Proceedings of the 2012 International Conference on Industrial Engineering and Operations Management

Istanbul, Turkey, July 3 6, 2012

Effects of Service Quality Dimensions on Customer Satisfaction and

Return Intention in Different Hospital Types
Fethi Calisir, Cigdem Altin Gumussoy, Ayse Elvan Bayraktaroglu and Burcu Kaya
Department of Industrial Engineering
Istanbul Technical University
Istanbul 34367, Turkey

Abstract
A modified SERVQUAL approach including usability as the sixth service quality dimension has been used to
evaluate the effect of service quality dimensions on customer satisfaction and return intention for four different
hospital types operating in Turkey: public, private, university, and military hospitals. The proposed research model
was tested with 292 patients from different hospital types, and results indicated that usability is an insignificant
factor in customer satisfaction and return intention prediction for all hospital types. Besides, empathy is the only
dimension having a predictive impact on customer satisfaction in all hospital types.

Keywords
Service quality, SERVQUAL, usability, hospital types, Turkey

1. Introduction
With the pervasion of the service sector in the world, the quality of promised service has been receiving increasing
recognition. According to Pakdil and Harwood [1], although the service sector has been slow in recognizing its
importance, service quality has become a hot topic since the 1990s, as it has been acknowledged as an integral part
of competitive advantage, increased patronage, and long-term profitability [2]. In the literature on service quality, it
is frequently mentioned that service quality is related to customer satisfaction and customer loyalty, both of which
are essential for survival in the highly competitive service sector.

Continuing increase of the elderly population and an increase in healthcare expenses have made the healthcare
sector a constantly growing part of the service industry. Since healthcare service quality directly affects the well-
being of consumers, the importance of service quality is especially high in this sector [1]. One way of improving
healthcare service quality is by using consumers perceptions of the provided healthcare service to develop
improvement plans [3]. SERVQUAL [4, 5] is a tool that measures service quality, based on the acceptance that
service quality is driven by the difference between expectations and actual performance, meaning that the gap
between consumers perceptions of the actual performance executed by the service provider and consumers
expectations of the ideal performance of the service provider defines the perceived service quality [6].

SERVQUAL was developed as an instrument intended for quality measurement in the service sector generally and
has been largely used in studies conducted on healthcare service quality [1, 7, 8, 9, 10, 11]. SERVQUAL has
received numerous criticisms since it was developed in the second half of the 1980s; however, it still abides as a
useful tool for service quality studies [12]. The generally used form of SERVQUAL consists of 5 determinants
representing 22 items. These five determinants are tangibles, reliability, responsiveness, assurance, and empathy.

As a developing country, in Turkey also, the elderly population and healthcare expenditures are increasing [13];
however, quality problems have always been an issue in the Turkish healthcare system. In the last decade and even
today, the Turkish healthcare system has been in a transition. The private sector has begun showing more interest in
the healthcare industry, and governments have tried to reconfigure the healthcare system to decrease the
expenditures. In this changing environment, service quality is important not only for issues related to competition
but also for increasing rationalisation, restructuring, and demands for accountability of public services. [2]

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Today, mainly four different types of hospitals are operating in the Turkish healthcare system: public hospitals,
university hospitals, private hospitals, and military hospitals. Public hospitals are financially supported by the state;
patients usually do not pay or pay a small amount for the received service. University hospitals are affiliated mostly
to state universities; however, since one of their main functions is research and education, university hospitals are
perceived to be more specialized in the treatment of some serious/advanced diseases. In private hospitals, patients
usually pay for the services they get, especially in case of not having a social security. Military hospitals are run by
Turkish Armed Forces, and all of their healthcare personnel are military personnel, and most of their patients are
military personnel or their family members.

