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A Review of Healthcare Service Quality Dimensions and their

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Article

A Review of Healthcare Journal of Health Management

21(1) 102–127, 2019
Service Quality Dimensions © 2019 Indian Institute of
Health Management Research
and their Measurement Reprints and permissions:
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DOI: 10.1177/0972063418822583
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Raghav Upadhyai1
Arvind Kumar Jain2
Hiranmoy Roy2
Vimal Pant3

Abstract
Service quality has been a matter of concern for public and private healthcare institutions across the
world. Increased focus on patient-centered care led to several researches in exploring what deter-
mines service quality and how can it be measured. The objective of this paper is to explore and sum-
marize the available pool of published knowledge as to understand what comprises healthcare service
quality, the underlying dimensions of healthcare service quality, and how it is measured. Literature
review, covering significant researches in the field of healthcare service quality, service quality dimen-
sions and its measurement was conducted on EBSCO and Google Scholar databases. Findings were
presented in the form of medical and non-medical aspects of healthcare service quality. It can be
concluded dimensionality in the healthcare service quality is context specific and patients weigh them
differently. Perceptions only measures dominate healthcare quality evaluation over gap score based
models. Further, healthcare service quality construct and its measurement has been primarily done
from the patient’s perspective, however, the provider’s perspective of the healthcare service quality
has not been taken into consideration.

Keywords
Healthcare, service quality, dimensions, measurement, SERVQUAL

1
IMS Unison University, Dehradun, Uttarakhand, India.
2
SOB, UPES, Dehradun, Uttarakhand, India.
3
NIFTEM, Sonipat, Haryana, India.

Corresponding author:
Raghav Upadhyai, IMS Unison University, Makkawala Greens, Mussoorie Diversion Road, Dehradun, Uttarakhand 248009, India.
E-mail: raghav.upadhyai@gmail.com
Upadhyai et al. 103

Introduction
The National Health Policy Draft of India, 2015, has posed serious concerns regarding the effectiveness
of care in healthcare services. Accessibility, availability and affordability of the quality of care are matter
of concern in developing countries like India (Deloitte, 2012). According to industry report (PwC, 2015),
the concern areas in Indian Healthcare sector are as follows:

1. 30 per cent of Indians do not have access to healthcare facilities.

2. 70 per cent of the Indian healthcare infrastructure is limited to the top 20 cities.
3. India accounts for 21 per cent global disease burden.
4. Non-communicable diseases alone consist of 63 per cent of the disease burden and shall affect the
economy to the extent of `23,000 within a decade.
5. By 2017, India needs to add 650,000 beds requiring a capital investment of `1,625 billion.
6. About 47 per cent and 31 per cent of healthcare needs in rural and urban India are financed
through loans.

According to National Health Policy (NHP) of India 2015, 5 per cent of the GDP is spent on health, and
80 per cent of medical expenditure is in the form of out-of-pocket expenses. The stipulated requirement
of WHO for doctor to patient ratio is 1:1000, whereas currently India has 0.7 doctors per 1,000 patients
creating a strong case of supply gap for quality healthcare services. Likewise, against the WHO stipu-
lated norm of 2.5 nurses per 1,000 patients, India has 1.7 nurses per 1,000 patients. According to WHO
estimates, India has 0.9 beds per 1,000 population. It is estimated that India will require 1.54 million
more doctors and 2.4 million nurses to cater to the demand. The Government expenditure on healthcare
in India is only 1.04 per cent of the GDP, which is about 4 per cent of the total government expenditure,
which is `957 per capita at current market prices (Central Bureau of Health Intelligence, 2015).
One of the principles of the national health policy (2015) of government is patient-centred and quality
of care: ‘Healthcare services would be effective, safe, and convenient, provided with dignity and confi-
dentiality with all facilities across all sectors being assessed, certified and incentivized to maintain qual-
ity of care’. In healthcare services, being a high-contact service, there is a greater need to maintain the
credibility by providing high-quality service (Yee, Yeung, & Cheng, 2010). Service quality is a major
predictor of both customer satisfaction and loyalty (Olorunniwo, Hsu, & Udo, 2006; Santouridis &
Trivellas, 2004; Sivakumar & Srinivasan, 2009). Improved quality of design and conformance to quality
leads to higher perceived value. This translates into higher prices, increased revenues and higher profit-
ability (Zeithaml, 2000). As the competition in the private healthcare has increased, there arises a pressing
need for providing higher service quality (Zarei, Arab, Froushani, Rashidian, & Ghazi Tabatabaei, 2012),
which measures the clinic’s competitiveness and degree of development of nation’s healthcare system
(Senic & Marinkovic, 2012). However, it is argued that quality service in itself may not guarantee profits
to the organizations, yet the price of nonconformance to quality can lead to a loss to a tune of 20 per cent
(Mukherjee, 2006, p. 62).
Patient experience significantly correlates with the hospital performance (Deloitte, 2016). However,
patient’s selective filtering, distortion and retention affect the perception of service delivered with the same
quality based on what they see and experience (Johnston & Clark, 2008, p. 129). As the customer passes
through a journey in pursuit of wellness and health in a healthcare setting, customer experience occurs
which are patients’ internal and subjective response to any direct or indirect contact with various touch
points in the hospital settings; however, these touch points do not have equal values (Meyer & Schwager,
2007). Patient’s experience in the healthcare setting is a summation of satisfaction (Brown & Swatrz, 1989)
104 Journal of Health Management 21(1)

