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International Journal of Health Care Quality Assurance

Emerald Article: Measuring, evaluating and improving hospital quality

parameters/dimensions - an integrated healthcare quality approach
Mosad Zineldin, Hatice Camgz-Akdag, Valiantsina Vasicheva

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To cite this document: Mosad Zineldin, Hatice Camgz-Akdag, Valiantsina Vasicheva, (2011),"Measuring, evaluating and improving
hospital quality parameters/dimensions - an integrated healthcare quality approach", International Journal of Health Care Quality
Assurance, Vol. 24 Iss: 8 pp. 654 - 662
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Received 11 November 2008
Revised 1 December 2008
Accepted 13 January 2009

Measuring, evaluating and

improving hospital quality
parameters/dimensions an
integrated healthcare quality
Mosad Zineldin
School of Business and Economics, Linnaeus University, Vaxjo, Sweden

Hatice Camgoz-Akdag
Department of Business Administration, Istanbul, Faculty of Economics and
Administrative Sciences, Kadir Has University, Turkey, and

Valiantsina Vasicheva
School of Social Sciences, Linnaeus University, Vaxjo, Sweden,
Purpose This paper aims to examine the major factors affecting cumulative summation, to
empirically examine the major factors affecting satisfaction and to address the question whether
patients in Kazakhstan evaluate healthcare similarly or differently from patients in Egypt and Jordan.
Design/methodology/approach A questionnaire, adapted from previous research, was
distributed to Kazakhstan inpatients. The questionnaire contained 39 attributes about five
newly-developed quality dimensions (5Qs), which were identified to be the most relevant attributes for
hospitals. The questionnaire was translated into Russian to increase the response rate and improve
data quality. Almost 200 usable questionnaires were returned. Frequency distribution, factor analysis
and reliability checks were used to analyze the data.
Findings The three biggest concerns for Kazakhstan patients are: infrastructure; atmosphere; and
interaction. Hospital staffs concern for patients needs, parking facilities for visitors, waiting time and
food temperature were all common specific attributes, which were perceived as concerns. These were
shortcomings in all three countries. Improving health service quality by applying total relationship
management and the 5Qs model together with a customer-orientation strategy is recommended.
Practical implications Results can be used by hospital staff to reengineer and redesign creatively
their quality management processes and help move towards more effective healthcare quality strategies.
Social implications Patients in three countries have similar concerns and quality perceptions.
Originality/value The paper describes a new instrument and method. The study assures
relevance, validity and reliability, while being explicitly change-oriented. The authors argue that
patient satisfaction is a cumulative construct, summing satisfaction as five different qualities (5Qs):
object; processes; infrastructure; interaction and atmosphere.

International Journal of Health Care

Quality Assurance
Vol. 24 No. 8, 2011
pp. 654-662
q Emerald Group Publishing Limited
DOI 10.1108/09526861111174215

Keywords Healthcare, Patient-staff relationship, Customer satisfaction, Quality management,

Kazakhstan, Egypt, Jordan, Patients, Customer services quality
Paper type Research paper

Healthcare satisfaction has gained greater importance, especially in developing
countries. It is both a service quality indicator and a quality component. Strong

