found that family members of patients in the US hospices were satisfied if they wereregularly informed about the patients’ condition. Williams et al. (2008) determined that


in healthcare

171

patient satisfaction did not improve after renovation of the emergency department ofa hospital under study. They further hypothesized that satisfaction scores mightimprove if the goals of renovation, efficiency and privacy were met.

7.4 Demographics in healthcare service qualityResearchers have always been interested in knowing the effect of demographicvariables on patient satisfaction. Social psychological theories propose that patients’evaluations are moderated, or mediated, by personal feelings of equity in the exchange,disconfirmation between desires and outcomes, individual preferences, socialcomparisons and other complex phenomena (Williams et al., 1998). These theoriessuggest that behavioural differences among patients can influence their attitudes(Reidenbach and Smallwood, 1990; Brennan, 1995). In healthcare industry particularly,patients’ needs differ based on age, gender, etc. and the health care seeking behavioursof different patient segments could produce experiences which influence differentquality judgments, and hence influence satisfaction positively or negatively. Tuckerand Adams (2001) determined that provider performance and access both affected thesatisfaction. But, the demographic variables such as age, gender, education, race,marital status and number of visits did not have any moderating effect on satisfaction.Braunsberger and Gates (2002) reported that healthier patients, older patients, males,those with a lower level of education, those who perceived higher system performanceand those with lower levels of system usage were more satisfied with their healthcareplan than their counterparts. Baldwin and Sohal (2003) attempted to include age,gender and location as moderating variables between quality and satisfaction. Butthe effect was not significant. Yavas et al. (2004) declared that different aspects ofservice quality and different consumer characteristics seemed to be associated withdifferent behavioural outcomes. While tangible elements of service quality were closelyassociated with positive word of mouth and commitment for female customers,timeliness aspect of service was related to complaint and switching behaviours. Thus,it is evident that demographic variables have an effect on patient perceived servicequality. Venn and Fone (2005) reported that patient satisfaction varied with age,gender, employment status and marital status. They also stated that satisfaction scorescould not be benchmarked until the differences in socio-demographic composition weretaken into account.

7.5 Benchmarking in healthcare serviceBenchmarking is recognized as an effective tool to improve the quality of services.It enables the service providers to improve their performance and thereby gaincompetitive edge. Booth et al. (2005) highlighted the barriers in benchmarking hospitalpractices internationally. They used patient data gathered from UK and New Zealandand found that the average length of stay and death rates were less in New Zealandthan in UK Guven-Uslu (2005) compared the perceptions of managers, cliniciansand finance personnel towards the implementation of benchmarking in the UK healthservices. The study found that patients and their expectations were not considered inbenchmarking processes. Stevanovic et al. (2005) outlined how benchmarking practiceswould aid in performance monitoring of public hospitals in New Zealand.The secondary and tertiary data from all public hospitals were collated andcompared to identify potential areas of improvement. Thus, benchmarking provides

BIJ16,2

172

the consumers with health information on hospital effectiveness, thereby assistingthem in making a good choice while selecting a healthcare service provider. It also aidsthe industry practitioners to standardize the practices across organizations bycomparing individual performances.

8. Research frameworkThis section deals with the findings from the literature and the current researchframework. The existing literature on service quality throws light on various aspectsof service delivery as follows:

. Antecedents and dimensions of service quality.

. Application of SERVQUAL and SERVPERF scales.

. Criticism on SERVQUAL.

. Comparison between SERVQUAL and SERVPERF.

. Conceptualization of service quality.

. Perceptual differences among different stakeholders about service provided.

. Differences in services offered by private and public hospitals.

. Link between service quality, customer satisfaction and behavioural intentions.

. Mediators and moderators in the context of service quality.

Even though much research has been conducted on service quality dimensions,a comprehensive framework combining various aspects of existing frameworks andmodels appears possible (in the sense a comprehensive framework incorporating all therelevant factors as constructs pertaining to healthcare). In Indian context, there isa dearth of an independent model of service quality as almost all the existing studiesapplied SERVQUAL framework, except that of Duggirala et al. (2008). They developedan instrument for measuring service quality from the patients’ and providers’perspectives. They also found significant differences between patients of private andgovernment hospitals. The current study extends their framework by incorporatingother dimensions, namely, corporate image and trustworthiness of the hospital.Besides, the current study has included items in every factor from the existingliterature on healthcare services, related services, Malcolm Baldrige National QualityAward (MBNQA, 2007) and Joint Commission International (JCI, 2007) frameworks,thus going beyond the SERVQUAL dimensions and their items.

In the current literature, there is not much work on the experience of users andobservers of the service, except for the works of Strasser et al. (1995) and Butler et al.(1996). Strasser et al. (1995), in their study used the instrument designed from patients’perspective to capture the perceptions of both patients and their family members. Theyrecommended extending their research by pair-wise administering of two separate butsimilar instruments to patients and their family members and obtaining theirperceptual difference. So, in this study, two instruments, one for patients and one fortheir attendants, have been developed. Strasser et al. (1995) and Butler et al. (1996) alsoclaimed that there existed an influence of family members on the patients regarding thehealthcare service. In healthcare, patient is physically or psychologically ill, and she/hemay not be in a position to choose the service provider. Therefore, it would be her/hisfamily members or friends (or attendants, in general), who mostly make decisions on


in healthcare

173

their behalf. However, the existing literature has not focused on this aspect, so far. So,the current study attempts to include attendants’ perspective as well in theservice-quality evaluation.

9. Service quality – attendants’ perspectiveHealthcare delivery systems in developing countries, where the resources are not inproportion to the demands placed on services of healthcare institutions, call for theincrease in the effectiveness of the health-care system by the efficient management ofhospitals. Hospitals in developing countries absorb more resources than any other kindof recurrent government spending on health. Review of the health sector in manycountries suggests that these large recurrent expenditures on hospitals involve a greatwaste of resources because of the technical and managerial inefficiency within hospitals(Tabish, 1998). Further, today’s buyers are better educated and more aware than in thepast. Hence, delivering quality service becomes vital. India has become a preferredmedical treatment destination, providing cost-effective treatment to the patients from allover the world. It is currently contributing to about 4 per cent of India’s GDP (DanishTrade Council, 2007). If the services provided are improved, there is a greater chance ofthis percentage contribution to grow. The healthcare system must perform variousfunctions, namely, oversight of the health system, public health service delivery,ambulatory service delivery and in-patient care and financing options (World Bank,2001). This paper focuses only on the in-patient care. Service quality has beenestablished to be an antecedent of customer satisfaction, which is again found toinfluence customers’ purchase intentions. Even though there are other antecedents ofcustomer satisfaction, viz., situation, individual personality, location and price, servicequality gains prominence because it is mostly within the overall control of the serviceprovider. Hence, understanding not only the dimensions of healthcare services but alsothe extent of their influence of patient satisfaction gives valuable insights to hospitalmanagers and administrators. In Indian context, patients’ attendants always accompanythe patients (particularly, in-patients) during their hospital stay. Attendants gainimportance in the context of Indian healthcare services due to the following:

(1) As patients are often in a state of physical or psychological discomfort, it isoften these attendants who are in a good position to judge the care provided.