with the individual transactions and interactions that create memorable events (Pine & Gilmore, 1998) that
have occurred in this journey. Thus, each dimension for measurement of the healthcare service quality may
weigh differently in various settings in the overall measurement of the service quality.
Hospital service quality-related studies have been done in various settings in India and across the
world namely Bahrain (Ramez, 2012), Bangladesh (Andaleeb, 2001), Burkina Faso (Baltussen, Yé,
Haddad, & Sauerborn, 2002), Egypt (Mostafa, 2005), Guiena (Haddad, Foureier, & Potvin, 1998),
Iran (Bahadori, Radabadi, Ravangard, & Baldacchin, 2015; Zarei et al., 2012), Malaysia (Amin &
Nasharuddin, 2013; Mohamed & Azizan, 2015), Mauritius (Ramsaran-Fowdar, 2008), Pakistan (Irfan, Ijaz,
& Farooq, 2012); Romania (Purcarea, Gheorghe, & Petrescu, 2013), Serbia (Senic & Marinkovic, 2012),
South Korea (Choi, Cho, Lee, Lee, & Kim, 2004), Taiwan (Chang, Chen, & Lan, 2013; Teng, Ing,
Chang, & Chung, 2007), Thailand (Santsanguan et al., 2015), Turkey (Altuntas, Dereli, & Yilmaz, 2012;
Pakdil & Harwood, 2005) and the USA (Berry & Bendapudi, 2007; Otani, Waterman, Faulkner, Boslaugh,
& Dunagan, 2010). The objective of this article is to explore and summarize this wide pool of unorganized
published available knowledge related to (a) healthcare service quality, (b) dimensions of healthcare
service quality, (c) and the measurement techniques in healthcare service quality into an organized piece
of work. Subsequent sections of this article will shed light on these three aspects of service quality in
the healthcare industry, which will be helpful in summarizing the existing knowledge and laying the path
from what is known to what is unknown.

Method
To identify the significant researches in the field of healthcare service quality, databases such as EBSCO
and Google Scholar were searched. The keywords used for the search included a combination of ‘health-
care’, ‘service’, ‘service quality’, ‘dimensions’ and ‘measurement’. The inclusion criteria of the search
results of articles for the purpose of this study were set as follows: (a) the paper should have been pub-
lished in peer-reviewed journal, (b) the paper should have been full text article in English, (c) the paper
should include analysis or views related to healthcare services and (d) the paper should have some quali-
tative and/or quantitative findings related to hospitals/healthcare settings. The literature search was con-
ducted from January to March 2017. A total of 124 articles met the inclusion criteria. Reviewing the title,
abstract and findings of the paper, the articles that do not meet inclusion criteria were dropped. Post
review of the paper, the findings were segregated into three broad themes identified for the purpose of
the study, namely, healthcare service quality, healthcare service quality dimensions and measurement of
healthcare service quality. We classified the identified dimensions from literature of healthcare service
quality into medical and non-medical aspects of care. The variables under study in previously researched
upon papers and presented in research articles were classified under the respective dimension of medical
and non-medical aspect of care.

Result
Under the theme of healthcare service quality, 21 research papers published between 1986 and 2016
were included. Fifty-two research articles published between 1985 and 2016 (almost all from the health-
care industry) were identified to understand the dimensions of healthcare service quality. Forty-two
Upadhyai et al. 105

research articles published between 1992 and 2016, measuring healthcare service quality, were short-
listed for the purpose of this study.
Healthcare studies conducted in 19 different countries were included in this study. However, articles
relating to customer satisfaction, loyalty, profitability and interlinkages along with their relations with
service quality were excluded from the study. Research articles in healthcare settings, pertaining to
patient ratings, satisfaction levels or models, government polices, and so on were not included, as they
were outside the purview of this research. The results section is divided into three conceptualized themes
of healthcare service quality, its dimensions and measurement. Each section highlights the work done
under each theme, and the salient and relevant knowledge serves the objective of this study.

Concept of Service Quality

Services could be defined as ‘Services are deeds, processes, and performances’ (Zeithaml & Bitner,
1996, p. 5). ‘An activity, benefit, or satisfaction offered for sale that is essentially intangible and
does not result in the ownership of anything’ (Kotler, Keller, Koshy, & Jha, 2013, p. 338). ‘An act or
performance that creates benefits for customers by bringing about a desired change in-or on behalf of
the recipient’ (Lovelock & Wright, 1999, p. 2). Services are strongly linked to quality and are assessed
on various parameters.
The customer’s evaluation of service quality is not only their subjective assessment of services meet-
ing the set standards but also their evaluation of performance in the process of service delivery. Customer
usually carries prior expectations from the services that they are going to utilize. The discrepancy which
is measured as a gap between the prior expectations of the customer before receiving the service and the
perception formed by the customer post receipt of the service is called perceived service quality
(Grönroos, 1984). Service Quality, thus, can be defined as the discrepancy between consumer’s percep-
tions of services and their expectations about that firm offering such services (Bolton & Drew, 1991;
Parasuraman, Zeithaml, & Berry, 1988). However, hospital service quality is the discrepancy between
patient’s or patient’s attendants’ perceptions of services and their expectations about that hospital offer-
ing such services (Aagja & Garg, 2010).
Although healthcare is also a service, yet inherently they are different from other industries in the
service sector. Healthcare is a credence service, in that clinical quality is often difficult for the patient to
judge even after the service is performed (Berry & Bendapudi, 2007):

1. Customers have some combination of illness, pain, uncertainty, fear and perceived lack of
control.
2. Customer may be reluctant co-producers because healthcare is a service that need but they may
not want.
3. Customers relish privacy physically, emotionally and spiritually.
4. Customers need whole person service.
5. Customers are at risk of being harmed.
6. Clinicians are stressed physically and emotionally.

Unlike some other service industries, the service providers are also the equal stakeholders in the
service delivery process, and their expectations and the perceptions about how a healthcare system
operates are equally important (Brown & Shwartz, 1989). Assessing service quality proved to be
106 Journal of Health Management 21(1)

controversial, especially in more ‘experiential’ services such as healthcare when expertise is required
(Purcarea et al., 2013). Service quality evaluation differs from service delivery professionals and the
receivers of it. While professionals outweigh design and delivery aspect of service, receivers evalu-
ate service on their overall perception of the service consumed (Brown & Swartz, 1989). The payer,
generally the third-party insurance companies, and in certain cases, the government and govern-
ment-aided agencies stress on the cost effectiveness of care one of the most important aspects of the
quality of care. The ‘cost of care’-based concept of quality is generally deemed flawed by the clini-
cians, and they feel duty-bound to overweigh life/health over the cost of such interventions. Further,
it can also be argued that the outcome of a procedure may be good in spite of the poor processes vice
versa (Ransom, Joshi, & Nash, 2005, p. 65). Thus, the concept of quality of care means different
things to different stakeholders involved in the healthcare system (Pai & Chary, 2016). The out-
comes are indicator of problems in quality, yet cannot determine whether poor or good quality of
care was being provided.