healthcare systems enable healthcare providers to deliver better quality and value to
patients (Radhika et al., 2007). Improved health status and patient satisfaction
measures are ongoing concerns for hospital staff as quantitative and qualitative
techniques are applied in continuous process improvement cycles (Deitrick et al., 2005).
People are dying daily following uncontrollable events such as automobile accidents or
chronic disease, but deaths following medical errors are preventable and a nations
healthcare system must reach the point where no patient will ever be a victim (Radhika
et al., 2007).
Competitiveness among healthcare organizations depends on patient satisfaction,
which is created by responding to patient views and needs, continuous healthcare
service improvement and overall doctor-patient relationship (Zineldin, 2006). The
challenges achieving healthcare excellence are many and difficult. Trusko et al.(2007),
for example, report how errors are difficult to measure for several reasons such as
inadequate reporting and varied definitions. Further complications arise because most
errors are not a single act but a chain of events. There are structure, personality,
patient and provider problems to consider. Demographic changes, political
environment, healthcare quality social perceptions and information technology can
dramatically change healthcare. All this creates a complex situation in which we assess
healthcare by analyzing patient satisfaction what is valued by patients, how they
perceive service quality and how these can be improved.
Our aim in this article is to examine the major factors affecting patients perception
of cumulative summation. The factors included in this summation include: technical;
functional; infrastructure; interaction and atmosphere in Almaty hospitals, adopted
from previous research (Zineldin, 2006) in Jordanian and Egyptian hospitals. This
research contributes to previous academic healthcare sector studies and quality
management in two ways: Zineldins (2006) model, including patient-physician
relationship behavioural dimensions and patient satisfaction, will be reviewed and
analyzed; and we empirically examine major factors affecting cumulative satisfaction
to address whether Kazakhstan patients evaluate healthcare quality similarly or
differently than Egypt and Jordan patients. Results can be used by staff to improve
healthcare quality and patient satisfaction by setting healthcare quality strategies.
Kazakhstan healthcare
Kazakhstan is an independent, central-Asian republic. It neighbours Russia, which has
a long border to the north, China to the east and Kyrgyzstan, Uzbekistan and
Turkmenistan to the south. The population was estimated as 14.8 million in 2002
(UNDP, 2002). The main population is diverse:
Kazakhs (52 percent);
Russians (31 percent);
Ukrainians (4 percent);
Germans (2 percent); and
11 percent others (UNDP, 1997).
The Kazakhstan population has decreased during the 1990s owing to lower birth rate
(UNDP, 1997) and migration.

hospital quality



Kazakhstan possesses enormous fossil fuel, mineral and metal reserves. The
country enjoyed strong economic growth owing to the booming energy industry
(Euromonitor International, 2007). Industrial sector managers hope to develop these
natural resources, while new trade ties are being sought with markets outside the
former Soviet Union. Kazakhstan has a promising economic prospect, given its vast
natural resources (Kulzhanov and Healy, 1999). Economic growth led to rising
consumer incomes, which consumers them to buy expensive over-the-counter
healthcare products (Euromonitor International, 2007).
Kazakhstans health indices, since the 1950s, generally improved, but have
deteriorated since the 1980s (McKee et al., 1998). In 1996, over 30 percent of the
Kazakhstan population had incomes below the poverty line according to a World Bank
funded National Living Standards Survey (UNDP, 1997). Life expectancy fell against a
continuing rise in EU countries. However, life expectancy is higher compared to lower
middle-income countries such as neighboring Turkey (Kulzhanov and Healy, 1999).
An extensive healthcare system developed during the Soviet era was state-owned
and centrally planned. The key principles were that services should be accessible to
everyone and free (Kulzhanov and Healy, 1999). Before independence, the Kazakhstan
Ministry of Health administered Moscow policy through a centrally organized
hierarchical structure, from the republic level to oblast/city administrations, then to the
subordinate level (World Health Organization, 1994). In the 1980s, the system began to
deteriorate and its management problems became apparent. The health sector
traditionally had been assigned low priority compared to other productive
economies. As budgets became tighter, healthcare services could not meet demand and
facilities were forced to unofficially transfer costs to the population as user charges
(Kulzhanov and Healy, 1999). The Committee of Health lacked capacity and power to
implement a comprehensive national health strategy. Messages from President Nur
Sultan Nazarbayev set out broad goals such as Kazakhstan 2030 and Health of the
Nation. The Kulzhanov and Healy (1999) report concluded that service quality
improvements are not evident especially since retraining healthcare professionals has
only just begun, with healthcare staff still experiencing poor working conditions and
low salaries that are not conducive to raising standards.
Currently the United States Agency for International Development (USAID) is
working with the Ministry of Health to revise health service clinical practice guidelines
to meet international standards. Primary healthcare doctors are being trained in family
medicine and small groups from academic institutions are being prepared as family
medicine teachers for medical and nursing schools. The USAID quality improvement
efforts are continuing by training healthcare staff to improve clinical practices focusing
on maternal and newborn services, family planning and disease management (United
States Agency of International Development, 2007).
5Qs model
Service quality in the literature is commonly attributed to two dimensions: technical
and functional (Gronroos, 2000). Technical quality is what the customer buys and
whether services fulfill their technical specifications and standards. Functional quality
describes how service products were delivered; i.e. service-customer relationships. The
SERVQUAL model is multidimensional and its operationalization means that many
variables have to be considered (Zineldin, 2006). However, the 5Qs model is an