(2) Hospitals in India consider the presence of a patient’s attendant necessary forthe following reasons:. Revealing patients’ identity: most Indian citizens do not have a uniform

official document to reveal their identity unlike in the West, where everyonehas a valid social security number. If a patient gets admitted in a criticalcondition, recognizing her/his identity becomes an issue in India, especiallyif in medico-legal cases. So, an attendant could help in resolving this issue.

. Responsibility in case of critical care: attendants have to take the responsibilityof patients in case of critical care by providing undertakings. If a majorsurgery is to be performed on a married female patient, her husband/parentshave to give an undertaking in order for the hospital authorities to proceedwith the surgery.

. Support provided to patients: attendants provide both physical andemotional support to the patients. In many cases, attendants generally

BIJ16,2

174

take care of financial needs of patients, as hospitals do not allow them topossess money themselves. Attendants also act as a bridge between hospitalauthorities and patients. Sometimes, attendants aid the treatment process byarranging for blood required for surgery, without which, surgery cannot beperformed. They also procure drugs required for treatment process in bothprivate and government hospital set-up. They carry out the function offetching food from home/outside, if food is not provided by the hospital.

So, not only the attendants aid the patients in choosing a particular care provider butthey also influence patients in forming their judgments about the service. Hence, itbecomes worthwhile to investigate service quality perceptions of attendants in thehealthcare context. Extending the study of Strasser et al. (1995), the current studyattempts to develop a separate questionnaire for capturing attendants’ perceptions.

10. Determinants of healthcare service quality: patients’ and attendants’perspectivesFrom the discussion so far, it is evident that any service consists of technical qualityand functional quality components. In healthcare, technical quality is the quality ofmedical care provided (outcome of care). Functional quality is the way in which care isprovided (process of care). It can further be divided into infrastructure, personnelquality, administrative procedures and safety indicators. The current study looks atcorporate image, social responsibility and the trustworthiness of hospital as additionalfactors of healthcare service quality. Hence, we postulate that the following are thedimensions of the hospital service quality:

. infrastructure;

. personnel quality;

. process of clinical care;

. administrative procedures;

. safety indicators;

. corporate image;

. social responsibility; and

. trustworthiness of the hospital.

A brief explanation of all these service quality dimensions and the related literature onthese variables are now presented. The measurement of these variables (on a seven-pointscale) is presented in the Appendix. In Table III, various dimensions of service qualityand some related studies are shown. A discussion of service-quality critical factors ordimensions follows.

10.1 InfrastructureInfrastructure includes the tangible features of a service delivery (including equipment,appearance of the firm/facility, signage, availability of resources, etc). It is also referredto as man-made physical environment or “servicescapes”. The facilities should not onlybe visually appealing, but also be hygienic, particularly in healthcare service.As services are primarily intangible, customers judge the quality of services based on


in healthcare

175

the tangible aspects of services. Technological capability of a hospital includingequipment to test and treat various ailments is a part and parcel of the hospitalinfrastructure. Parasuraman et al. (1985), in their SERVQUAL model, used “tangibles”as a dimension of service quality. Sureshchandar et al. (2002a) also considered“tangible” elements of service as a component of service quality. Olorunniwo et al.(2006) endorsed “tangibles” to be an essential ingredient of service delivery.

Reidenbach and Smallwood (1990) and Otani and Kurz (2004) used the constructs,“physical surroundings” and “pleasantness of surroundings” in their studies,respectively, to denote the physical facilities and ambience. JCI Accreditation (2007)has also identified “facilities management” as a key function in hospitals.

10.2 Personnel qualityIt refers to quality of all the personnel involved in delivering service. The personneloffering service are expected to be responsive, reliable, friendly, sincere and competentby the customers. Personnel quality consists of all the interactions between servicepersonnel and patients including moments of truth, critical incidents, service recovery,etc. Parasuraman et al. (1985) made use of assurance, empathy and responsivenessdimensions to indicate the quality of personnel. Sohail and Shaik (2004) identified“contact personnel” as one of the factors to influence service quality evaluations in

Table III.Proposed critical factorsor dimensions of servicequality in healthcare

Dimension Typology of dimension Important related literature

Infrastructure Tangibles; facilities; physicalenvironment; accommodation aspect

Parasuraman et al. (1985);Sureshchandar et al. (2002a);Olorunniwo et al. (2006); Reidenbachand Smallwood (1990) and Otani andKurz (2004)

Personnel quality Empathy; assurance; responsiveness;courtesy; human element of servicedelivery; interpersonal care

Parasuraman et al. (1985); Sohail andShaik (2004); Issac et al. (2003);Andaleeb (1998) and Hasin et al.(2001)

Process of clinical care Primary quality; technical quality;treatment process and its outcome;reliability; understanding of illness

Gronroos (1982); Baldwin and Sohal(2003) and Rohini and Mahadevappa(2006)

Administrativeprocedures

Process of service delivery;non-human element of servicedelivery; punctuality; waiting time

Sureshchandar et al. (2002a); Boshoffand Gray (2004) and Duggirala et al.(2008)

Safety indicators Safety indicators Poon and Low (2005); Duggirala et al.(2008)

Corporate image Image; reputation; brand image Gronroos (1990); Caruana (2002) andHong and Goo (2004)

Social responsibility Social responsibility; stakeholderfocus

Chiu and Lin (2004); Sureshchandaret al. (2002a); MBNQA (2007) andDuggirala et al. (2008)

Trustworthiness of thehospital

Patient confidence; relationship ofmutual respect; trust (of the patienton the hospital)

Parasuraman et al. (1985);Balasubramanian et al. (2003);Sureshchandar et al. (2002a); Iyer andMuncy (2004)

BIJ16,2

176

business schools. Issac et al. (2003) used soft factors like employee competence andclient focus, while evaluating software quality from customers’ perspective. Friendlyand courteous staff viz., doctors, nurses, paramedical and support staff, tend toimprove patients’ perceptions of the hospital.

Andaleeb (1998) had three of the five dimensions, “competence of staff”, “demeanour”and “communication” related to patient-staff interaction, which reinstates theimportance of patient’s relationship with hospital employees. Hasin et al. (2001) used“courtesy” and “respect and caring”, respectively, to represent personnel quality in theirresearches on healthcare.

10.3 Process of clinical careThis is the core service or primary service or technical quality of hospital service.It explains “whats” of a service including the width and depth of services. This aspectof service is taken for granted by the customers. When a hospital fails in this aspect,patients do not attach any importance to other aspects, i.e. even if the personnel arefriendly in a hospital, the patient may not perceive the service to be of high quality ifthe doctor lacks the necessary competence and skill. Gronroos (1982) opined thatservice quality’s essential constituent was “technical quality”.

At the same time, this aspect of service is also difficult to evaluate as patients lackthe technical knowledge to judge the quality of treatment provided (Rohini andMahadevappa, 2006). Baldwin and Sohal (2003) included safety, reliability, technicalability and skills of dental practitioners in the factor “skill and ability”.