Service Quality in Healthcare

Quality of care is defined as having three domains: patient safety, clinical effectiveness and patient expe-
rience (compassion, dignity and respect) (Black, Varaganum, & Hutchings, 2014). WHO noted that the
quality in health services should be safe (avoiding injuries to people for whom the care is intended),
effective (providing evidence-based healthcare services to those who need them), people-centred (pro-
viding care that responds to individual preferences, needs and values) and timely (reducing waiting times
and sometimes harmful delays). The IOM definition of quality of care is ‘the degree to which health
services for the individuals and populations increase the likelihood of desired health outcomes and are
consistent with the current professional knowledge’. The IOM definition stresses on the technical per-
formance and the current professional knowledge available. The current professional knowledge is a
relative assessment, which may vary not only across the countries but also between individuals. Further,
healthcare customers are in a state of physical or psychological discomfort or in both (Duggirala,
Rajendran, & Anantharaman, 2008); therefore, their feedback regarding evaluation of the healthcare
service quality may be erroneous.
Inadequate quality may arouse various emotions in the patients, their family members and their
attendants ranging from frustration and despair, anxiety over costs and complexities of care, tension
due to inconvenience in getting what is needed for care and, alienation from care system which has
little time in understanding and meeting their needs (Ransom et al., 2005, p. 6). Service quality can
lead to overuse, while inadequate levels of service quality may lead to underuse and, at times, may be
bypassed (Andaleeb, 2001).
Healthcare quality-specific research has identified various attributes which include Technical perfor-
mance, management of interpersonal relationships, amenities of care, and responsiveness to patient’s
preferences, efficiency and cost effectiveness (Ransom et al., 2005, p. 26). Grönroos (1984) classified the
quality as technical and functional quality. He further added that technical quality is a prerequisite to the
functional quality. Donabedian (1966) stated that the evaluation of healthcare service quality involves
three aspects of healthcare, namely, structure (i.e., well-qualified, well-appointed and well-organized
settings), process (appropriateness and skill in the actions performed) or outcome (health status-related
indicators). Donabedian (1988) also stressed upon the technical quality in the healthcare system along
with the interpersonal elements of quality. The technical aspects are the knowledge and judgement of the
Upadhyai et al. 107

service provider while information exchange between the provider of care and the receiver of care
increases the collaboration in the care. Baltussen et al. (2002) also favoured the concept of technical
quality and interpersonal quality in healthcare services. Piligrimiene and Buciuniene (2008) noted that
functional aspects of the quality are more important for the patients than the technical aspects of quality;
however, healthcare professionals are more inclined towards the technical aspects of care. De Silva
and Valentine (2000) were of the opinion that the responsiveness and satisfactions are two different
constructs, while the later evaluates the clinical interactions in the healthcare facility and the former
evaluates the quality of health system.
We created a template from the literature, which classifies the quality in healthcare into medical and
non-medical aspects. This classification is made available in Table A1. The medical aspects of care
which directly affects the health and wellness of the patients include technical quality, outcome quality
and interpersonal quality. The non-medical aspects of quality which indirectly affect the well-being of
the patient through their interaction with the patients in the process of service delivery include services-
capes, accessibility and responsiveness.

Dimensions of Healthcare Service Quality

Parasuraman et al. (1985) identified 10 dimensions of service quality in five different industries.
Later, they reduced these dimensions to five, namely, responsiveness, assurance, tangibility, empathy
and reliability (RATER), which are widely used across industries in various service settings including
healthcare (Altuntas et al., 2012; Bahadori et al., 2015; Brahmbhatt, Baser, & Joshi, 2011; Irfan et al.,
2012; Izogo & Ogba, 2015; Jandavath & Byram, 2016; Kheng, Mahamad, Ramayah, & Mosahab, 2010;
Kondasani & Panda, 2015; Pramanik, 2016; Raajpoot, 2004; Ramez, 2012; Ramsaran-Fowdar, 2008;
Sohail, 2003; Thiakarajan & Krishnaraj, 2015; Ting-Kwong Luk & Layton, 2004; Venkateswarlu, Ranga,
& Sreedhar, 2015; Zarei et al., 2012). However, service quality dimensions are context-specific
(Ladhari, 2008). Healthcare quality is mostly reported on dimensions such as structural aspects of care,
processes and outcomes (Rothberg, Morsi, Benjamin, Pekow, & Lindenauer, 2008). Further, hospital
patients have different priorities to different attributes (Dagger, Sweeney, & Johnson, 2007; Otani et al.,
2010). The dimensions of healthcare service quality can also be classified under medical and non-medical
aspects of care.
The medical aspects of care include three dimensions, namely, technical, outcome and interpersonal.
The technical dimension of healthcare quality includes knowledge, skills and judgement of the care
giver and the medical facilities available (Baltussen et al., 2002; Donabedian, 1988; Grönroos, 1984;
Piligrimiene & Buciuneine, 2008). The outcome dimension of quality includes effective, efficient, equi-
table, timely, safe and patient-centred care (Donabedian, 1988; World Health Organization [WHO],
2000). Interpersonal dimension of quality includes information exchange, friendliness, attentiveness
and developing understanding and collaboration through information exchange (Baltussen et al., 2002;
Chahal & Kumari, 2010, 2012; McKinsey, 2015).
The non-medical aspects of care affect the health and wellness indirectly and include three dimen-
sions, namely servicescapes, accessibility and responsiveness. Servicescapes include the basic amenities
and the physical environment in which the service is delivered (Grönroos, 1984; Lovelock & Wright,
1999 p. 32). This may include accommodation, appearance of building, landscaping, staff member’s
uniform, signage, cleanliness, and so on. According to WHO, Accessibility includes location of the facil-
ity, consumption of time reach it and the financial affordability of care. The ease in admission, billing,
108 Journal of Health Management 21(1)

discharge and other non-health related processes are also included in this dimension. Responsiveness
here relates to the expectations from care which is reasonable as a human being (De Silva & Valentine,
2000). This includes dignity and autonomy of patient, confidentiality of care, prompt attention, access to
social support networking during care and quality in basic amenities. Table A1 presents a classification
of major attributes of care that have been studied, under the identified six dimensions of medical and
non-medical aspects of care. It can be noted that most of the studies reviewed partially and cover all the
attributes of healthcare service quality dimensions.

