Int. J. Behavioural and Healthcare Research, Vol. 5, Nos.

1/2, 2015 1

Service quality in healthcare establishments:

a literature review

Faisal Talib*
Mechanical Engineering Section,
University Polytechnic,
Faculty of Engineering and Technology,
Aligarh Muslim University,
Aligarh, India
Email: ftalib77@yahoo.co.in
*Corresponding author

Mohammed Azam and Zillur Rahman

Department of Management Studies,
Indian Institute of Technology Roorkee,
Roorkee, India
Email: inboxazam@gmail.com
Email: yusuffdm@iitr.ernet.in

Abstract: Over the past two decades, Indian healthcare establishments (HCEs)
have embraced service quality (SQ) and SQ dimensions in some way to their
organisation in order to improve the patient’s satisfaction level. However, a
recent report indicated that there is little evidence of leading Indian researchers
working on healthcare quality and related areas in healthcare sector. Moreover,
the perception is that whatever research has been conducted is fragmented, very
specific in nature and specialised. In light of this, the purpose of the present
study is to develop an extensive and systematic literature search on healthcare
quality, SQ, development and application of SERVQUAL and to understand
the link between SQ and patient satisfaction. The paper further identifies the
healthcare quality dimensions and models for HCEs. Finally, it was concluded
that further research is necessary to develop conceptual underpinning and
analytical models based on quantitative studies. The outcome of this study will
help Indian healthcare practitioners and quality experts to take initiative in
implementing hospital SQ dimensions in their organisations as well as may
propose a framework/model for enhanced performance.

Keywords: service quality; SQ; SERVQUAL; healthcare establishments;

HCEs; India.

Reference to this paper should be made as follows: Talib, F., Azam, M. and
Rahman, Z. (2015) ‘Service quality in healthcare establishments: a literature
review’, Int. J. Behavioural and Healthcare Research, Vol. 5, Nos. 1/2,
pp.1–24.

Biographical notes: Faisal Talib is an Assistant Professor at Mechanical

Engineering Section, University Polytechnic, Faculty of Engineering and
Technology, Aligarh Muslim University, Aligarh, (UP), India. He holds PhD
degree from IIT Roorkee and Masters in Industrial and Production Engineering
from AMU. He has 18 years of teaching experience and has more than

Copyright © 2015 Inderscience Enterprises Ltd.

2 F. Talib et al.

60 publications to his credit in national/international journals and conferences.

His special interest includes quality engineering, TQM, service quality, quality
concepts, industrial management, operations management, qualitative and
quantitative techniques and quality management in service industries.

Mohammed Azam holds PhD degree from IIT Roorkee and is MD (in Social
and Preventive Medicine); MBA (with Hospital Management and Quality
Management as special subject) and LLB (with administrative law as special
subject). He has a long experience of practice of public health, community
medicine and also as administrator of hospital being in-charge of various
Cantonment General Hospitals as well as Director of Health at various levels
with administrative jurisdiction over a number of hospitals while serving the
Indian Army.

Zillur Rahman is an Associate Professor at Department of Management

Studies, IIT Roorkee. He is a recipient of the Emerald Literati Club Highly
Commended Award and one of his papers was The Science Direct Top 25
Hottest Article. His work has been published and cited in various journals
including Management Decision, Managing Service Quality, International
Journal of Information Management, Industrial Management and Data
Systems, The TQM Magazine, International Journal of Service Industry
Management, Information Systems Journal, Decision Support Systems, Journal
of Business and Industrial Marketing and to name a few.

1 Introduction

In the era of competitive environment, service sector is under tremendous pressure to

deliver continuing performance and quality improvement while being customer focused.
In recent years, it was observed that healthcare has become one of the extremely complex
industries in the world (Bertolini et al., 2011). There are an increasingly number of
medical specialisations, complex therapies and equipments, disease burden, increasing
healthcare quality dimensions, rapid growth in the world healthcare market and several
service units revolve around different organisations (Ovretveit, 2000). The need to
increase the effectiveness and efficiency of healthcare services in the present situation is
the need of the hour and requires attention towards continuous improvement. Indeed,
there has been an unprecedented interest on behalf of social organisations, physicians,
doctors, healthcare management and government alike into the investments both financial
and human in deploying continuous improvement to improve healthcare services by
focusing on different management tools like continuous quality improvement (CQI); total
quality management (TQM); business process reengineering (BPR); accreditation
programs, simulation models etc. These management tools have brought subsequent
benefits to nursing, medical, administrative staff as well as to the patients but still their
understanding is limited (Savitz et al., 2000; Papadopoulos, 2011).
Papadopoulos (2011) in his qualitative study explores the link between continuous
improvement (CI) and dynamic actor associations through a case of lean thinking
implementation in UK national health service and suggested that the implementation of
CI depends on the emergence of a favouring network from the dynamic associations
between heterogeneous entities. Bertolini et al. (2011) carried out the BPR of surgical
ward in a hospital in order to improve the efficiency of the ward. They identified a
 Service quality in healthcare establishments: a literature review 3