10.4 Administrative proceduresAdministration of hospital includes the processes of admission, stay and discharge ofpatients. Many studies reported that patients are not happy with the long waiting times fordiagnosis, treatment, etc. in the hospitals across countries. The ease of gettingappointments, ambulance services, simplicity of admission and discharge, etc. all areessential in ensuring a hassle-free treatment to patients. Efficient administration makespatients appreciate service offered better. Service delivery processes should be standardizedso that customers could receive a hassle-free service (Sureshchandar et al., 2002a).

During the whole hospitalisation experience and at each “contact point” allemployees should demonstrate that they care about its patients, are careful in protectingand enhancing the hospital’s reputation, do everything to gain the patients’ confidence inthe hospital and ensure that patients feel safe during their hospitalization (Boshoff andGray, 2004). One of the important issues of administrative processes is the delay atdifferent stages of the patient’s hospital stay (Duggirala et al., 2008). So, well-definedadministrative procedures are required to make the patients’ stay in the hospitala pleasant one.

10.5 Safety indicatorsFirms have to make their employees and customers feel safe and secure, because if eitherof these is threatened, it exerts a tremendous psychological impact on both. The safety iscritical as it relates to the survival concerns, which are basic needs of individuals.A service firm failing make their customers feel safe, loses out on everything. Poon andLow (2005) considered “safety and security” as an important construct of service qualityin hospitality services.


in healthcare

177

A hospital has to address safety critical issues in order to provide a good servicebecause patients visit hospitals to improve their health status and thereby the qualityof their life. Provision of ramps and elevators, checking for drugs causing allergicreaction in patients are some of the precautions to be taken by the hospital to avoid anycrisis and enable a comfortable stay for patients. Further, the safety of customers whohave special needs (e.g. use of ramps, elevators, etc.) has also to be considered. Olderpeople (both patients and their attendants) and physically challenged people are inneed of special facilities to take care of their needs. This is particularly important inhealthcare services, as it deals with the survival of patients. So far only Duggirala et al.(2008) seemed to have used “safety indicators” as a dimension of service quality.

10.6 Hospital imageThe existing literature on service quality argues that delivering core service isa necessary but not sufficient condition for customer satisfaction. Gronroos (1990)realized the role of “image” in the conceptualization of service quality, and emphasizedit as a filter in the perception of service quality in addition to the technical andfunctional quality dimensions. Caruana (2002) and Hong and Goo (2004) found that“corporate image” enjoyed by a service firm influenced its customer satisfaction. Theimage a firm enjoys also plays a pivotal role of conveying to a customer what the firmhas to offer in terms of technical and functional qualities. The image affects theexpectations of the customers and hence it is important in making the customers haverealistic expectations. So, even in healthcare services, the reputation of hospital has tobe considered as an element of service quality.

10.7 Social responsibilityIt is an inseparable aspect of services, although ignored by several studies. Customersnot only solicit good service but also fair service from the service providers. Chiu andLin (2004) observed that customers might perceive higher service quality if thebusiness satisfied their self-actualization needs, e.g. a customer might be willing topatronize a firm when he realizes that it is involved in a social cause such as charitywork, promoting environmental awareness, etc. Sureshchandar et al. (2002a) tooka similar view and asserted that an organization which displayed social responsibilitywould be revered and valued by customers. MBNQA (2007) emphasizes that socialresponsibility is a vital indicator of quality of service.

A service firm cannot be concerned only about its profitability but also about thesociety, as a whole. For example, if a hospital provides free treatment to economicallydowntrodden people, it certainly would boost the hospital’s image and thereby improvepatients’ perceptions of service quality. Duggirala et al. (2008), in their study on Indianhealthcare service, also emphasized on “Social Responsibility”.

10.8 Trustworthiness of the hospitalThe trustworthiness of hospital measured by the sense of well-being he feels in thehospital, security, etc. does influence the confidence the patient has on the hospital.This will in turn play a role in the overall evaluation of service provided.Balasubramanian et al. (2003) considered “perceived trustworthiness” as a componentof online service which could be a determinant of customer satisfaction. Ability to

BIJ16,2

178

provide service as promised is considered to be a necessary aspect of service deliveryby Parasuraman et al. (1985) and Sureshchandar et al. (2002a).

Iyer and Muncy (2004) considered that level of trust patients had varied acrosspatient categories and segmented the patients based on the level of the trust they hadon the service provider.

This section has provided a detailed discussion on the determinants of healthcareservice quality. The next section proposes a framework to conceptualize the healthcareservice.

11. The proposed conceptual frameworkA conceptual framework for healthcare service quality, based on the literature reviewand discussions presented in previous sections is shown in Figure 1. The frameworkconceptualizes service quality on various primary and secondary dimensions, namely,infrastructure, personnel quality, trustworthiness of the hospital, administrativeprocedures, process of clinical care, social responsibility, hospital image and safetyindicators. The dimensions have been already explained in Section 10. The proposedinstrument for measuring these dimensions is provided in Appendix. Items have beenmodified largely in order to suit the context of healthcare services. One of the criticisms

Figure 1.A conceptual framework

for healthcare servicequality

SERVICE QUALITY DIMENSIONS

Infrastructure

Personnel Quality

Process of Clinical Care

AdministrativeProcedures

Safety Indicators

Hospital Image

Social Responsibility

Trustworthiness of theHospital

CUSTOMERSATISFACTION

BEHAVIOURALINTENTIONS


in healthcare

179

on SERVQUAL was it focused only on the functional aspects of service and noton technical aspects. Therefore, the dimension, “process of clinical care” could beadapted from Duggirala et al. (2008). To make the instrument more comprehensive, twodimensions, namely, hospital image and trustworthiness of the hospital, have beenadded. Many of the items could be added with respect to these dimensions. Appendixgives the list of items, which could be adapted and modified from SERVQUAL,Duggirala et al. (2008), MBNQA (2007) and JCI (2007) and those items which areproposed in the present study.

The instrument for measuring patients’ perceptions could be supplemented withanother instrument with same dimensions but the items modified to captureattendants’ perceptions. In the case of attendants, the items can be rephrased so as toobtain attendant’s perception of service provided to the patient. For example, the firstitem in “social responsibility” would appear as “Fair medical treatment provided to thepatient by the hospital” in the instrument developed for capturing attendants’perceptions, as opposed to “Fair medical treatment provided to the you by the hospital”in the instrument meant for patients’ perspective.

The issue of what and how to provide service that best attracts and retains customershas been gaining centrality of late. The current study addresses this issue by uncoveringthe critical determinants of healthcare service quality. The present study also adoptsrelevant aspects of MBNQA (2007) and JCI (2007) frameworks towards measuringservice quality dimensions from patients’ and attendants’ perspective. Hence, theframework developed is comprehensive, and could be adopted by hospitals inmeasuring and monitoring the service quality perceptions of the service receivers.The instruments developed can be used by hospital administrators and managers ofhealthcare institutions to measure the level of service delivered by them. This studywould also help the service providers to identify the similarities and differences in thepreferences of these two customer groups, namely, patients and attendants, in order tomake strategic decisions. In turn they could decide where to make trade-offs whileallocating resources so as to meet the needs of diverse customer groups.