In the literature, there is an amount of studies on the service quality of Turkish hospitals. Most of them have used
SERVQUAL as their quality assessment tool. Lonial et al. [8] tried to evaluate the reliability and validity of
SERVQUAL in the Turkish context without mentioning the type of the hospital where they conducted the study.
They employed courtesy as the sixth dimension of SERVQUAL. They found that, although service quality has an
effect on overall quality, there is no significant relationship between service quality and customer loyalty. In
addition, Aykac et al. [13] used courtesy as the sixth dimension in their study conducted in a university hospital.
Pakdil and Harwood [1] used a 10-dimension SERVQUAL scale in their study conducted in a preoperative
assessment clinic. In their 2004 dated study, Yldz and Erdogmus [14] developed a patient satisfaction measurement
tool based on SERVQUAL and implemented it in 31 different hospitals, without mentioning the hospital types.
Caha [15] assessed private hospitals in terms of service quality. Taner and Antony [16] compared public and private
hospitals in terms of service quality and concluded that private hospitals scored better. Bakar et al. [17, 18] applied
the SERVQUAL survey to the patients of a university hospital network and revealed the relationships between
patients profiles and patients expectation scores. Kara et al. [19] found out that in Turkish public healthcare
services, intangible dimensions have more importance than the tangible dimensions in terms of service quality and
customer satisfaction. However, to our knowledge, there is no study assessing the service quality of four different
hospital types operating in Turkey.

The aim of this study is to evaluate the effect of service quality dimensions on customer satisfaction and customer
loyalty for four different hospital types operating in Turkey. In this study, we employed a modified SERVQUAL
scale, which includes human factors considerations [20] that measure service quality in hospitals. Strawdermann
and Koubek [20] added a sixth dimension named usability to the existing five dimensions. According to them,
increased productivity, decreased task time and cost, decreased errors, and increased accuracy are all benefits of
improved usability [20], and these benefits can be matched with some of the service quality dimensions, which
shows that usability and service quality are reconcilable. The results of their study showed that addition of the
usability dimension supported the performance of their model, especially in the case of return intentions [20].

2. Methodology
The proposed model can be seen in Figure 1. Definitions of the service quality dimensions, adopted from
Strawdermann and Koubek [20], are listed next. It is assumed that a persons perception of service quality is the
composition of that persons perception of all these dimensions.

Reliability: Delivering the promised performance dependably and accurately

Tangibles: Appearance of organizations facilities, employees, equipment, and communication materials
Responsiveness: Willingness of the organization to provide prompt service and help customers
Assurance: Ability of an organizations employees to inspire trust and confidence in the organization through their
knowledge and courtesy
Empathy: Personalized attention given to a customer
Usability: Ease of learning and memorizing of where, how and from whom to receive the offered service

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 Figure 1: Proposed model

In the literature, it is frequently argued that service quality affects customer satisfaction and/or return intentions
positively (repatronage intention/purchase behavior/return behavior) [1, 6, 8, 13, 20]. To evaluate this affect
on different hospital type basis, we selected customer satisfaction and return intentions as dependent variables.

Data used in this study were collected from a total of 292 patients of different hospital types. Randomly selected
patients from different hospital types filled in a questionnaire. The demographic profile of the participants is
presented in Table 1. Strawdermann and Koubeks [20] survey items were adopted for the questionnaire. The
questionnaire consisted of questions that measure the expectations of patients from a health service and their
perceptions of the actual service they received. Respondents answered the questions on a seven-point Likert scale.
The difference between the perceptions of actual experience and expectations has been used to evaluate the service
quality. Negative difference means that the actual performance failed to reach the expectations. Positive score means
that their actual experience was better than their expectations. The respondents also evaluated their satisfaction and
return intention to the same hospital in the future on a seven-point Likert scale.

Table 1: Characteristics of the sample for each hospital type

Public H. University H. Private H. Military H.