number of areas for improvement. Moreover, the discrete event simulation approach led
to an understanding of the most efficient management choices.
Büyüközkan and Çifçi (2012) proposed a combined fuzzy analytic hierarchy process
(AHP) and fuzzy technique for order performance by similarity to ideal solution
(TOPSIS)-based strategy analysis of electronic service quality (e-SQ) in Turkish
healthcare industry. The work showed the applicability of the e-SQ framework via
internet in this industry. Additionally, Untachai (2013) examined the SQ in a hospital of
Thailand and proposed a model consisting of five components such as reliability,
tangible, response, cost and empathy. He concluded that patients evaluate the healthcare
SQ on these five basic dimensions.
In order to determine an organisation’s level of quality management (QM) and CI,
many studies have used Malcolm Baldrige National Quality Award (MBNQA) model
(Counte and Meurer, 2001). The MBNQA process requires organisations to submit an
application documenting their success, which usually includes competitive benchmarking
(Blazey, 2005). Meyer and Collier (2001) empirically tested the Baldrige model of QM
for healthcare industry using data from US hospitals and determined the causal
relationships among the Baldrige healthcare pilot criteria. It was suggested that the
MBNQA healthcare criteria provides a useful framework to analyse QM practices in the
healthcare settings. Adoption of other quality approaches like Six Sigma, CQI, TQM and
many others have achieved considerable success in several healthcare case studies (Talib
et al., 2010; Kacak et al., 2014; Agus, 2005) but still there is much scope to study quality
of services and patients’ perception of quality in healthcare organisations as suggested by
the current literature review.
Moreover, competitiveness among healthcare organisations depends on healthcare
satisfaction which is achieved through patient satisfaction (Zineldin et al., 2011). Patient
satisfaction is created by responding to patient views and needs, continuous healthcare
service improvement and overall doctor-patient relationship. There are number of factors
and events which affect the patients’ perception and healthcare excellence. These factors
include technical, functional, infrastructural, interaction, political environment, healthcare
quality, social perceptions and information technology which can dramatically change
healthcare (Zineldin et al., 2011; Zineldin, 2006). All this creates a complex situation in
which assessment of healthcare can be analysed through patient satisfaction.
A comprehensive review of literature has been carried in the present work that
discusses the definition of health, healthcare quality, studies on Indian healthcare quality,
SQ, development and application of SERVQUAL, as well as link between SQ and patient
satisfaction followed by discussion on different aspects of healthcare quality perceived by
patients. Finally, the paper identifies the critical dimensions of healthcare quality and
models from selected studies for the healthcare establishments (HCEs).
The rest of this paper is organised as follows: next section presents a comprehensive
review of literature on definition of health, healthcare quality, overview and status of
Indian healthcare system and studies on healthcare quality in Indian HCEs. In the
subsequent section, literatures on various components of SQ such as definition,
development and applications are provided followed by literature review on some
previous studies based on SQ in healthcare as well as relationship between SQ and
patient satisfaction are presented. Last section provides a brief conclusion of this study
including implications and scope for further research.
4 F. Talib et al.

2 Literature review

2.1 Health defined

Health and healthcare need to be distinguished from each other for no better reason than
that the former is often incorrectly seen as a direct function of the latter. Health is clearly
not the mere absence of disease. Good health confers on a person or groups’ freedom
from illness and the ability to realise one’s potential. Health is therefore best understood
as the indispensable basis for defining a person’s sense of well being. The health of
population is a distinct key issue in public policy discourse in every mature society often
determining the deployment of huge society. They include its cultural understanding of ill
health and well-being, extent of socio-economic disparities, reach of health services,
quality and costs of care and current bio-medical understanding about health and illness.
One widely accepted health definition is in the World Health Organization’s
(WHO’s) constitution: “Health is a state of complete physical, mental and social well
being and not merely an absence of disease or infirmity” [WHO, (1948), p.100]. In recent
years, this statement has been amplified to include leading a socially and economically
productive life [Park, (2007), p.13]. Healthcare is defined as “a multitude of services
rendered to individual, families or communities by health service professionals for
promoting, maintaining, monitoring or restoring health” (Last, 1993). Within these
definitions, standards for maintaining health are discernible, which healthcare staff
should strive to achieve.

2.2 Healthcare quality

Healthcare quality has several interpretations. According to Institute of Medicine (2001),
healthcare quality can be assessed from two viewpoints: patients and technical or
professional. The former includes assessment of service provider’s ability to meet
customer demand, customers’ perception and satisfaction. Customer perception with
respect to evaluation of healthcare quality has been supported by a number of researchers
(Mashhadiabdol et al., 2014; Kitapci et al., 2014). Many studies observe that quality
perceptions impact satisfaction, meaning that the service quality (SQ) is the preceding
thing of satisfaction (Parasuraman et al., 1994; Kitapci et al., 2014; Dasanayaka et al.,
2012). Liyanage and Egbu (2005) emphasise that to improve quality, healthcare staff
have to be medically qualified and clinically effective. The Quality Digest (2001)
introduces quality as fulfilling customer requirements at a lower cost with built-in
preventive actions in the processes, ensuring the best product to the end user with timely
delivery. According to Walters and Jones (2001), serious deficiencies are likely to occur
if there is any attempt to achieve quality without fully understanding customer
requirements and expectations. To remain customer-focused, one must review how a
business is managed, i.e., begin with customer problems, needs and priorities. Rose et al.
(2004) emphasise customer factors, organisational performance and healthcare and
hospital SQ components. For patients, switching providers could be detrimental to their
health, as treatment and non-compliance costs could influence healthcare outcomes and
create psychological trauma owing to the uncertainty of adjusting to a new service
provider (Ovretveit, 2000). Typical patient complaints include long waiting times, high
costs and unfriendly, apathetic and uncaring staff. It is, therefore, important to identify
 Service quality in healthcare establishments: a literature review 5

healthcare quality parameters that are practically useful for the organisation, patient and
society.
Improving quality of healthcare services and patient satisfaction apart from increasing
accessibility and affordability to its population in the face of limited resources have
become a major challenge for developing countries and have gained increasing attention
in recent years (Badri et al., 2009, 2008; Narang, 2011; Talib et al., 2011; Dasanayaka
et al., 2012; Zineldin, 2006; Kacak et al., 2014; Uzochukwu et al., 2004). Literature on
healthcare quality stresses the importance of patient’s views as an essential tool for
assessing and improving SQ. It suggests that majority of healthcare institutions are going
for a patient-centred attitude. Consequently, many studies have used patient satisfaction
as an outcome in their studies to measure the performance of healthcare institutions
(Azam et al., 2012b; Badri et al., 2009; York and McCarthy, 2011).