We propose a seven-point Likert scale (ranging from 1 indicating “very low” level ofservice to 7 indicating “very high” level of service) to measure the perceptions ofservices offered. A hospital scoring less than “4” in a dimension indicates thatcustomers perceive low level of quality and has to improve its services with respect tothat dimension. Further, a hospital which has high scores in patients’ perceptions mayscore low with respect to attendants’ perceptions. This means that it has to design newstrategies to take care of the attendants’ needs. Thus, a hospital can compare itsperformance in terms of the service quality dimensions and its customers’ satisfactionwith the benchmarks set by the best in class among similar hospitals. A hospital canalso monitor its performance over time. Further, a hospital can do functionalbenchmarking by using the service quality dimensions across its departments.

The goal of any business is to satisfy customers’ needs, which in turn would resultin customer satisfaction. A multiple regression analysis of customer satisfaction as thedependent variable and service quality dimensions as independent variables would aidin understanding those dimensions which impact the customer satisfaction the most.This could be done with respect to both patient and attendant perspectives. This wouldenable the service providers to prioritize the dimensions on which they have to focusfirst. The study can also be extended by obtaining the importance attached to each

BIJ16,2

180

dimensions by the respondents. Thereafter, a performance-importance analysisproposed by Martilla and James (1977) could be undertaken. This analysis wouldreveal to the practitioners how to allocate or economize resources and where it isessential to focus for quality improvement.

12. Summary and conclusionsThe paper has provided a detailed overview of literature in service quality in general,and healthcare service quality, in particular. A conceptual research framework hasbeen proposed to measure service quality from the perspectives of patients as well asattendants. Two instruments, one each for patients and attendants, have beendeveloped for this purpose. Any hospital embarking on a journey towards total qualitymanagement should understand its customers as “Quality” is defined as satisfyingcustomer needs. For hospitals, understanding the customers’ needs marks the startingpoint of their journey. These hospitals could use the service quality perceptions as“voice of customers”, which would in turn serve to construct “house of quality” fromorganizational perspective. As discussed in the literature review, hospitals have to beaware of their customer (patient) requirements so as to satisfy them. The satisfiedcustomers spread their word mouth and in turn persuade their family and friends toavail of services from a particular hospital. These recommendations play a significantrole in patient purchase decision, as mostly patients depend on their attendants foravailing healthcare services. The satisfied patients also remain loyal and are willing topay more for enhanced services. In this regard, a path analysis of ServiceQuality ! Customer Satisfaction ! Behavioural Intentions could be done.

In this age, every company attempts to get the maximum information about theircustomers so that they could understand their requirements better than before so as tosatisfy them. The current research helps the practitioners not only to understandcustomer preferences by measuring the service quality through its dimensions. Thehospitals could use the instrument to collect data about their customers, in order tomake strategic decisions. For example, a hospital scoring low on certain dimensionscould probe into their systems more if there are any assignable causes of customerdissatisfaction. The hospitals could also strive to segment the customers into variouscategories so that they could know where to position themselves in future. Further,hospitals could use the data obtained from their customers to benchmark their serviceswith their competitors’ services. For this purpose they compare the service qualityperceptions of their customers and the customers of their competitors. The sources ofsatisfaction and dissatisfaction in both cases would help hospitals to identify theirprospective areas of improvement.

References

Akama, J.S. and Kieti, D.M. (2003), “Measuring tourist satisfaction with Kenya’s wildlife safari:a case study of Tsavo West National Park”, Tourism Management, Vol. 21 No. 1,pp. 876-96.

Akan, P. (1995), “Dimensions of service quality: a study in Istanbul”, Managing Service Quality,Vol. 5 No. 6, pp. 39-43.

Alexandris, K., Dimitriadis, N. and Markata, D. (2002), “Can perceptions of service quality predictbehavioral intentions? An exploratory study in hotel sector in Greece”, Managing ServiceQuality, Vol. 12 No. 4, pp. 224-31.


in healthcare

181

Andaleeb, S.S. (1998), “Determinants of customer satisfaction with hospitals: a managerialmodel”, International Journal of Healthcare Quality Assurance, Vol. 11 No. 6, pp. 181-7.

Arasli, H., Ekiz, E.H. and Katircioglu, S.T. (2008), “Gearing service quality into public and privatehospitals in small islands: empirical evidence from Cyprus”, International Journal ofHealthcare Quality Assurance, Vol. 21 No. 1, pp. 8-23.

Babakus, E. and Boller, G.W. (1991), “An empirical assessment of the SERVQUAL scale”, Journalof Business Research, Vol. 24 No. 3, pp. 253-68.

Babakus, E. and Mangold, W.G. (1992), “Adapting the SERVQUAL scale to hospital services:an empirical investigation”, Health Services Research, Vol. 26 No. 2, pp. 767-86.

Babakus, E., Pedrick, D.L. and Inhofe, M. (1993), Empirical Examination of a Direct Measure ofPerceived Service Quality Using SERVQUAL Items, Memphis State University, Memphis,TN, unpublished manuscript.

Balasubramanian, S., Konana, P. and Menon, N.M. (2003), “Customer satisfaction in virtualenvironments: a study of online investigating”, Management Science, Vol. 49 No. 7,pp. 871-89.

Baldwin, A. and Sohal, A. (2003), “Service quality factors and outcomes in dental care”,Managing Service Quality, Vol. 13 No. 3, pp. 207-16.

Berry, L.L., Parasuraman, A. and Zeithaml, V.A. (1988), “The service-quality puzzle”, BusinessHorizons, September-October, pp. 35-43.

Bitner, M.J. (1990), “Evaluating service encounters: the effect of physical surroundings andemployee responses”, Journal of Marketing, Vol. 54, April, pp. 69-82.

Bitner, M.J. and Hubbert, A.R. (1994), “Encounter satisfaction versus overall satisfaction versusquality”, in Rust, R.T. and Oliver, R.L. (Eds), Service Quality: New Directions in Theory andPractice, Sage, London, pp. 72-94.

Blanchard, C., Comm, C.L. and Mathaisel, D.F.X. (2008), “Adding value to service providers:benchmarking Wal-Mart”, Benchmarking: An International Journal, Vol. 15 No. 2,pp. 166-77.

Booth, M., James, P. and Stevanovic, V. (2005), “Benchmarking of hospital activity data:an international comparison”, Benchmarking: An International Journal, Vol. 12 No. 6,pp. 515-22.

Boshoff, C. and Gray, B. (2004), “The relationships between service quality, customer satisfactionand buying intentions in the private hospital industry”, South African Journal BusinessManagement, Vol. 35 No. 4, pp. 27-38.