Medical Aspects of Care

The technical dimension of care include attributes such as delivery personnel (Haddad et al., 1998; Pai
& Chary, 2013; Satsanguan, Fongsuwan, & Trimetsoontorn, 2015), instruments used (Ramsaran-Fowdar,
2008), medicine availability (Krishnamoorthy & Srinivasan, 2014; Mohamed & Azizan, 2015; Rao,
Peters, & Bandeen-Roche, 2006), human performance and skills (Mostafa, 2005; Piligrimiene &
Buciuniene, 2008), knowledge (Olorunniwo et al., 2006; Piligrimiene & Buciuniene, 2008), competence
and professionalism (Ramsaran-Fowdar, 2008), physician and nursing care (Duggirala et al., 2008;
Krishnamoorthy & Srinivasan, 2014; Otani et al., 2010). The outcome dimension of care include attrib-
utes apart from reliability include need (Teng et al., 2007; Ting-Kwong Luk & Layton, 2004), sanitation
(Teng et al., 2007), fair and equitable (Krishanamoorthy & Srinivasan, 2014; Ramsaran-Fowdar, 2008),
timely (Ravichandran et al., 2010), prevention (Prakash & Mohanty, 2012), promptness (Senic &
Marinkovic, 2012), personalization (Pai & Chary, 2013), pain management (Makarem & Al-Amin,
2014), safety (Thiakarajan & Krishnaraj, 2015) and personalization (Pai & Chary, 2016). The interper-
sonal aspects of care apart from assurance include informed choice (Donabedian, 1988; Prakash &
Mohanty, 2012), medical communication (Andaleeb, 2001; Duggirala et al., 2008; Kondasani & Panda,
2015; Makarem & Al-Amin, 2014; Pai & Chary, 2013; Piligrimiene & Buciuniene, 2008; Rao et al.,
2006), and customization and attention (Teng et al., 2007).

Non-Medical Aspects of Care

The servicescapes dimension of care include attributes such as infrastructure (Donabedian, 1988;
Duggirala et al., 2008; Mohamed & Azizan, 2015; Rao et al., 2006; Satsanguan et al., 2015), facility
(Haddad et al., 1998; Mostafa, 2005), cleanliness (Hasin, Seeluangsawat, & Shareef, 2001), food and
room (Otani et al., 2010), physical environment (Chahal & Kumari, 2010, 2012; Chang et al., 2013;
Kondasani & Panda, 2015; Krishnamoorthy & Srinivasan, 2014; Pai & Chary, 2013) and cleanliness
(Makarem & Al-Amin, 2014). The accessibility dimension deals with attributes such as financial and
physical access (Baltussen et al., 2002; Thiakarajan & Krishnaraj, 2015), convenience (Choi et al.,
2004; Teng et al., 2007), admission and discharge (Aagja & Garg, 2010; Amin & Nasharuddin, 2013;
Makarem & Al-Amin, 2014; Otani et al., 2010) and other administrative process (Duggirala et al.,
2008; Mohamed & Azizan, 2015; Pai & Chary, 2013, 2016; Prakash & Mohanty, 2012), preference of
place (Thiakarajan & Krishnaraj, 2015). Responsiveness dimension is on the most studied dimensions of
care with attributes such as compassion (Haddad et al., 1998), dignity (Haddad et al., 1998; Piligrimiene
& Buciuniene, 2008), conduct (Baltussen et al., 2002), sincerity (Raajpoot, 2004), confidentiality
(Piligrimiene & Buciuniene, 2008), courtesy (Pilgrimiene & Buciuniene, 2008; Ravichandran et al.,
2010), social responsibility (Aagja & Garg, 2010; Amin & Nasharuddin, 2013; Duggirala et al., 2008),
Upadhyai et al. 109

trust (Pai & Chary, 2013; Prakash & Mohanty, 2012) and privacy (Donabedian, 1988; Kondasani &
Panda, 2015)