2.3 The Indian healthcare system

Health is an essential component of nation’s development and is vital to the growth of
economy and internal stability of the country. Assuring a minimal level of healthcare to
its population is a critical constituent of the development process. Since independence,
India has built up a vast health infrastructure and health personnel at primary, secondary
and tertiary care in public, voluntary and private sectors. The Indian healthcare system
include medical care providers, physicians, specialist clinics, nursing homes, hospitals,
medical diagnostic centers, pathology laboratories and paramedical institutions including
Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH)
institutions, which have been set-up for producing skilled human resources (Planning
Commission Report, 2010).
Considerable achievements have been made over the last five decades in an effort to
improve health standards, such as life expectancy, child mortality, infant mortality,
maternal mortality and patient satisfaction. But still the country is dealing with rising cost
of healthcare and growing expectations of the people. High healthcare costs can lead to
entry into poverty. The importance of public provisioning of quality healthcare to enable
access to affordable and reliable health services cannot be underestimated. The challenge
of quality health services to the people of India has to be urgently met. Given the
magnitude of the problem, there is need to transform public healthcare into an
accountable, accusable and affordable system of quality services during the next five year
plan (Planning Commission Report, 2010).
Currently, healthcare is one of India’s largest service industries, in terms of revenue
and employment. During the 1990s, Indian healthcare grew at a compound annual rate of
16%. In year 2009, the total value of the sector was more than $35 billion. By 2012,
India’s healthcare sector is projected to grow to nearly $70 billion (Planning Commission
Report, 2010). Figure 1 depicts the predicted growth pattern of Indian healthcare sector.
According to ASSOCHAM and YES BANK Report (2010), during the period 2000–
2009, the sector has registered a growth of 9.3%, comparable to the sectoral growth rate
of other developing nations such as Mexico and Brazil. According to the report, the
growth of the sector will be driven by healthcare facilities in private and public sectors,
medical tourism and medical insurance sectors. The per capita expenditure on health is
around $80 in India as compared to $230 for China and $6,714 for the USA. Also, there
are 60 doctors per 100,000 persons which is way below the other countries like Brazil,
Russia and China having 115, 425 and 106 respectively (The Times of India, 2009).
6 F. Talib et al.

Further, the current share of public expenditure on health as proportion of gross domestic
product (GDP) is 1% and will rise to a target of 2–3% of GDP by 2012. Private spending
accounts for almost 80% of the total healthcare expenditure and is quite dominant in the
healthcare sector. Inadequate public investment in health infrastructure has given an
opportunity to private hospitals to capture a large share of the market. Some of the
prominent corporate hospital networks in the country are Apollo Hospital, Fortis
Healthcare, Max Healthcare, Wockhardt Hospital and Manipal Group. Simultaneously, a
number of new players like Artemis Health Institute, Paras Group and MediCity among
others are also in the process to set-up their establishments in the country.

Figure 1 Growth of Indian healthcare industry

3
Year

0 100 200 300

US Dollar (in billion)

Source: Planning Commission Report (2010)

Apart from the above statistics that reflect the state of affairs of Indian healthcare sector,
the ‘voice of the customer’ in healthcare is weak. The above facts and statistics are a
pointer to the fact that all is not well for healthcare sector in India. Accessibility,
infrastructure (facilities and equipment) and personnel are some of the major factors for
the deteriorating quality of healthcare facilities. This coupled with the patients’ economic
conditions, weak ‘voice of the customer’ and the high credence attributes that are
endemic in healthcare services (Zeithaml and Bitner, 2003).
The Indian healthcare industry is witnessing a sudden paradigm shift in last five year
(Figure 1). Though this change was inevitable and the industry has been working towards
it for a decade now, this has been visible only in last two years. All sectors in India are
undergoing a change from unorganised to an organised structure and so is also seen in
healthcare. The growth and sudden interest in the healthcare business can be attributed to
many factors. Some of them are: strong Indian economy, increasing options for
healthcare financing, growth in medical tourism, increasing opportunities in healthcare
delivery, saturation of other sectors like IT, retail and gradual corporatisation of the
healthcare sector.
 Service quality in healthcare establishments: a literature review 7

Notwithstanding the sector’s rapid growth and potential, in many respects, but still
India’s healthcare falls well below international benchmarks for physical infrastructure
and manpower and even falls below the standards existing in comparable developing
countries. Thus, India’s healthcare sector needs to scale up considerably in terms of the
availability and quality of its physical infrastructure as well as human resources so as to
meet the growing demand and to compare favourably with international standards. Also,
despite the giant steps taken by the Indian healthcare industry, there is a need for
improvement in customer service.