Boulding, W., Kalra, A., Staelin, R. and Zeithaml, V.A. (1993), “A dynamic process model ofservice quality: from expectations to behavioural intentions”, Journal of MarketingResearch, Vol. 30 No. 1, pp. 7-27.

Braunsberger, K. and Gates, R.H. (2002), “Patient/enrolee satisfaction with healthcare and healthplan”, Journal of Consumer Marketing, Vol. 19 No. 7, pp. 575-90.

Brennan, P.F. (1995), “Patient satisfaction and normative decision theory”, Journal of theAmerican Medical Informatics Association, Vol. 2 No. 4, pp. 250-9.

Brown, S.W. and Swartz, T.A. (1989), “A gap analysis for professional service quality”, Journal ofMarketing, Vol. 53, April, pp. 92-8.

Butler, D., Oswald, S.L. and Turner, D.E. (1996), “The effects of demographics on determinants ofperceived health-care service quality: the case of users and observers”, Journal ofManagement in Medicine, Vol. 10 No. 5, pp. 8-20.

Buttle, F. (1996), “SERVQUAL: review, critique, research agenda”, European Journal ofMarketing, Vol. 30 No. 1, pp. 8-32.

BIJ16,2

182

Carman, J.M. (1990), “Consumer perceptions of service quality: an assessment of the SERVQUALdimensions”, Journal of Retailing, Vol. 66, pp. 33-55.

Carman, J.M. (2000), “Patient perceptions of service quality: combining the dimensions”, Journalof Services Marketing, Vol. 14 No. 4, pp. 337-52.

Caruana, A. (2002), “Service loyalty: the effects of service quality and the mediating role ofcustomer satisfaction”, European Journal of Marketing, Vol. 36 Nos 7/8, pp. 811-28.

Caruana, A., Ewing, M.T. and Ramaseshan, B. (2000), “Assessment of the three-column formatSERVQUAL: an experimental approach”, Journal of Business Research, Vol. 49 Nos 11/12,pp. 57-65.

Chen, T.L. and Lee, Y.H. (2006), “Kano two-dimensional quality model and importance-performance analysis in the student’s dormitory service quality evaluation in Taiwan”,The Journal of American Academy of Business, Vol. 9 No. 2, pp. 324-31.

Chiu, H. and Lin, N. (2004), “A service quality measurement derived from a theory of needs”,The Service Industries Journal, Vol. 24 No. 1, pp. 187-204.

Choi, K., Lee, H., Kim, C. and Lee, S. (2005), “The service quality dimensions and patientsatisfaction relationships in South Korea: comparisons across gender, age and types ofservice”, Journal of Services Marketing, Vol. 19 No. 3, pp. 140-9.

Christensen, C., Bohmer, R. and Kenagy, J. (2000), “Will disruptive innovations cure health care?”,Harvard Business Review, September-October, pp. 103-12.

Coulthard, L.J.M. (2004), “Measuring service quality: a review and critique of research usingSERVQUAL”, International Journal of Market Research, Vol. 46 No. 4, pp. 479-97.

Cronin, J.J. Jr and Taylor, S.A. (1992), “Measuring service quality: a reexamination andextension”, Journal of Marketing, Vol. 56 No. 3, pp. 55-68.

Cronin, J.J. and Taylor, S.A. (1994), “SERVPERF versus SERVQUAL: reconcilingperformance-based and perceptions-minus-expectations measurement of servicequality”, Journal of Marketing, Vol. 58, January, pp. 125-31.

Cunningham, L.F., Young, C.E. and Lee, M. (2002), “Cross-cultural perspectives of service qualityand risk in air transportation”, Journal of Air Transportation, Vol. 7 No. 1, pp. 3-27.

Curry, E. and Sinclair, A. (2002), “Assessing the quality of physiotherapy services usingSERVQUAL”, International Journal of Health Care Quality Assurance, Vol. 15 No. 5,pp. 197-205.

Duggirala, D., Rajendran, C. and Anantharaman, R.N. (2008), “Patient perceived dimensions oftotal quality service in healthcare”, Benchmarking: An International Journal, Vol. 15 No. 5,pp. 560-83.

Danish Trade Council (2007), The Indian Healthcare Sector, Royal Danish Embassy, Bangalore.

de Ruyter, K., Wetzels, M. and Bloemer, J. (1998), “On the relationship between perceived servicequality, service loyalty and switching costs”, International Journal of Service IndustryManagement, Vol. 9 No. 5, pp. 436-53.

Duffy, J.A.M., Fitzsimmons, J.A. and Jain, N. (2006), “Identifying and studying best-performingservices: an application of DEA to long-term care”, Benchmarking: An InternationalJournal, Vol. 13 No. 3, pp. 232-51.

Galguera, L., Luna, D. and Mendez, M.P. (2006), “Predictive segmentation in action: using CHAIDto segment loyalty card holders”, International Journal of Market Research, Vol. 48 No. 4,pp. 459-79.

Gan, C., Clemes, M., Limsobunchai, V. and Weng, A. (2006), “A logit analysis of electronicbanking in New Zealand”, International Journal of Marketing, Vol. 24 No. 6, pp. 360-83.


in healthcare

183

Glaveli, N., Petridou, E., Liassides, C. and Spathis, C. (2006), “Bank service quality: evidence fromfive Balkan countries”, Managing Service Quality, Vol. 16 No. 4, pp. 380-94.

Gonzalez, M.E., Quesada, G., Mack, R. and Urrutia, I. (2005), “Building an activity-based costinghospital model using quality function deployment and benchmarking”, Benchmarking:An International Journal, Vol. 12 No. 4, pp. 310-29.

Gronroos, C. (1982), Strategic Management and Marketing in the Service Sector, Swedish Schoolof Economics and Business Administration, Helsinki.

Gronroos, C. (1984), “A service quality model and its marketing implications”, European Journalof Marketing, Vol. 18 No. 4, pp. 36-44.

Gronroos, C. (1990), Service Management and Marketing, Lexington Books, Lexington, MA.

Guven-Uslu, P.G. (2005), “Benchmarking in health services”, Benchmarking: An InternationalJournal, Vol. 12 No. 4, pp. 293-309.

Hasin, M.A.A., Seeluangsawat, R. and Shareef, M.A. (2001), “Statistical measures of customersatisfaction for health care quality assurance: a case study”, International Journal ofHealth Care Quality Assurance, Vol. 14 No. 1, pp. 6-13.

Herstein, R. and Gamliel, E. (2006), “The role of private branding in improving service quality”,Managing Service Quality, Vol. 16 No. 4, pp. 306-19.

Hong, S.C. and Goo, Y.J.J. (2004), “A causal model of customer loyalty in professional servicefirms: an empirical study”, International Journal of Management, Vol. 21 No. 4, pp. 531-41.

India Brand Equity Foundation (2007), Healthcare, available at: ww.ibef.org/industry/healthcare.aspx, dtd, March 20.

Issac, G., Rajendran, C. and Anantharaman, R.N. (2003), “Determinants of software quality:customer’s perspective”, Total Quality Management & Business Excellence, Vol. 14 No. 4,pp. 1053-1070.