# of Participants 69 73 75 75
Female 49% 55% 56% 36%
Gender
Male 51% 45% 44% 64%
Min 14 17 17 17
Age Max 80 82 77 80
Mean 42.7 44.3 44.6 35.9
Primary school 45.3% 25.3% 14.7% 12%
High school 38.7% 38.7% 48% 49.3%
Education Bachelor degree 16% 30.7% 36% 32%
Masters degree 0% 2.7% 1.3% 4%
PhD degree 0% 2.7% 0% 2.7%

Before continuing with the regression analysis, the reliability of the measurement scale was checked. All Cronbachs
Alpha values were greater than 0.60, showing good reliability.
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3. Results
To reveal the effect of service quality on customer satisfaction and return intention, regression analysis was
conducted via SPSS. The results are presented in Table 2.

Table 2: Regression analysis results

Adjusted p Value for

Dependent Hospital
R Regression Equation
Variable Type
Square Model
Public H. 0.610 .000 CS = 6.455 + 0.309*R + 0.573*E
Customer University H. 0.409 .000 CS = 6.788 + 0.382*RE + 0.297*E
Satisfaction Private H. 0.372 .000 CS = 6.632 + 0.613*E
Military H. 0.370 .000 CS = 6.278 + 0.313*T + 0.400*E
Public H. 0.402 .000 RI = 6.424 + 0.315*RE + 0.368*A
University H. 0.276 .000 RI = 6.468 + 0.494*A
Return Intention
Private H. 0.322 .000 RI = 6.700 + 0.584*RE
Military H. 0.443 .000 RI = 6.339 + 0.334*T + 0.478*E

According to the results just presented, usability does not seem to have any effect on customer satisfaction and
return intention for all hospital types. This result is inconsistent with the results presented by Strawderman and
Koubek [20], which exhibited that usability has a significant role in consumer satisfaction and return intention
prediction. In addition to that, usability is the only dimension that seemed to be insignificant in all regression
models. The highest adjusted R-square value was obtained from the regression model testing the relationship
between customer satisfaction and service quality for public hospitals. Accordingly, reliability and empathy are the
dimensions significantly affecting customer satisfaction in public hospitals, and they explain 61% of the variance in
customer satisfaction.

Empathy is the only dimension that has a significant effect on customer satisfaction for all hospital types. In fact, in
the case of private hospitals, empathy is the only service quality dimension having a predictive impact on customer
satisfaction. The military hospital is the only hospital type that has same dimensions in regression models predicting
both customer satisfaction and return intention. These are tangibles and empathy. The tangibles dimension has a
significant effect on customer satisfaction and return intention only in the case of military hospitals.

5. Conclusion
The effect of SERVQUAL dimensions on customer satisfaction and return intention has been assessed for each
hospital type. Results indicating that empathy has an influence on customer satisfaction for all hospital types show
that customers expect and appreciate a customer-focused service concept. This might be a result of general
perception that due to high demand (high patient numbers), heavy workload, and performance considerations (it is
generally expected that healthcare workers treat a certain number of patients in a certain time period), healthcare
employees do not give patients personalized attention, especially in hospital types other than private.

For private hospitals patients, responsiveness is influential on return intentions. This might be due to the perception
that if they pay for the promised service, then they might expect to receive more attention and information from
employees when they need it. In case of university hospitals, assurance is the only influential factor on return
intentions. This is consistent with the fact that since most patients of university hospitals look for special care for
their chronic/rare/serious diseases, they might look for higher assurance from a hospital. Both responsiveness and
assurance have an effect on the return intention of public hospitals patients.

Tangibles are important for customer satisfaction and return intention for military hospitals patients only. This is
partially consistent with Kara et al.s [19] study, which suggested that in Turkish public healthcare services,
intangible dimensions have more importance than the tangible dimensions in terms of service quality and customer
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satisfaction. Strict rules on order, formation, and appearance in military hospitals might have an impact on this
result. Since most of the patients of military hospitals are military personnel and their families, they might expect
increased care with regard to the appearance of the hospital environment.

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