2.4 Literature on Indian studies in healthcare quality

Numerous studies are available on Indian healthcare focusing on various healthcare

aspects and related issues such as SQ, SQ dimensions, SQ model, customer satisfaction
(CS) and many others. Some of the studies have been undertaken to measure the
perception of patient/beneficiaries of hospital services regarding SQ (Rahman and
Qureshi, 2009; Dasanayaka et al., 2012; Sohail, 2003). Despite these attempts, there is
still lack of literature available on development of an integrated quality model for Indian
HCEs. Some of the selected studies on healthcare and related issues in Indian context as
reported in the healthcare literature are presented in Table 1.

Table 1 Literature on Indian healthcare studies

Study Objective Methodology/approach Major findings

Deshwal To identify the SQ
et al. (2014) dimensions that play an
important role in patient
satisfaction in campus
clinics in Delhi and assess
student satisfaction with
service and suggest ways
to improve areas of
dissatisfaction
Padma et al. To provide strategic
(2014) recommendations to
Indian hospital
administrators for
improving SQ by
analysing performance
dimensions and the
importance attached to
them by patients and
attendants
Questionnaire survey The dimensions that
using convenience affects patient satisfaction
sampling method was were: staff
used to approach professionalism; clinic
respondents staff reliability; clinic
accessibility and basic
facilities; tangibles;
cleanliness; awareness of
the clinic/diseases and
how clinic staff deals
with emergencies
Patient and attendant Patients and attendants
perceptions were have different
collected using a perceptions. Different
questionnaire customers have different
needs of which providers
need to be aware to better
serve their consumers
8 F. Talib et al.
Table 1 Literature on Indian healthcare studies (continued)
Study Objective
Chaudhuri To identify capabilities
and Lillrank required for healthcare
(2013) service providers to
provide mass services and
provide directions to
conduct empirical studies
to understand the
phenomenon of mass
personalisation
Talib and To examine the current
Rahman status and demographic
(2013) characteristics of Indian
healthcare and hospitality
industries
Azam et al. To identify and
(2012a) conceptualise quality
parameters in healthcare
establishment (HCE) at
professional technical
level as well as at
supportive managerial
level
Khan et al. To measure SQ
(2012) performance in corporate
hospitals using AHP
Narang To measure the
(2011) perception of patients
towards quality of
services in public
healthcare centres in rural
India
Methodology/approach
A literature review
followed by field visits
and interviews conducted
at a leading healthcare
service providers
Questionnaire survey of
120 Indian healthcare
and, hotels and tourism
companies were
conducted and employed
chi-square statistical test
Questionnaire survey of
440 bed multi-specialty
government hospital of
North India
SERVQUAL model and
AHP tool was adopted
A reliable and validated
instrument was employed
for the study. Mixed
sampling technique was
employed to select the
sample
Major findings
Literature review coupled
with field visits and
interviews helped in
identifying the key
research questions related
to mass personalisation of
Indian healthcare system
The finding present a
holistic picture of current
status of these two Indian
service industries which
may help the Indian
service managers and
practitioners to further
exploit opportunities in
these two industries
Validated the parameters
with acceptance of these
quality dimensions by the
hospital staff appreciating
its practical utility for
patient care both from
professional technical and
management point of
view
The ranking of the
dimensions like
reliability, assurance,
tangible, empathy and
responsiveness were done
to get best quality of
services
The opinions of the
respondents towards
healthcare quality were
not very favourable.
Negative scores were
obtained on items,
‘availability of adequate
medical equipments’ and
‘availability of doctors for
women’. Education,
gender and income were
found to be significantly
associated with user
perception
 Service quality in healthcare establishments: a literature review
Table 1 Literature on Indian healthcare studies (continued)
Study Objective
Chahal and To examine the three
Kumari dynamics of customer
(2011) relationship management
(CRM), namely, SQ, CS
and customer loyalty
(CL) in the healthcare
sector through indoor
patients’ judgment
Yeoh (2011) To contribute to the
literature on emerging
multinationals by
studying the
internationalisation
strategies of two
established companies in
the Indian pharmaceutical
industry: Ranbaxy and
Wockhardt
Gaur et al. To examine how patients’
(2011) loyalty and confidence in
their doctors, are
influenced by doctors’
interaction behaviour,
namely, listening and
explaining behaviour
Dongre et al. To evaluate the
(2010) possibility of marketing
specific low-cost drugs
across segmented markets
in India.
Methodology/approach
About 400 indoor patients
from different
departments were
selected using
proportionate stratified
random sampling method.
Data validity and
reliability were duly
assessed using
exploratory factor
analysis (EFA). The data
were then analysed using
structural equation
modelling
A longitudinal case-study
approach was utilised to
capture Ranbaxy’s and
Wockhardt’s dynamic
internationalisation
patterns
Primary data collection
followed by reliability
and validity tests. Finally
regression analysis was
performed
Empirical study based on
the primary data gathered
through actual field
survey. The study
analyses the attitudes,
perceptions and
experiences from 20
healthcare organisations
from different parts of the
State of Karnataka in
India
9
Major findings
Based on data analysis,
the direct effect of CRM
dynamics, i.e., physical
environment quality
(PEQ) and interaction
quality (IQ) on SQ and
their ultimate effect on
CS and CL is found to be
significant. However, the
model fit values came out
poor
The internationalisation
patterns of Ranbaxy and
Wockhardt suggest that
the mainstream
internationalisation
models are more effective
in explaining exploitative
learning while the
emerging
internationalisation
models are more effective
in explaining exploratory
learning
The study demonstrates
that doctors’ interaction
behaviour is instrumental
in developing an effective
relationship with their
patients and boosts
patients’ confidence in
their doctors. Also,
effective interaction
enhances patients’ loyalty
to their service providers
The survey findings
revealed that patients
would be happy and
would have better access
to medicine if the same is
offered at a lower price.
Doctors are willing to
prescribe generic drugs.
Generic drug market has
good economic feasibility
10 F. Talib et al.