Measurement Techniques in Healthcare Service Quality

Measurement of patient expectations as well as perceptions provides a valuable insight into the process
by which the quality of health care service is evaluated (Babakus & Mangold, 1992). Service quality
dimensions are difficult to measure because they are determined by the recipients of health care and
are measured in terms of patient perceptions of the healthcare experience (Kilbourne, Duffy, Duffy, &
Giarchi, 2004). ‘SERVQUAL’ (Parasuraman et al., 1988) and its modifications had been the most preva-
lent scale used to measure the service quality in the healthcare settings, which measure the gap between
the expectations and perceptions of the service providers. However, SERVQUAL scale has been criti-
cized in various studies (Babakus & Mangold, 1992; Cronin & Taylor, 1992, 1994; Teas, 1994; Teas &
Kenneth, 1993). Further, it is argued that the SERVQUAL is context-specific, and the instrument is chal-
lenged for its universality, instead it needs to be customized to fit the nature of specific service (Andaleeb,
2001; Babakus & Mangold, 1992). Further, perceptions of the services may exceed for some customers
with low expectations from the healthcare systems (Sohail, 2003); hence, performance only scores
‘SERVPERF’ are adequate to measure service quality (Brady, Cronin, & Brand, 2002; Cronin & Taylor,
1992; Prakash & Mohanty, 2012) and have higher predictive validity of customer’s satisfaction
(Babakus & Mangold, 1992; Cronin & Taylor, 1994; Lee, Lee, & Yoo, 2000; Prakash & Mohanty, 2012;
Ramez, 2012; Ting-Kwong Luk & Layton, 2004). Jain and Gupta (2004) were of the opinion that for
comparisons between the settings in the same industry of different ones SERFPERF should be a
preferred research instrument; however, for diagnosing the areas of concern in the service delivery
process, SERVQUAL has the better diagnostic results. Of late, Ramsaran-Fowdar (2008) developed a
scale ‘PRIVHEALTHQUAL’ to measure the service quality in private hospitals. Aagja and Garg (2010)
developed a similar type of scale ‘PubHosQual’ for Government hospitals.
The studies conducted to measure the dimensions of the service quality include OPD, IPD and dis-
charged patients who had availed some kind of general or specialized care in public of private medical
facilities. It can be argued that not only patients but also the people accompanying them are also the
healthcare service consumes (Padma, Rajendran, & Sai, 2009). Certain studies have also incorporated
this view by measuring the response regarding healthcare service quality from their family members
(Pai & Chary, 2016; Pakdil & Harwood, 2005; Ramsaran-Fowdar, 2008; Satsanguan et al., 2015), their
guardians (Chowdhury, 2008), their attendants (Aagja & Garg, 2010; Prakash & Mohanty, 2012;
Sivakumar & Srinivasan, 2009).
Almost all the studies used questionnaire as an instrument to measure the service quality, which was
primarily based on items in the SERVQUAL questionnaire or modified form of it. For such question-
naire-based studies, the minimum sample selected range from 100 respondents (Duggirala et al., 2008)
to 2,448 respondents (both IPD and OPD) (Rao et al., 2006). Otani et al., (2010) conducted telephonic
interviews with 4,320 patients who were discharged from the facility within 7–14 days. E-mail and
postal surveys were also conducted with discharged patients by Purcarea et al. (2013); however, Chahal
and Kumari (2012) and Dheepa , Gayathri and Karthikeyan (2015) used schedule for collecting responses.
The number of items used in the studies varied between 15 (Sohail, 2003) and 86 (Duggirala et al., 2008)
using 3–7-point Likert scale for measuring the dimensions of service quality. These dimensions vary
according to country, culture, government vs. private facility, types of healthcare need, urban vs rural
patients, and so on leading most of the researchers to the identification of the specific factors affecting
110 Journal of Health Management 21(1)

service quality. Principal component analysis, factor analysis, ANOVA, correlation, multiple regression
and structured equation modelling have been used as various analytical techniques to identify and measure
various dimensions of service quality as shown in Table A2.

Discussion
In recent times, many companies have started service quality measurement programmes (Bolton &
Drew, 1991). Patient satisfaction is, however, the most important parameter for the assessment of quality
of health care services provided (Amin & Nasharuddin, 2013; Gupta & Rokade, 2016; Jandavath &
Byram, 2016), but is not always the correct indicator (Cleary & Edgam-Levitan, 1997). Service quality
assessment starts with the formation of customer’s expectations; however, customer satisfaction can
only be assessed post-delivery of service (Bolton & Drew, 1991; Boulding, Kalra, Staelin, & Zeithaml,
1993; Caruana, 2002; Cronin & Taylor, 1994). Thus, measuring service quality based on satisfaction
ratings can be biased as a customer may get well yet may not be satisfied with the quality of care or vice
versa. Patient satisfaction varies with the consumer characteristics such as education (Pakdil & Harwood,
2005), consumer’s stage in service delivery (Dagger et al., 2007) and information shared during and after
the treatment (McKinsey, 2015).
Medical and non-medical aspects of the care become an obvious classification of the dimensions of
healthcare service quality. Customers of the healthcare services weigh the empathy and support provided
by the health professional rather than outcomes of the treatment or the technical knowledge of the ser-
vice provider (McKinsey, 2015). The five dimensions, namely reliability, assurance, tangibility, respon-
siveness and empathy, are the most researched upon dimensions in healthcare services. However, certain
dimensions like hospital image (Pai & Chary, 2016) indicate towards branding aspect of the healthcare
facility. These dimensions are context-specific and have been mostly identified from the demand
side, that is, patients. In services like healthcare that require high experience and credence properties
(Zeithaml, 2000), the dimensions of healthcare service quality need to be evaluated from the supply side
as well, that is, providers’ (Choi et al., 2004).
SERVQUAL (Parasuraman, Berry, & Zeithaml, 1991) using the gap score between patient’s expecta-
tions and perceptions of the performance of service delivered and SERVPERF (Cronin & Taylor, 1994)
with performance only measures are widely used as measurement tool for service quality evaluations.
The inherent ability of SERVQUAL to calculate the gap between the expectations and preconceptions of
service delivered on the five dimensions allows administrator the chance to pinpoint the area where the
gap is high. Further, SERVQUAL allows assigning weightage to various dimensions as perceived by the
customers. However, it does not tell the way to close these gaps, and it is left for the managerial capabili-
ties. Apart from addition of other relevant dimensions specific to the service settings in the SERVQUAL
model, most of the studies have not measured the desired, adequate and perceived service as called by
the originators of SERVQUAL themselves (Parasuraman et al., 1994).
In light of the available literature, every attempt has been made by us to include almost all the studies
relevant to the healthcare service quality, its dimensions and measurement techniques. There may be
abundance of the various studies, which may have been conducted by the institutions themselves for
internal consumption. This study may be fruitful for getting insights into knowing the different concep-
tualization of service quality in healthcare as viewed in other conventional services.
Upadhyai et al. 111

Conclusion and Scope for Future Research

The published knowledge summarized in this study suggests that there is no single set of dimensions or
measurement standard available for the evaluation of healthcare service quality. Almost all the methods
and scales used for measurement of healthcare service quality have not incorporated the view of service
providers as the patients alone are not capable of assessment of technical side of service quality. Dyadic
view, that is, the examination of both the parties, client and the provider, of evaluation of service quality
and satisfaction of the service encounter is necessary for gaining understanding of the evaluation process
(Brown & Swartz, 1989). Thus, there is a need to identify the service quality dimensions from the service
provider’s side. Further, the existing standards of accrediting the healthcare institutions are related to the
structure and process of delivery. This makes the task of Governments in managing and measuring the
healthcare service quality in country like India a challenging one. We need to look beyond ‘what should
be?’ and look towards ‘what could be?’ there in the healthcare service quality incorporating both demand
and supply side expectations and perceptions.
Appendix A