Iyer, R. and Muncy, J.A. (2004), “Who do you trust?”, Marketing Health Services, Summer,pp. 26-31.

Jabnoun, N. and Chacker, M. (2003), “Comparing the quality of private and public hospitals”,Managing Service Quality, Vol. 13 No. 4, pp. 290-9.

Jabnoun, N. and Khalifa, A. (2005), “A customized measure of service quality in the UAE”,Managing Service Quality, Vol. 15 No. 4, pp. 374-88.

Jain, S.K. and Gupta, G. (2004), “Measuring service quality: SERVQUAL vs SERVPERF scales”,Vikalpa, Vol. 29 No. 2, pp. 25-37.

Johns, N., Avci, T. and Karatepe, O.M. (2004), “Measuring service quality of travel agents:evidence from Northern Cyprus”, The Service Industries Journal, Vol. 24 No. 3, pp. 82-100.

Joint Commission International (2007), Joint Commission International Centre for Patient Safety,Joint Commission International, Boulevard, IL.

Jones, C. (2004), “Developing a scorecard for service quality”, Management Services, April,pp. 8-15.

Joseph, M. and Joseph, B. (1997), “Service quality in education: a student perspective”, QualityAssurance in Education, Vol. 5 No. 1, pp. 132-8.

Jun, M. and Cai, S. (2001), “The key determinants of internet banking service quality: a contentanalysis”, International Journal of Bank Marketing, Vol. 19 No. 7, pp. 276-91.

Kano, N., Seraku, N., Takahashi, F. and Tsuji, S. (1984), “Attractive quality and must-be quality”,Journal of Japanese Society for Quality Control, Vol. 14 No. 2, pp. 39-48.

Ko, Y.J. and Pastore, D.L. (2005), “A hierarchical model of service quality for the recreationalsport industry”, Sport Marketing Quarterly, Vol. 14 No. 2, pp. 84-97.

BIJ16,2

184

Kotler, P. (1991), Marketing Management: Analysis, Planning, Implementation and Control,Prentice-Hall, Englewood Cliffs, NJ.

Kumar, A., Antony, J. and Dhakar, T.S. (2006), “Integrating quality function deployment andbenchmarking to achieve greater profitability”, Benchmarking: An International Journal,Vol. 13 No. 3, pp. 290-310.

Lau, P.M., Akbar, A.K. and Fie, D.Y.G. (2005), “Service quality: a study of luxury hotels inMalaysia”, The Journal of American Academy of Business, Vol. 7 No. 2, pp. 46-56.

Lee, H., Lee, Y. and Yoo, D. (2000), “The determinants of perceived service quality and itsrelationship with satisfaction”, Journal of Services Marketing, Vol. 14 No. 3, pp. 217-31.

Li, B., Riley, M.W., Lin, B. and Qi, E. (2006), “A comparison of customer satisfaction between theUPS and Fedex”, Industrial Management & Data Systems, Vol. 106 No. 2, pp. 182-99.

Lin, C.P. and Ding, C.G. (2005), “Opening the black box: assessing the mediating mechanism ofrelationship quality and the moderating effects of prior experience in ISP service”,International Journal of Service Industry Management, Vol. 16 No. 1, pp. 55-80.

Mai, L.W. (2005), “A comparative study between UK and US: the student satisfaction in highereducation and its influential factors”, Journal of Marketing Management, Vol. 21 Nos 7/8,pp. 859-78.

Malcolm Baldrige National Quality Award (2007), National Institute of Standards Technology,Gaithersburg, MD.

Martilla, J.A. and James, J.C. (1977), “Importance-performance analyses”, Journal of Marketing,Vol. 41, pp. 77-9.

Min, H., Min, H. and Chung, K. (2002), “Dynamic benchmarking of hotel service quality”,The Journal of Services Marketing, Vol. 16 No. 4, pp. 302-21.

Nadiri, H. and Hussain, K. (2005), “Perceptions of service quality in North Cyprus hotels”,International Journal of Contemporary Hospitality Management, Vol. 17 No. 4, pp. 469-80.

Narayan, B., Rajendran, C. and Prakash Sai, L. (2009), “Scales to measure and benchmark servicequality in tourism industry: a second-order factor approach”, Benchmarking: AnInternational Journal, Vol. 15 No. 4, pp. 469-93.

Natalisa, D. and Subroto, B. (1998), “Effects of management commitment on service quality toincrease customer satisfaction of domestic airlines in Indonesia”, Singapore ManagementReview, Vol. 25 No. 1, pp. 85-105.

O’Connor, S.J., Trinh, H.Q. and Shewchuk, R.M. (2001), “Perceptual gaps in understandingpatient expectations for healthcare service quality”, Quality Management in Healthcare,Vol. 9 No. 2, pp. 26-42.

Oliver, R.L. (1980), “A cognitive model of the antecedents and consequences of satisfactiondecisions”, Journal of Marketing Research, Vol. 17 No. 4, pp. 460-9.

Oliver, R.L. (1981), “Measurement and evaluation of satisfaction process in retail settings”,Journal of Retailing, Vol. 57 No. 3, pp. 25-48.

Oliver, R.L. (1989), “Processing of the satisfaction responses in consumption: a suggestedframework and research propositions”, Journal of Consumer Satisfaction, Dissatisfactionand Complaining Behavior, Vol. 2 No. 1, pp. 1-16.

Oliver, R.L. (1993), “A conceptual model of service quality and service satisfaction: compatiblegoals, different concepts”, in Swartz, T.A., Bowen, D.A. and Brown, S.W. (Eds), Advancesin Services Marketing and Management, Vol. 2, JAI Press, New York, NY.

Olorunniwo, F. and Hsu, M.K. (2006), “A typology analysis of service quality, customersatisfaction and behavioral intentions in mass services”, Managing Service Quality, Vol. 16No. 2, pp. 106-23.


in healthcare

185

Olorunniwo, F., Hsu, M.K. and Udo, G.J. (2006), “Service quality, customer satisfaction andbehavioral intentions in the service factory”, Journal of Services Marketing, Vol. 20 No. 1,pp. 59-72.

Oppewal, H. and Vriens, M. (2000), “Measuring perceived service quality using integratedconjoint experiments”, International Journal of Bank Marketing, Vol. 18 No. 4, pp. 154-69.

Otani, K. and Kurz, S. (2004), “The impact of nursing care and other healthcare attributes onhospitalized patient satisfaction and behavioural intentions”, Journal of HealthcareManagement, Vol. 49 No. 3, pp. 181-97.

Pakdil, F. and Harwood, T.M. (2005), “Patient satisfaction in a pre-operative assessment clinic:an analysis using SERVQUAL dimensions”, Total Quality Management, Vol. 16 No. 1,pp. 15-30.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), “A conceptual model of service qualityand its implications for future research”, Journal of Marketing, Vol. 49, pp. 41-50.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), “SERVQUAL: a multiple-item scale formeasuring consumer perceptions of service quality”, Journal of Retailing, Vol. 64, pp. 12-40.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1991), “Refinement and reassessment of theSERVQUAL scale”, Journal of Retailing, Vol. 67 No. 4, pp. 420-50.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1994), “Reassessment of expectations as acomparison standard in measuring service quality: implications for future research”,Journal of Marketing, Vol. 58, January, pp. 111-24.