Table 1 Literature on Indian healthcare studies (continued)

Study Objective Methodology/approach Major findings

Aagja and To measure perceived Literature review using A reliable and valid scale
Garg (2010) service quality of public Delphi method. Experts’ called public hospital SQ
hospitals. opinion on development (PubHosQual) was
of scale. Survey and scale developed to measure the
validation five dimensions of
hospital SQ: admission,
medical service, overall
service, discharge process
and social responsibility
Padma et al. To determine the Based on the existing Two instruments for
(2009) dimensions of SQ in models and the literature measuring the dimensions
Indian hospitals, from the on healthcare services, a of hospital SQ, one each
perspectives of patients framework is proposed to from the perspective of
and their family conceptualise and patients and attendants,
members/friends (referred measure hospital SQ are proposed
to as ‘attendants’)

3 Service quality

Voluminous literature is available on SQ with studies ranging from exploration of its

inherent dimensions to its impact on service outcomes. This section presents an overview
of the existing literature on the definitions of SQ, its development, measurement and
application in healthcare sector as well as its influence on patient satisfaction.

3.1 SQ defined
According to Padma et al. (2009), SQ means perceived SQ, the literature on healthcare
SQ has considered evaluating services from patients’ perception. Patients are interested
not only in the quality of care but also in the quality of service. Generally, healthcare
organisations do not pay significant attention to quality of services. Lim and Tang (2000)
argued that SQ can be used as a strategic differentiation weapon for building distinctive
advantages. The literature on SQ suggest that it can be broken down into two distinct
dimensions (Grönroos, 2000; Zineldin et al., 2011). They are: technical dimension and
process/functional dimension. Technical dimension in the healthcare sector is defined
primarily on the basis of the technical accuracy of the medical diagnoses and procedures,
or the conformance to professional specification and standards. Functional dimension
refers to the manner in which the healthcare service is delivered to the patients and
quality of patient relationship with the organisation.
Parasuraman et al. (1988), who developed the widely used SERVQUAL scale,
defined SQ as a judgment or evaluation relating to service superiority. They explained
SQ on five dimensions i.e., tangibility, empathy, assurance, reliability and
responsiveness. They further elaborated SQ as the gap between customers’ expectations
of service and their perception of the service experience. They proposed SERVQUAL
framework to assess perceived SQ for variety of sectors. SERVQUAL quality is a
multidimensional concept and in order to operationalise it, many variables have to be
considered (Zineldin, 2006). According to Rust and Oliver (1994), SQ stems from service
 Service quality in healthcare establishments: a literature review 11

specific attributes or cues, while satisfaction involves a wider range of determinants,

including quality judgments, needs and equity perceptions. They developed a three
dimensional concept of SQ: service product, service environment and service delivery.
While Otani et al. (2009) observed that the excellent service attributes that influence on
patient satisfaction and loyalty are admission, nursing care, physician care, staff care,
food and room. Similarly, Camgöz-Akdağ and Zineldin (2010) asserted that SQ in
healthcare not only depends on the quality of physicians but also includes the staff,
nurses, building, waiting room, equipments and machines used during care of patient. It
can further be said that healthcare quality and patient satisfaction is more detailed than
just dividing the quality of service into technical and functional dimensions.
The technical, functional and SERVQUAL quality models can be expanded into a
structure of five quality dimensions namely quality of object-the technical quality,
quality of processes-the functional quality, quality of infrastructure-the basic resources,
quality of interaction-measures the quality of information exchange and quality of
atmosphere-the relationship and interaction process between the parties are influenced by
the quality of the atmosphere in a specific environment where they cooperate and operate
(Zineldin, 2000).

3.2 Development of SERVQUAL

Parasuraman et al. (1985) asserted that perceived SQ is an overall evaluation similar to
attitude. They proposed that SQ is a function of the differences or gaps between
customers’ expectation and performance along the quality dimensions and therefore, this
model is called ‘gaps model’. Gaps model indicates five gaps during service delivery
process, which may lead to dissatisfaction of the customers. Later, Parasuraman et al.
(1988) refined their existing model and came up with a new scale to measure SQ known
as ‘SERVQUAL’. This scale consisted of five dimensions namely tangibles, reliability,
responsiveness, assurance and empathy. The description of these dimensions is as
follows:
• tangibles-physical evidence in a service facility (e.g., personnel, equipment, etc)
• 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 convey trust
and confidence
• empathy-caring and individualised attention provided to customers.
Since than several SQ models have been evolved from different authors’ works (Table 2).
But Parasuraman et al. (1985, 1988) SERVQUAL model is the prominent one. Despite
controversies regarding SERVQUAL validity and reliability (Purcărea et al., 2013;
Newman et al., 2001; Cronin and Taylor, 1992); its application, with or without
modification, is common especially in healthcare sector. Parasuraman et al. (1991)
further addressed the issues raised by Babakus and Boller (1992) by vindicating the use
of gap scores for measuring SQ. They modified the negatively worded items in their
instrument to improve the overall reliability values of the scale. Cronin and Taylor (1992)
disagreed with the gaps-score measurement and proposed that measuring SQ in terms of
performance alone would be sufficient and developed performance-only measurement
12 F. Talib et al.