Table A1. Classification of Major Attributes in Healthcare Studies Under Medical and Non-medical Aspects of Care

Medical Aspects Non-Medical Aspects

Author (Year) Technical Outcome Interpersonal Servicescapes Accessibility Responsiveness
Donabedian, A. (1988) Outcome Informed Structure Privacy, confidentiality,
choice concern, empathy,
honesty, tact, sensitivity
Haddad, S., Fourner, P., Potvin, Delivery, personnel   Facility   Respect, compassion,
L. (1998) dignity
Andaleeb, S. S. (2001)     Assurance,     Responsiveness,
communication discipline, Baksheesh
Hasin, M. A. A., Seeluangsawat,       Cleanliness   Service of staff
R., Shareef, M. A. (2001)
Baltussen, R. M. P. M., Ye, Y., Adequacy of resources   Delivery   Financial and Personal practices &
Haddad, S., Sauerborn, R. S. physical access conduct
(2002)
Sohail, S. S. (2003)   Reliability Assurance Tangibles   Responsiveness,
empathy
Luk, S. T. K. W., Layton, R.   Outcome,   Tangibles   Assurance, empathy &
(2004) reliability, need responsiveness
Duong, D. V., Binns, C. V., Lee,   Delivery Interpersonal Facility Access  
A. H., Hipgrave, D. B. (2004) aspects
Choi, K. S., Cho, W. H., Lee, S.,         Convenience  
Kim, C. (2004)
Raajpoot, N. (2004)   Reliability Assurance Tangibles   Sincerity
Rao, K. D., Reters, D. H., Medicine availability   Medical Infrastructure   Staff and doctor's
Roche, K. D.(2006) information behaviour
Mostafa, M. M. (2005) Human performance Reliability   Facility    
Olorunniwo, F., Hsu, M. K., Knowledge     Tangibles Access Recovery and
Udo, G. F. (2006) responsiveness
Teng, C. I., Ing, C. K., Chang,   Sanitation Need Quiet Convenience Assurance
H. Y., Chung, K. P. (2007) management,
customization,
attention
Dagger, T. S., Sweeny, J. C.,     Interaction Atmosphere,    
Jhonson, L. W. (2007) tangibles
Piligrimiene, Z., Buciuniene, I. Skills, knowledge,   Effective Tangibles Accessibility Respect, confidentiality,
(2008) capability, credibility communication courtesy, empathy
Fowdar, R. R. R. (2008) Core medical services, Reliability, fair, Records, Tangibles   Responsiveness,
professionalism, equitable information assurance, empathy
skill, competence, dissemination
equipment
Duggirala, M., Rajendran, C., Doctors' and nursing   Communication Infrastructure Administrative Overall experience
Ananthraman, R. N. (2008) care, paramedic quality, procedure with care, social
process of care, safety responsibility
indicators
Kheng, L. L., Mahamad, O.,   Reliability Assurance Tangibles   Responsiveness,
Ramayah, T., Mosahab, R. empathy
(2010)
Mosahab, R., Mahamad, O.,   Reliability Assurance Tangibles   Responsiveness,
Ramayah, T. (2010) empathy
Aagja, J. P., Garg, R. (2010) Medical quality       Admission, Social responsibility
discharge
Otani, K., Waterman, B., Physician and nursing   Staff care Food and Admission  
Faulkner, K. M., Boslaugh, S., care room
Dunagan, W. C. (2010)
(Table A1 Continued)
(Table A1 Continued)

Medical Aspects Non-Medical Aspects

Author (Year) Technical Outcome Interpersonal Servicescapes Accessibility Responsiveness
Ravichandran, K., Mani R. T.,   Timely   Modern   Responsiveness,
Kumar, S. A., Prabhakaran, S. equipment courtesy, willingness
(2010) to help
Brahmbhatt, M., Baser, N.,   Reliability Process Tangibles Policy Assurance, empathy
Joshi, N. (2011)
Altuntas, S., Dareli, T., Yilmaz,   Reliability Assurance Tangibles   Responsiveness,
M. K. (2012) empathy
Ramez, W. S. (2012)   Reliability Assurance Tangibles   Responsiveness,
empathy
Irfan, S. M., Ijaz, A., Farooq, M.   Reliability Assurance Tangibles   Responsiveness,
M. (2012) empathy
Prakash, A., Mohanty, R. (2012) Treatment, diagnosis, Prevention Education   Administration Trust
research
Arun Kumar, G., Manjunath, S.   Reliability   Tangibles   Responsiveness,
J., Chethan, K. C. (2012) empathy
Senic, V., Marinkovic, V. (2012)   Promptness Personal Tangibles    
relationships
Zarei, A., Arab, Md., Froushani,   Reliability   Tangibles   Responsiveness,
A. R., Tabatebaei, S. M. G. empathy
(2012)
Chahal, H., Kumari, N. (2012) Expertise     Process,   Attitude, behaviour
physical
environment
Chang, C. S., Chen, S. Y., Lan,   Reliability Assurance Environment   Responsiveness
Y. T. (2013) and space
Amin, M., Nasharuddin, S. Z. Medical service       Admission, Social Responsibility
(2013) discharge
Pai, Y. P., Chary, S. T.(2013) Personnel quality Personalization Communication Physical Administrative Image, trustworthiness,
environment procedures process of care,
and relationship
infrastructure
Krishnamoorthy, V., Srinivasan, Medical service, Equality   Physical Admission, Empathy
R. (2014) medical care, availability ambience, discharge
of medicine infrastructure,
tangibility
Makarem, S. C., Al Amin, M.   Pain Nurse, Cleanliness Discharge Responsiveness,
(2014) Management physician and information quietness
medication
communication
Venkateshwarlu, P., Ranga, V.,   Reliability Assurance Tangibles   Responsiveness,
Sreedhar, A. (2015) empathy
Izogo, E. E., Ogba, I. E. (2015)   Reliability Assurance Tangibles   Responsiveness,
empathy
Bahadori, M., Raadabadi, M.,   Reliability Assurance Tangibles   Responsiveness,
Ravangard, R., Baldacchino, D. empathy
(2015)
Dheepa, T., Gayathri, N.,   Reliability Assurance Tangibles   Responsiveness,
Karthikeyan, P. (2015) empathy
Satsanguan, L., Fongsuwan, W., Personnel quality Reliability Service of Infrastructure    
Trimentsoontron, J. (2015) support staff
Mohamed, B., Azizan, N. A. Medical and nursing   Interaction Infrastructure Administrative  
(2015) care procedure
Kondasani, R. K. R., Panda, R.   Reliability Communication Physical   Customer friendly
K. (2015) environment staff, responsiveness,
privacy and safety,
consideration
Thiakarajan, A., Krishnaraj, A.   Safety,     Preference of Product/service
S. R. (2015) consideration place, hospital consideration
charges
(Table A1 Continued)
(Table A1 Continued)