instrument that assures reasonable relevance, validity and reliability, while being
explicitly change oriented. The interaction process between service provider and
receiver is influenced by specific environmental atmospheres where both operate (Ford
et al., 1998; Zineldin, 2000, 2004; Robicheaux and El-Ansary, 1975). This is applicable in
a hospital, medical center or private medical clinics where patients and healthcare staff
work (Zineldin, 2006). The atmosphere can affect perceived service quality by
improving or by making it worse, which affects health. Healthcare service quality
depends on staff, buildings, waiting rooms, technical apparatus, etc. Healthcare quality
and patient satisfaction are more involved than just dividing service quality into
technical and functional. Zineldin (2000) expanded technical-functional and
SERVQUAL quality models into a five quality dimensions (5Qs) framework:
Q1. Object technical quality (what customers receive), which measures
treatment; the main reason why patients visit hospitals.
Q2. Processes functional quality (how healthcare staff provides core services). It
measures how well healthcare activities are implemented.
Q3. Infrastructure basic resources needed to perform healthcare services.
Q4. Interaction information exchange (e.g. percentage patients told when to
return for check-ups, time spent by physicians or nurses understanding
patient needs), financial and social exchange.
Q5. Atmosphere relationship and interaction process between parties are
influenced by specific environments where they operate. In developing
countries, unfriendly atmosphere explains poor care. Consequently,
atmosphere indicators should be considered critically.
Our aim was to examine the major factors affecting patients perception of cumulative
summation. We tried to figure out whether there is any similarity among Kazakhstan,
Egyptian and Jordanian patients. This study concerns Kazakhstan inpatients. A
questionnaire, adapted from Zineldin (2006), was distributed. Our questionnaire
contained 39 attributes about five newly developed dimensions (5Qs), felt to be most
relevant to hospitals. The questionnaire was translated into Russian to provide a better
understanding, increase response rates and improve data quality. The sample size was
250, enough for statistical analysis. In total 195 usable questionnaires were received.
We used frequency distribution, factor and reliability analysis to analyze our data. One
variable (expressed as percentages) was considered at a time to obtain responses
associated with different values. As frequency distributions are a descriptive, we show
how respondents perceive each attribute related to healthcare quality. WE used factor
analysis to transform original into new, correlated variables called factors (Malhotra,
2007), which are used to identify key points emerging from questionnaires. Factor
analysis is an interdependent technique where all independent relationships are
examined. It identifies how patients perceive hospital quality and major points where
hospital staff need to improve. Reliability tests were used to examine the extent to
which scales produce consistent results if measurements are repeated. Reliability tests
were applied to all 39 attributes. In short, factor analysis discovers which 5Qs
dimensions are perceived important in Kazakhstan.

hospital quality


Analysis and results

Our questionnaire had a good reliability score (Cronbach a 95:7). Factor analysis
reduced 39 variables associated with the 5Qs model as attributes to nine new, salient
variables. Factors with Eigenvalues greater than 1 were retained. The resulting
component factor matrix is given in Table I. Table II shows the 5Qs model factors and
their corresponding quality attributes.

Factor 1: Infrastructure
The highest loading factors were rooms appearance and hospital cleanliness the
patients biggest concerns. Forty-one percent said rooms were average; 25.6 percent
said it was bad and 11.8 percent said very bad. Almost 31 percent rated hospital
cleanliness average; 26.2 percent bad and 12.3 percent very bad.
Factor 2: Atmosphere 1
This factor related to staff attitude towards Kazakhstan inpatients. The highest
loading factor was nurses politeness; second was other hospital staff politeness and
third was physician politeness. Almost 35 percent said that nurses politeness was
average and 25 percent said it was good. Hospital staff politeness was perceived as 37.9

Table I.
Rotated component factor
matrix (only significant
components are

Quality Object3 (QO3)