scale, which is known as ‘SERVPERF’ instrument. Parasuraman et al. (1994) responded

to these concerns and again revised their original instrument accordingly. However,
Carman (1990) arrived at a different dimensional structure while using SERVQUAL
scale in a study pertaining to hospitals. Nine dimensions were found: admission service,
tangible accommodations, tangible food, tangible privacy, nursing care, explanation of
treatment, access and courtesy afforded visitors, discharge planning and patient
accounting. These dimensions explained sufficient variance in SQ.
Table 2 Hospital SQ dimensions and models from selected studies

Author(s) SQ dimensions/model
Parasuraman et al. (1985) Tangibles, reliability, responsiveness, communication, credibility,
security, competence, courtesy, understanding and access
Parasuraman et al. (1988) Tangibles, reliability, responsiveness, assurance and empathy
Carman (1990) Admission, tangibles accommodation, tangible food, tangible
privacy, nursing, explanation visitor access, courtesy, discharge
planning and patient accounting
Edvardsson et al. (1994) Experience, knowledge and competence of hospital personnel,
combined with their commitment and willingness to serve the
customer, reliability, trust, empathy and handling of critical
factors
Zairi (1998) Deming prize, Malcolm Baldridge National Quality Award
(MBNQA), European Quality Award and the George M Low
NASA quality award
Ovretveit (2000) Client, professional and management quality
Zeithaml et al. (2002) Information availability, ease of use, privacy/security, graphic
style reliability
Raduan et al. (2004) Security; performance aesthetics, convenience, economy and
reliability
Duggirala et al. (2008a) Infrastructure, personnel quality, process of clinical care,
administrative procedures, safety indicators, overall, experience of
medical care received and social responsibility
Padma et al. (2009) Infrastructure, personnel quality, process of clinical care,
administrative procedures, safety indicators, corporate image,
social responsibility, trustworthiness of the hospital
Aagja and Garg (2010) Admission, medical service, overall service, social responsibility,
discharge (PubHosQual Model)
Zineldin et al. (2009) Object, processes, infrastructure, interaction and atmosphere
Hsieh (2012) MOT Model: managerial, operational and technical quality
dimensions
Untachai (2013) Reliability, tangible, response, cost and empathy
Deshwal et al. (2014) Staff professionalism, clinic staff reliability, clinic accessibility
and basic facilities, tangibles, cleanliness, awareness of the
clinic/diseases and how clinic staff deals with emergencies

Lim and Tang (2000) added ‘accessibility/affordability’, Tucker and Adams (2001)
‘caring and outcomes’ while Johnston (1995) increased SERVQUAL to 18 dimensions,
 Service quality in healthcare establishments: a literature review 13

which generally fall under those identified by Potter et al. (1994): technical,
interpersonal, amenities and environment. Hence, it can be believed that SERVQUAL
modifications vary from researcher to researcher and is still the most widely used model
in the field of SQ. Table 2 provides a summary of dimensions and models on
SERVQUAL as used by different researchers in their studies.
Further, several researchers have identified the advantages of adopting SERVQUAL,
some of them are (Isik et al., 2011; Rohini and Mahadevappa, 2006; Padma et al., 2009):

• it is accepted as a standard for assessing different dimensions of SQ

• 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 standardised analysis procedure to aid interpretation and results.

3.3 Applications of SERVQUAL

During the past few decades, SQ has become a major area of attention to practitioners,
managers and researchers owing to its strong impact on business performance, lower
costs, customer satisfaction (CS), customer loyalty (CL) and profitability (Newman et al.,
2001; Dagger and Sweeney, 2006; Kuo et al., 2009; Khan et al., 2012; Kitapci et al.,
2014). There have been several important researches on SQ especially the application of
SERVQUAL framework. Several attempts have also been made to apply this framework
in different industries and sectors like healthcare, banking, hospitality, tourism and many
others to assess customers’ perceptions of SQ (Rohini and Mahadevappa, 2006;
Duggirala et al., 2008a, 2008b; Kitapci et al., 2014). An examination of the literature on
SERVQUAL in different sectors is depicted in Table 3.
Table 3 Applications of SERVQUAL

Sector Literature
Healthcare Curry and Sinclair (2002), O’Connor and Shewchuk (2003), Boshoff and
Gray (2004), Taner and Antony (2006), Duggirala et al. (2008a, 2008b),
Ramsaran-Fowdar (2008), Padma et al. (2009), Butt and de Run (2010),
Isik et al. (2011), Khan et al. (2012), Dasanayaka et al. (2012), Abuosi and
Atinga (2013), Purcărea et al. (2013), Duan et al. (2014) and
Mashhadiabdol et al. (2014)
Banking Gan et al. (2006), Herington and Weaven (2007), Poolthong and
Mandhachitara (2009), Tsoukatos and Mastrojianni (2010), Awan et al.
(2011), Al-Zubaidi and Al-Asousi (2012) and Choudhury (2013)
Hospitality and Lau et al. (2005), Nadiri and Hussain (2005), Narayan et al. (2009), Qin et
tourism al. (2010), Crick and Spencer (2011), Bastič and Gojčič (2012), Lee (2014)
and Albayrak and Caber (2015)
Education Mai (2005), Sahu (2007), Shekarchizadeh et al. (2011), Abili et al. (2012),
Al-Borie and Damanhouri (2013), Alnsour et al. (2014) and Shahin et al.
(2014)
14 F. Talib et al.