Medical Aspects Non-Medical Aspects

Author (Year) Technical Outcome Interpersonal Servicescapes Accessibility Responsiveness
Jandavath, R. K. N., & Byram,   Reliability Assurance Tangibles   Responsiveness,
A. (2016) empathy
Pramanik, A. (2016)   Reliability Assurance Tangibles   Responsiveness,
empathy
Pai, Y. P., Chary, S. T. (2016) Personnel Clinical care Communication Healthscapes Administrative Relationship,
process, procedure
personalization
Pramanik, A. (2016)   Reliability   Tangibility   Responsiveness,
empathy, assurance
Source: The authors.
Table A2. Measurement Techniques in Healthcare Service Quality

Method of Data No. of Items Analytical

Author Types of Respondents Sample Size Collection Used Scale Technique
Babakus E., Mangold, Discharged in 13 443 Mail-based   5-point Likert scale (5 = EFA and CFA
W. G. months questionnaire strongly agree and 1 =
strongly disagree)
Haddad, S., Fourner,   241 Questionnaire 20 items    
P., Potvin, L.
Andaleeb, S. S. Patient who utilized 207 Questionnaire 25 7-point Likert scale (1 = Factor analysis
health services in 12 strongly disagree, 7 = strongly and regression
months agree)
Hasin, M. A. A., IPD and OPD IPD = 138, Questionnaire 18   ANOVA
Seeluangsawat, R., OPD = 255
Shareef, M. A.
Brady, M. K., Cronin   2,278   10   CFA
Jr, J. J., Brand, R. R.
Caruana, A. Quantitative 200 Postal 21 3-point scale for perception CHAID
questionnaire (worse than expected, about
as expected, better than
expected)
Baltussen, R. M. P. M.,   1,081 Questionnaire 20 5-point Likert scale (−2 Factor analysis
Ye, Y., Haddad, S., very unfavourable+2 very
Sauerborn, R. S. favourable)
Sohail, S. S. Discharged patients 150 Mail-based 15 5-point Likert scale (1 = CFA
within 6 months questionnaire strongly agree and 2 = GAP score
strongly disagree)
Jain, S. K., Gupta, G.   400 Questionnaire 22 5-point Likert scale GAP score and
outcome score
Kilbourne, W. E., Nursing home residents 294 Questionnaire 22 7-point Likert scale (1 = SEM
Duffy, J. A., Duffy, M., in long term care disagree very strongly and 7 =
Giarchi, G. agree very strongly)
(Table A2 Continued)
(Table A2 Continued)

Method of Data No. of Items Analytical

Author Types of Respondents Sample Size Collection Used Scale Technique
Luk, S. T. K. W.,   288 Questionnaire 24   EFA
Layton, R.
Duong, D. V., Binns, Prenatal and 396 Interview 20 3-point scale (favourable, PCA
C. V., Lee, A. H., postpartum women neutral, unfavourable)
Hipgrave, D. B.
Choi, K. S., Cho, W. Outpatients 537 Self-administered 30 7-point Likert scale (1 = Factor analysis
H., Lee, S., Kim, C. questionnaire strongly disagree and 7 =
strongly agree)
Verhoef, P. C., Inbound calls   Telephonic   5-point Likert scale (very Regression
Antonides, G., questionnaire unpleasant–pleasant, very analysis
DeHoog, A. N. dissatisfied–satisfied)
Raajpoot, N.   222 Focus group and 24   Item response
then mail survey theory, EFA,
CFA and
conjoint analysis
Pakdil, F., Harwood, Preoperative patients 669 Questionnaires 22 Three for expectations (very  
T. N. and their family important, important, not
members important), perceptions on
5-point Likert scale (1 =
excellent, 2 = very good, 3 =
good, 4 = fair, 5 = poor)
Rao, K. D., Reters, D. Inpatient and outpatient 1,837 Questionnaire 16 5-point Likert type scale PCA and
H., Roche, K. D. outpatients and (Pictorial money scale regression
611 inpatients one rupee = completely
agree, 75 p = agree, 50 p =
neither agree nor disagree,
25 p disagree, zero paise =
completely disagree)
Mostafa, M. M. About to be discharged 332 Questionnaires 22 5-point Likert type scale PCA,
patients (strongly disagree to strongly discriminant
agree) analysis,
ANOVA
Olorunniwo, F., Hsu, Employees of major 311 Questionnaire 29 7 -point Likert scale (1 = Focus group
M. K., Udo, G. F. corporations, state and strongly disagree to 7 = and WTA, EFA
federal government strongly disagree) and CFA
establishments and
MBA students
Rohini, R., Patients and 500 patients Questionnaire 22 7-point Likert scale GAP score
Mahadevappa, B. management (100 from each
hospital), 40
responses from
management
Teng, C. I., Ing, C. K., Patients admitted in 271 (253) Questionnaire 47 5-point Likert scale (strongly Factor analysis
Chang, H. Y., Chung, surgical wards disagree to strongly agree)
K. P.
Dagger, T. S., Sweeny,       1353   Four focus
J. C., Jhonson, L. W. group
interviews, mail
survey, standard
content analysis
procedure
Piligrimiene, Z.,            
Buciuniene, I.
Chowdhury, Md. M. U. Patients and their 1,100 patients. Questionnaire 21 7-point Likert scale GAP score
guardians. Management 800
personnel management
personnel
Fowdar, R. R. R. Patients and family 260 Questionnaire 47 7-point Likert scale Factor analysis
members having visited and linear
GP in 1 year regression
Duggirala, M., Patients undergone 100 Questionnaire 86 7-point Likert scale CFA. bivariate
Rajendran, C., medical treatment and correlations.
Ananthraman, R. N. hospital stay in the Multiple
recent past regression
analysis
(Table A2 Continued)
(Table A2 Continued)