Quality Object4(QO4)
Quality Process1(QP1)
Quality Process2(QP2)
Quality Process4(QP4)
Quality Process5(QP5)
Quality Process6(QP6)
Quality Infrast.1(QI1)
Quality Infrast.2(QI2)
Quality Infrast.3(QI3)
Quality Infrast.5(QI5)
Quality Infrast.6(QI6)
Quality Infrast.7(QI7)
Quality Infrast.8(QI8)
Quality Infrast.9(QI9)
Qual. Infrast.10(QI10)
Qual. Infrast.11(QI11)
Quality Interac.1(QInt1)
Quality Interac.2(QInt2)
Quality Interac.4(QInt4)
Quality Interac.5(QInt5)
Quality Interac.6(QInt6)
Quality Atm.1(QA1)
Quality Atm.3(QA3)
Quality Atm.4(QA4)
Quality Atm.5(QA5)
Quality Atm.7(QA7)
Quality Atm.8(QA8)
Quality Atm.9(QA9)



5Qs model attributes (components)

Factor 1

(QI5) Food temperature

(QI6) Professional appearance of physicians and nurses
(QI7) Professional appearance of other hospital employees
(QI8) Rooms physical appearance
(QI9) Hospital cleanliness
(QI10) Competence of staff filing insurance documents
(QI11) Visitor parking
(QA1) Nurses responsiveness patient needs
(QA3) Politeness physicians
(QA4) Politeness nurses
(QA5) Politeness other hospital staff
(Qint4) Getting hold of hospital personnel on the phone
(Qint5) Time spent by staff understanding your needs
(Qint6) Waiting time for refunds
(QP4) Time between admission and getting into your room
(QP5) Speed and ease of discharge
(QP6) Timing of meals
(QA7) Hospital concern for family and visitors
(QA8) Sleeping
(QA9) Pleasantness and appeal of hospital room
(QI1) Skills of nurses attending you
(QI2) Skills of those performing your tests
(QI3) Skill of physicians attending you
(QP1) Waiting for medication (QP2) Waiting for tests
(QO3) Sense of security from physical harm in hospital
(QO4) Hospital staff concern for your particular needs
(Qint1) Explanation about your treatment
(Qint2) Instruction upon release from hospital

Factor 2

Factor 3
Factor 4
Factor 5
Factor 6
Factor 7
Factor 8
Factor 9

percent average, 19 percent good and 19.5 percent bad. Physician scores were 31.3
percent average and 30.8 percent good.
Factor 3: Interaction
Waiting time for refunds had the highest loading. Time staff spent understanding
patient needs was second. When refunds were the subject, 40.5 percent felt it was
average and 27.7 percent bad. Staff understanding was rated average by 41.5 percent
and 22.6 percent said it was bad.
Factor 4: Process
The highest loading was speed and ease of discharge. The second highest loading was
given to the component related to time between admission and getting into your room.
Discharge was judged average by 39.5 percent and bad by 26.7 percent. Time between
admission and getting to rooms was 35.9 percent average and 29.7 percent bad.
Factor 5: Atmosphere 2
Even though atmosphere was mentioned in the second factor, it occurred again to
stress its importance in hospitals. The highest loading was family sleeping
accommodation, which was perceived as 21.5 percent bad, 20.5 percent very bad

hospital quality

Table II.
5Qs model attributes and
corresponding factors


and 38.5 percent average. The second highest loading was room pleasantness and
appeal; rated 40.5 percent average, 21.5 percent bad and 19.5 percnet very bad.