Prahalad, C.K. and Ramaswamy, V. (2003), “The new frontier of experience innovation”, MITSloan Management Review, Vol. 44 No. 4, pp. 12-18.

PricewaterhouseCoopers (2007), Healthcare in India: Emerging Market Report, Vol. 20,November 20.

Poon, W.C. and Low, K.L.T. (2005), “Are travelers satisfied with Malaysian hotels?”,International Journal of Contemporary Hospitality Management, Vol. 17 No. 3, pp. 217-27.

Ramsaran-Fowdar, R.R. (2008), “The relative importance of service dimensions in a healthcaresetting”, International Journal of Health Care Quality Assurance, Vol. 21 No. 1, pp. 104-24.

Reidenbach, R.E. and Smallwood, B.S. (1990), “Exploring perceptions of hospital operations by amodified SERVQUAL approach”, Journal of Healthcare Marketing, Vol. 10 No. 4, pp. 47-55.

Rhodes, R.L., Mitchell, S.L., Miller, S.C., Connor, S.R. and Teno, J.M. (2008), “Bereaved familymembers’ evaluation of hospice care: what factors influence overall satisfaction withservices?”, Journal of Pain and Symptom Management, Vol. 35 No. 4, pp. 365-71.

Richard, M.D. and Allaway, A.W. (1993), “Service quality attitudes and choice behaviour”,Journal of Service Marketing, Vol. 7 No. 1, pp. 59-68.

Rohini, R. and Mahadevappa, B. (2006), “Service quality in Bangalore hospitals – an empiricalstudy”, Journal of Services Research, Vol. 6 No. 1, pp. 59-85.

Rose, R.C., Uli, J., Abdul, M. and Ng, K.L. (2004), “Hospital service quality: a managerialchallenge”, International Journal of Health Care Quality Assurance, Vol. 17 No. 3,pp. 146-59.

Rust, R.T., Zahorik, A.J. and Keiningham, T.L. (1995), “Return on quality (ROQ): making servicequality financially accountable”, Journal of Marketing, Vol. 59, April, pp. 58-70.

Sahay, A. (2008), “Hospital, heal thyself”, Outlook Business, May 31, p. 77.

Shemwell, D.J., Yavas, U. and Bilgin, Z. (1998), “Customer service provider relationships:an empirical test of a model of service quality, satisfaction and relationship orientedoutcome”, International Journal of Service Industry Management, Vol. 9 No. 2, pp. 155-68.

BIJ16,2

186

Silvestro, R. and Johnston, R. (1990), “The determinants of service quality – enhancing andhygiene factors”, Proceedings of the QUIS II Symposium, St John’s University, New York,NY, July.

Sohail, M.S. (2003), “Service quality in hospitals: more favourable than you might think”,Managing Service Quality, Vol. 13 No. 3, pp. 197-206.

Sohail, M.S. and Shaik, N.M. (2004), “Quest for excellence in business education: a study ofstudent impressions of service quality”, International Journal of Educational Management,Vol. 58, p. 65.

Stevanovic, V., Feek, C. and Kay, R. (2005), “Using routine data for benchmarking andperformance measurement of public hospitals in New Zealand”, Benchmarking:An International Journal, Vol. 12 No. 6, pp. 498-507.

Strasser, S., Schweikhart, S., Welch, G.E. II and Burge, J.C. (1995), “Satisfaction with medical care:it is easier to please patients than their family members and friends”, Journal of HealthcareMarketing, Vol. 15 No. 3, pp. 34-45.

Sureshchandar, G.S., Rajendran, C. and Anantharaman, R.N. (2002a), “Determinants of customerperceived service quality: a confirmatory factor analysis approach”, Journal of ServicesMarketing, Vol. 16 No. 2, pp. 9-34.

Sureshchandar, G.S., Rajendran, C. and Anantharaman, R.N. (2002b), “The relationship betweenservice quality and customer satisfaction: a factor specific approach”, Journal of ServicesMarketing, Vol. 16 No. 4, pp. 363-79.

Sureshchandar, G.S., Rajendran, C. and Kamalanabhan, T.J. (2001), “Customer perceptions ofservice quality: a critique”, Total Quality Management, Vol. 12 No. 1, pp. 111-24.

Tabish, S.A. (1998), “Towards development of professional management in Indian hospitals”,Journal of Management in Medicine, Vol. 12 No. 2, pp. 109-19.

Tam, J.L.M. (2004), “Customer satisfaction, service quality and perceived value: an integrativemodel”, Journal of Marketing Management, Vol. 20 Nos 7/8, pp. 897-917.

Tamimi, H.A. and Amiri, A.A. (2003), “Analysing service quality in the UAE Islamic banks”,Journal of Financial Services Marketing, Vol. 8 No. 2, pp. 119-32.

Taylor, S.A. and Baker, T. (1994), “An assessment of the relationship between service qualityand customer satisfaction in the formation of consumers’ purchase intentions”, Journal ofRetailing, Vol. 7 No. 2, pp. 163-78.

Teas, K.R. (1993), “Expectations, performance evaluation, and consumers’ perceptions ofquality”, Journal of Marketing, Vol. 57, October, pp. 18-34.

Ting, D.H. (2004), “Service quality and satisfaction perceptions: curvilinear and interactioneffects”, The International Journal of Bank Marketing, Vol. 22 No. 6, pp. 407-20.

Tucker, J.L. and Adams, S.R. (2001), “Incorporating patients’ assessments of satisfaction andquality: an integrative model of patients’ evaluations of their care”, Managing ServiceQuality, Vol. 11 No. 4, pp. 272-87.

Tsoukatos, E. and Rand, G.K. (2006), “Path analysis of perceived service quality, satisfaction andloyalty in Greek insurance”, Managing Service Quality, Vol. 16 No. 5, pp. 501-19.

van der Wiele, T., Boselie, P. and Hesselink, M. (2002), “Empirical evidence for the relationshipbetween customer satisfaction and business performance”, Managing Service Quality,Vol. 12 No. 3, pp. 184-93.

Venn, S. and Fone, D.L. (2005), “Assessing the influence of socio-demographic factors and healthstatus on expression of satisfaction with GP services”, Clinical Governance:An International Journal, Vol. 10 No. 2, pp. 118-25.


in healthcare

187

Verhoeven, J.W.M., Pieterse, M.E. and Pruyn, A.T.H. (2006), “Effects of interior color onhealthcare consumers: a 360 degree photo simulation experiment”, Advances in ConsumerResearch, Vol. 33 No. 3, pp. 292-3.

Wait, S. and Nolte, E. (2005), “Benchmarking health systems: trends, conceptual issues andfuture perspectives”, Benchmarking: An International Journal, Vol. 12 No. 5, pp. 4436-48.