3.4 SQ in healthcare (application of SERVQUAL)

Measuring SQ in healthcare industry is difficult to evaluate as understanding the patient
perception and satisfaction is quite complex and significant (Padma et al., 2009). The
plausible reason may be that in healthcare industry, different hospitals provide the same
type of services, but they do not provide the same quality of services (Youseff et al.,
1996). Thus, studying the SQ in healthcare is essential. Furthermore, consumers today are
more aware of alternatives being offered and rising standards of services. These changes
have increased their expectations (Lim and Tang, 2000). With increased competition due
to globalise and tough market conditions as well as the need to satisfy patients, the
elements of quality control, quality service and effectiveness of medical treatment have
become vital (Suki et al., 2011). To overcome these issues, SERVQUAL scales have
been widely used in healthcare studies to assess customers’ perception of SQ in a number
of service categories like patient satisfaction, acute care hospital, etc. (Lim and Tang,
2000; Taner and Antony, 2006; Zineldin et al., 2009; Dasanayaka et al., 2012;
Mashhadiabdol et al., 2014). Its use in healthcare has produced varied results suggesting
that it need further improvement (Duggirala et al., 2008a; Purcărea et al., 2013; Kitapci
et al., 2014).
In a study conducted by Rohini and Mahadevappa (2006), applied SERVQUAL
framework and factors in their study on Bangalore (India) hospitals. They obtained the
perceptions of both the patients and the hospital management. The study concluded that
there exist an overall gap between patient’s perceptions and expectations and also
between management’s perception of patients’ expectations and patient’s expectations.
The authors provided recommendations to fill those gaps.
Sohail (2003) measured the SQ in Malaysia using the SERVQUAL model and found
that all scores for perception exceeded the expectations for all measures examined. This
indicated that the perceived value of SQ has exceeded the initial expectation for all
variables within all dimensions. This would suggest that hospitals in Malaysia provide
services that exceed the expectations of their patients. The t-test confirmed the finding of
the study.
Aagja and Garg (2010) developed a scale for measuring perceived SQ for one
multi-specialty public hospital in Ahmedabad (India) from the user’s (patient’s)
perspective. The objective was to measure perceived SQ of public hospitals. PubHosQual
was developed to measure the five dimensions of hospital SQ: admission, medical
service, overall service, discharge process and social responsibility. Duggirala et al.
(2008a) proposed that healthcare SQ consisted of seven dimensions, namely,
infrastructure, personnel quality, process of clinical care, administrative processes, safety
indicators, overall experience of medical care and social responsibility.
Strawderman (2005) performed researched on human factors. To model SQ, six
dimensions were proposed whereby the five dimensions of SERVQUAL were used (i.e.,
responsiveness, reliability, assurance, empathy and tangibles). A sixth dimension,
usability, was added in a modified survey instrument termed SERVUSE. Both
measurement tools, SERVQUAL and SERVUSE, were found to be significant predictors
of SQ, satisfaction and behavioural intention in the healthcare setting.
In another study by Eleuch (2011) assessed Japanese patients’ healthcare SQ
perceptions through a nonlinear approach. The study relies on a nonlinear approach to
assess patient overall quality perceptions in order to enrich knowledge. Furthermore, the
research was conducted in Japan where healthcare marketing studies were scarce owing
 Service quality in healthcare establishments: a literature review 15

to cultural and language barriers. Japanese culture and healthcare system characteristics
are used to explain and interpret the results.
In a study conducted by Butt and de Run (2010) developed and test validated the
SERVQUAL model to measure the Malaysian private health SQ. Means, correlations,
principal component and confirmatory factor analysis (CFA) were performed to establish
the modified SERVQUAL scale’s reliability, underlying dimensionality and convergent,
discriminant validity. A moderate negative quality gap for overall Malaysian private
healthcare SQ was found. A moderate negative quality gap on each SQ scale dimension
was also indicated. The major contribution of the study was that it offered a way to assess
private healthcare SQ and successfully developed a scale that can be used to measure
health SQ in Malaysia.
Further, Abuosi and Atinga (2013) examined two key issues in healthcare institutions,
one to assess patients’ hospital SQ perceptions and expectation using SERVQUAL and
other to outline the distinct concepts used to assess patient perceptions. In doing so, they
observed that patient expectations were not being met during medical treatment.
Perceived SQ was rated lower than expectations for all variables. Implying that the
hospital managers should consider stepping up staffing levels by client-centred training
programs to help clinicians deliver care to patients’ expectations.
A recent study by Akdag et al. (2014) applied the fuzzy multiple criteria
decision-making (MCDM) to evaluate the SQ of Istanbul (Turkey) hospitals. The authors
make use of many MCDM techniques to evaluate the hospitals SQ like AHP, TOPSIS,
Yager’s min-max approach together with some numerical application techniques. The
results were obtained and compared.
In spite of SERVQUAL’s popularity, some authors developed their own instrument to
measure SQ, which may accomplish their research objectives.