Factor 6: Staff skills

Factor 6 supports the first factor also infrastructure related, which stresses its
importance. The highest loading element was patient testing; second, physician skills
and third, nurses skills. Almost 29 percent said that nurses were good, 31.8 percent
said they were average and 22.6 percent felt nurses were bad. Thirty-five percent said
that testing was average. Thirty-four percent said physicians were average, 33.3
percent good and only 11.3 percent said they were very good.
Factor 7: Waiting time
Factor 7 supports Factor 4. Waiting for medication had the highest loading and
waiting for tests the second highest. Slightly more than 42 percent said medication
waiting time was average and 21.0 percent said it was good. Waiting time for tests was
said to be 35.4 percent average and 27.2 percent good.
Factor 8: Object
This factor includes components relating to preventing physical harm, which had the
highest loading and hospital staff concern for patients particular needs had the second
highest. Security was rated 39 percent average and 24 percent bad. Hospital staff
concern was perceived as 36.4 percent average and 25 percent good.
Factor 9: Adequacy
Factor 9 supports Factor 3. It relates to explaining treatments (highest loading) and
hospital discharge information. Explanation regarding patient treatment was
perceived by respondents as 33.8 percent average and 28.7 percent bad, while 22.1
percent said that it was good. Hospital discharge was said to be 35.4 percent average,
27.7 percent good and 23.6 percent bad.
Discussion, conclusion and implications
The first and most important factor for Kazakhstan patients was hospital
infrastructure. It is clear that all attributes related to healthcare quality and patient
satisfaction were no more than average. Twenty-four from 39 attributes had responses
leaning towards negative; only 15 were predominantly positive. When each 5Qs model
topic was analyzed, we see that object (medical treatment) and atmosphere (staff
attitude) are perceived more negatively. Processes were seen to be neither negative nor
positive. Infrastructure and interaction tended towards the negative. When frequencies
and factor analysis are combined, the three factors that concern Kazakhstan inpatients
are: infrastructure; atmosphere; and interaction (Table III).
Patients were most dissatisfied with visitor parking. Second was the time between
arrival and getting into a room. Third was room pleasantness and appeal. Fourth was
admission speed and ease. Fifth, food taste and sixth was sleeping accommodation.
Seventh was waiting time for refunds and eighth was hospital staff concern for family
and visitors. The ninth problem was staff competence filing insurance and the tenth
most critical problem was food temperature.
One objective was to compare Kazakhstan, Jordanian and Egyptian health services.
The ten shortcomings listed in Table III were similar in all three countries. Hospital




Critical Percentages


Visitor parking



Time between admission and getting into

your room
Pleasantness and appeal of hospital room


Speed and ease of admission


Food taste


Family sleeping accommodation


Waiting time for refund


Hospital staff concern for family and visitors


Competence of staff filing insurance



Food temperature

50 percent bad and very bad,

31.8 percent average
48 percent bad and very bad,
35.9 percent average
46 percent bad and very bad,
40.9 percent average
45 percent bad and very bad,
36.9 percent average
45 percent bad and very bad,
37.4 percent average
42 percent bad and very bad,
38.5 percent average
41 percent bad and very bad,
40.5 percent average
41 percent bad and very bad,
39 percent average
41 percent bad and very bad,
34.4 percent average
40 percent bad and very bad,
32.3 percent average

staff concern for patients needs, parking facilities for visitors, waiting time for refunds
and food temperature were all common shortcomings for patient satisfaction in all
three countries.
A strategy to improve Kazakhstan hospital patient satisfaction is focussing on
infrastructure (Q3) and atmosphere (Q5), which are also concerns in the other two
countries. Zineldin (2006) felt that Egyptian and Jordanian patient satisfaction data will
be helpful for Kazakhstan hospitals because the most critical healthcare shortcomings,
which lead to patient dissatisfaction, are the same. Healthcare service improvement is
achieved by applying total relationship management (TRM) and the 5Qs model with a
customer orientation strategy. According to TRM, improving quality and patient
satisfaction requires good atmosphere, infrastructure and relationships between
physicians, nurses and other hospital employees. All health service personnel should
be included in developing guidelines and measuring standards (Longo, 1994).
We used the 5Qs model to measure patient satisfaction with medical care; also used
in the Egyptian and Jordanian studies. The 5Qs model encompasses technical,
functional, interaction, infrastructure and atmosphere qualities and services. The
results can be used by hospital managers to reengineer and redesign their quality
management processes. This model is just a short-term initial improvement step. For
long-term benefits, service quality should be continuously measured and improved.
Our study focuses on service quality measurement. However, cost measures, physician
and nurse performance, and salary distribution might also be measured in detail.
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Table III.
Most critical healthcare



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Corresponding author
Hatice Camgoz-Akdag can be contacted at:

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