Wei-Shong, L.P. and Kuo-Chung, M.A. (2006), “The internal performance measures of banklending: a value added approach”, Benchmarking: An International Journal, Vol. 13 No. 3,pp. 272-89.

Williams, B., Coyle, J. and Healty, D. (1998), “The meaning of patient satisfaction: an explanationof high reported levels”, Social Science & Medicine, Vol. 47 No. 9, pp. 1351-9.

Williams, J.S., Lee, M.A. and Morrissey, T. (2008), “Remodeling patient satisfaction?”, Annals ofEmergency Medicine, Vol. 51 No. 4, p. 499.

Wisner, J.D. and Corney, W.J. (2001), “Comparing practices for capturing bank customerfeedback: internet versus traditional banking”, Benchmarking: An International Journal,Vol. 8 No. 3, pp. 240-50.

World Bank (2001), Better Health Systems for India’s Poor, Report No. 24124, World Bank,Washington, DC.

Wu, W.Y., Hsiao, S.W. and Kuo, H.P. (2004), “Fuzzy set theory based decision model fordetermining market position and developing strategy for hospital service quality”, TotalQuality Management, Vol. 15 No. 4, pp. 439-56.

Yavas, U., Benkenstein, M. and Stuhldreier, U. (2004), “Relationships between service quality andbehavioural outcomes: a study of private bank customers in Germany”, The InternationalJournal of Bank Marketing, Vol. 22 No. 2, pp. 144-57.

Zeithaml, V.A., Berry, L.L. and Parasuraman, A. (1996), “The behavioral consequences of servicequality”, Journal of Marketing, Vol. 60, April, pp. 31-46.

AppendixThis section provides the items which measure the variables described in Section 5.A seven-point scale can be used to measure the patients’ perception of services provided by thehospital, where “1” indicates “very low” level of service and “7” indicates “very high” level ofservice.

Infrastructure. Ease and quickness in getting ambulance services from the hospitalf.. Cleanliness and comfort (e.g. well-ventilated, with minimal noise level) of your ward-room

and toiletf.. Infection-free environment/treatment provided by the hospital during your stayb.. Adequacy of overall security prevalent in the hospitalc.. The support provided by hospital management to your attendant in taking care of youa.. Level of availability of required drugs in timef.. Level of availability of required blood in timef.. Level of availability of doctors and nurses, as and when required in your wardf.. Level of availability of medical equipment in proper working conditione.. Timely and hygienic food supplied to wards and roomsf.

BIJ16,2

188

. Level of availability of life-support facilities to manage any sudden deterioration in healthconditionb.

. Good house-keeping facilities (e.g. pillows, buckets, mugs, dressing material, etc)f.

. Extent to which physical facilities and infrastructure in hospital are visually appealingd.

. Presence of mechanisms to gather patient’s needs (e.g. comment cards, satisfactionsurveys, etc.)a.

. Presence of signs in prominent places about patients’ well-being and preventive measuresto increase health awareness among patients and visitors (e.g. advertisements abouteffects of tobacco, cleanliness of water, etc.)f.

Personnel quality. Courtesy shown by the hospital administrative staff to youe.. Level of availability of doctors and nurses, as and when required in your wardf.. Nurses’ care and responsiveness to youa.. Courtesy shown by the hospital management to your visitorsf.. Punctuality of doctors while conducting ward roundse.. Competency and skill of doctorsf.. Competency and skill of paramedical and support staff.&&

. Courtesy and attentiveness shown by nurses to youe.

. Teamwork demonstrated by doctors and nursing stafff.

. Doctors’ friendly and caring attitude with due understanding of your feelings and needse.

. Extent to which the hospital staff addressed your concerns and requirements withunderstanding and caring attitudee.

. Courtesy shown by the hospital management to your visitorsf.

Process of clinical care. Medical advice and instructions provided by doctors at the time of your dischargec.. Pre-operative advice given to you by doctorsa.. Post-operative care provided by the hospital to youf.. Delay or cancellation of your scheduled admission/surgerya

. Fruitfulness of the medical treatment received by youa.

. Correct assessment of your health condition by doctorsa.

. Explanation offered by the doctor about treatment procedures and outcomese.

. Information and apprisal provided by doctors about your health, medical tests andtreatment proceduresa.

. Interactions among doctors of appropriate specialties with regard to (i.e. in respect of)your medical caref.

. Promptness of handling unforeseen/unexpected complications (arising in the process ofmedical/surgical treatment) by the medical team a.

Administrative procedures. Ease of consulting with doctors (within a reasonable waiting time)e.


in healthcare

189

. Prompt, simple and clear admission processes and proceduresa.

. Ease of getting diagnostic tests donef.

. Simplified administrative procedures with respect to bill payment and dischargef.

. Enforcement of visiting policy (e.g. visiting hours)f.

. Clear information and instructions provided by the hospital administration to you abouthospital rules and proceduresa.

. Assistance provided to you by the staff in arranging for additional care or services (e.g.physiotherapy)a.

. The support provided by the hospital management to your attendant in taking care ofyou.

Safety measures. Adequacy of hygienic care and procedures (e.g. wearing gloves) followed by the hospital

personnelf.. Response to your allergic reaction to drugs by the medical stafff.. Presence of safety and comfort measures (e.g. handrails in aisles, ramps designed for

wheelchairs) in the hospitalf.

Corporate image. Sincerity, honesty and ethics followed by the hospital in providing medical services to

youa.. Reputation enjoyed by the hospitalb.. Investment in new technologies and innovative practices by the hospitala.

Social responsibility. Fair medical treatment provided to you by the hospitalf.. Provision of medical services with nominal cost to the needy patientsf.. Ethical principles followed by the hospital in delivering medical care to patients among

different segments in the societyf.

Trustworthiness of the hospital. Your level of confidence in the doctors who treated youe.. Presence of correct, accurate and reliable billing system in the hospitale.. Hospital provided services as promised and on timed.. Extent to which the services, functioning and administration of the hospital are crediblea.. Maintenance of patient privacy and confidentiality by the hospitalc.

Note: all the eight dimensions of service quality are common to both patients’ and attendants’perspectives. In the case of attendants, the items can be rephrased so as to obtain attendant’sperception of service provided to the patient. For example, the first item in “social responsibility”would appear as “Fair medical treatment provided to the patient by the hospital” in theinstrument for capturing attendants’ perceptions.

BIJ16,2

190

Source: aitems added in the present study; bitems adopted from JCI; citems adopted fromMBNQA; ditems adopted from SERVQUAL; eitems modified from SERVQUAL; fitems modifiedfrom Duggirala et al. (2008).

Corresponding authorChandrasekharan Rajendran can be contacted at: [email protected]


in healthcare

191

To purchase reprints of this article please e-mail: [email protected] visit our web site for further details: www.emeraldinsight.com/reprints

A conceptual framework of service quality in healthcare: Perspectives of Indian patients and their...

Documents

Transcript of A conceptual framework of service quality in healthcare: Perspectives of Indian patients and their...