Method of Data No. of Items Analytical

Author Types of Respondents Sample Size Collection Used Scale Technique
Aagja, J. P., Garg, R. Patients and attendants 200 Questionnaire 24   CFA
Kheng, L. L., Mahamad, Customers of 10 banks 238 Questionnaires   7-point Likert scale (1 = Regression
O., Ramayah, T., strongly disagree, 7 = strongly
Mosahab, R. agree)
Mosahab, R.,   147 Questionnaire     Linear
Mahamad, O., Regression
Ramayah, T.
Otani, K., Waterman, Discharged (7–14 days) 4,230 Telephonic   5-point Likert scale Regression
B., Faulkner, K. M., interview
Boslaugh, S., Dunagan,
W. C.
Ravichandran, K., Mani   300 Questionnaire     Regression
R. T., Kumar, S. A.,
Prabhakaran, S.
Santouridis, I., Random intercepts on 205 Interviewer     Multiple
Trivellas, P. streets and shopping administered Regression
centres questionnaire
Sivakumar, C. P., Patients and patient’s 472   22 7-point Likert (strongly agree Multiple
Srinivasan, P. T. attendants to strongly disagree) regression
Brahmbhatt, M., Baser,   246 Questionnaire 41 Modified SERVQUAL scale  
N., Joshi, N.
Prakash, A., Mohanty, Discharged patients and 169 Questionnaire 26 7-point (1 = very low, 7 = Factor analysis
R. attendants very high) and artificial
neural networks
Altuntas, S, Dareli, T., Discharged (IPD) 281 Questionnaire   5-point Likert scale AHP and ANP
Yilmaz, M. K.
Arun Kumar, G., Discharged 185 Questionnaire   5-point Likert scale t-test,
Manjunath, S. J., regression
Chethan, K. C. analysis
Senic, V., Marinkovic, OPD patients 152 Questionnaire 18 7 point (1 = completely PCA, SEM
V. disagree, 7 = completely agree)
Zarei, A, Arab, Md., Discharged 983 Questionnaire 21   Factor Analysis
Froushani, A. R.,
Tabatebaei, S. M. G.
Ramez, W. S. Discharged (within 1 235 Questionnaire     Factor analysis,
year) regression and
correlation
Chahal, H., Kumari, N. Discharges (IPD) 400 Schedule 62 5-point (5 = strongly agree, 1 Hierarchical
= strongly disagree) approach
Chang, C. S., Chen, S.   285 Questionnaire   5-point (5 = strongly agree, 1 SEM
Y., Lan, Y. T. = strongly disagree)
Purcarea, V. L., Discharged patient 183 Questionnaire 22 5-point (5 = strongly agree, 1  
Gheorghe, I. R., (e-mail) = strongly disagree)
Petrescu, C. M.
Naik, J. R. K., Anand, Admitted patients for 145 Questionnaire 24 (16 5-point Likert scale Regression and
B., Bashir, I. more than 2 days SERVQUAL correlation
and others)
Amin, M., Admitted patients for 216 Questionnaire   7-point (1 = strongly agree, 7 CFA, SEM
Nasharuddin, S. Z. more than 1 day = strongly disagree)
Krishnamoorthy, V., Discharged 197 Questionnaire 30   EFA, multiple
Srinivasan, R. through (e-mail or regression
by post)
Dheepa, T., Gayathri,   286 Interview schedule 23   Factor analysis
N., Karthikeyan, P. and multiple
regression
Satsanguan, L., Discharged Patients and 219 Questionnaire 20 7-point (1 = strongly agree to EFA, CFA, SEM
Fongsuwan, W., their relatives 7 = strongly disagree)
Trimentsoontron, J.
Thiakarajan, A.,            
Krishnaraj, A. S. R.
Venkateshwarlu, P., Patients and visitors 300 Questionnaire 22 5-point (very important, Regression and
Ranga, V., Sreedhar, A. important, moderately correlation
important, less important,
unimportant)
(Table A2 Continued)
(Table A2 Continued)

Method of Data No. of Items Analytical

Author Types of Respondents Sample Size Collection Used Scale Technique
Izogo, E. E., Ogba, I. E.   384 Questionnaire 32 7-point (7 = very strongly PCA
(22 Service agree, 1 = very strongly
Quality, 5 disagree)
Customer
Satisfaction,
5 Loyalty)
Mohamed, B., Azizan, Discharged patients 235 Questionnaire 35 5-point (1 = strongly disagree PLS-SEM
N. A. (not more than 12 to 5 = strongly agree)
months)
Kondasani, R. K. R., Patients visited 475 Questionnaire 55 5-point (5 = strongly agree to Focus
Panda, R. K. 1 = strongly disagree) group (for
questionnaire
design) factor
analysis,
regression and
correlation
Bahadori, M., Admitted patients 385 Questionnaire 30 5-point (1 = strongly disagree, CFA
Raadabadi, M., 5 = strongly agree)
Ravangard, R.,
Baldacchino, D.
Jandavath, R. K. N., Admitted patients 493   28   SEM
Byram, A.
Pai, Y. P., Chary, S. T. Family, relatives and   Focus group 66 10-point (1 = not relevant at  
friends who had visited followed by all and 10 = very relevant)
the hospital known to questionnaire
researcher
Pramanik, A. Admitted and discharged 368 Questionnaire 22    
Irfan, S. M., Ijaz, A., Discharged and OPD 369 Questionnaire 22   SEM
Farooq, M. M.
Source: The authors.
Upadhyai et al. 123

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of
this article.

Funding
The authors received no financial support for the research, authorship and/or publication of this article.

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