3.5 SQ and patient satisfaction

In recent years, SQ and patient satisfaction has gained increasing attention especially in
healthcare context (Azam et al., 2012b; Badri et al., 2006, 2009; York and McCarthy,
2011; Owusu-Frimpong et al., 2010). Also, past studies showed that there is a strong link
between SQ and patient satisfaction (Andaleeb, 2001; Badri et al., 2009; Kitapci et al.,
2014). In the healthcare literature, SQ and patient satisfaction have been considered as
two major issues. Importance of patient satisfaction especially service encounters is well
documented in the marketing and management literature (Meirovich and Bahnan, 2008).
SQ in service encounters is frequently depicted as being the outcome of an interactive
process between the service provider and the service receiver. The interactive features of
SQ in service encounters are thus, crucial to the ultimate outcome (Owusu-Frimpong
et al., 2010). Further, patient satisfaction in healthcare organisations is considered crucial
when planning, implementing, evaluating service delivery, as well as in quality
improvement, overall customer relationship management (CRM) and strategic planning
initiatives (Evenhaim, 2000). In fact, meeting patient’s needs and developing healthcare
standards are obligatory for high quality care (Badri et al., 2009).
There are several studies which focus on SQ and patient satisfaction. Many of them
provided empirical evidences for the positive link between SQ and patient satisfaction
(Lim and Tang, 2000; Strawderman, 2005; Padma et al., 2010; Lee et al., 2012).
Gonzàlez et al. (2005) confirmed the positive relationship between patient satisfaction
and healthcare SQ during hospital stay. Dagger and Sweeney (2006) also supported with
16 F. Talib et al.

the finding that SQ is closely related to the CS. They further asserted that performance of
SERVPERF is better than SERVQUAL in explaining CS. A study by Boshoff and Gray
(2004) on CS and loyalty among patients in the private healthcare industry in South
Africa observed that SERVQUAL dimensions like nursing staff empathy, assurance and
tangibles, impact positively on patients’ loyalty.
Similarly, a study by Hong and Goo (2004) observed the path SQ → CS → loyalty to
be significant in Taiwanese service firms. Otani and Kurz (2004) concluded that nursing
was more important in improving CS and behavioural intentions than other factors.
Another study by Tam (2004) found that as customers’ perceptions of the quality of the
service increased, they felt more satisfied with the service and in turn perceived higher
value.
A study by Curry and Sinclair (2002) utilised the SERVQUAL model to establish that
patient satisfaction is enhanced when communication between patients and providers is
such that patients have access to information relating to their conditions and treatment.
Lin and Ding (2005) looked into the moderating effect of prior information technology
experience on the link between network quality and satisfaction. The effect was not found
to be significant, while it significantly affected the link between and service recovery and
satisfaction. Suhonen et al. (2004) proposed an individualised care model linking patient
satisfaction with nursing care, patient autonomy and perceived health related quality of
life. Their approach included dimensions related to healthcare quality and patient
satisfaction.
A comprehensive structural equation-based SQ and patient satisfaction model was
developed and presented by Badri et al. (2009) to measure the patient’s condition before
and after discharge in United Arab Emirates public hospitals. The structural equation
modelling (SEM) supported the healthcare quality-patient status-satisfaction model.
Further, a study by Owusu-Frimpong et al. (2010) explored patients’ satisfaction with
access to treatment in both the public and private healthcare sectors in London. The
results revealed varying access experiences among public and private care users.
Padma et al. (2010) conceptualise hospital SQ into its component dimensions from
the perspectives of patients and their attendants and analysed the relationship between SQ
and CS in government and private hospitals of India. The study revealed that the hospital
service providers have to understand the needs of both patients and attendants in order to
gather a holistic view of their services. The study allowed the hospital administrators to
benchmark their hospitals with those of their competitors by comparing the mean values
of the dimensions of SQ. The study also allows a comparison of the performance of
government and private hospitals in terms of the services offered.
In another study by York and McCarthy (2011) on patient, staff and physician
satisfaction, developed a new model and instrument for measuring customer-satisfaction
level and compared it with traditional techniques using data gathered from healthcare
clinics. Findings suggested that the ultimate question provides similar ratings to existing
models at lower costs.
Finally, Kitapci et al. (2014) investigated the effect of SQ dimensions on patient
satisfaction, identified the effect of satisfaction on word-of-mouth communication and
repurchase intention and searched a significant relationship between word-of-mouth and
repurchase intention in Turkish healthcare industry. The study adopted SERVQUAL
variables and utilised SEM. They found that empathy and assurance dimensions are
positively related to CS. Additionally, CS has a significant effect on word-of-mouth and
repurchase intention which were found to be highly related.
 Service quality in healthcare establishments: a literature review 17

The related literature acknowledges the importance of SQ and patient satisfaction and
thus, the researchers may use this feedback for further study in improving the
performance of HCEs.

4 Conclusions

This study present the extensive literature review on various aspects pertaining to
healthcare quality and its related issues. The literature is classified into various categories
like definitions of health, healthcare quality, studies on Indian healthcare system, SQ,
development and application of SERVQUAL, as well as link between SQ and patient
satisfaction. Literature review on different studies applied to link SQ and patient
satisfaction for healthcare organisations has also been reported. From review of this
literature, certain gaps were identified and these gaps provide a direction to conduct the
present research efforts. An attempt has been made in this research which contribute to
the body of knowledge on the above identified issues and areas to create scope for future
research in HCEs. This paper also discerns the hospital SQ dimensions and models from
selected studies for the HCEs as suggested by a number of authors. In continuation to
this, some key healthcare SQ dimensions were identified which may be utilised for
development of an integrated model of quality for HCEs as suggested by some
researchers. The implications of this study elucidate an understanding that the
management of SQ requires both a focus on healthcare quality dimensions as well as
day-to-day operational management. It is recommended that healthcare researchers and
practitioners focus on the critical dimensions identified herein and employ this literature
survey to manage and better understand the nature of hospital QM practices not only
India but across wider geographical regions and over longer time periods. Moreover, the
outcome of this literature review is important for Indian healthcare managers and
practitioners with respect to the outpatient aspects of SQ. They should make effort to
modernise hospitals and should successfully improve the level of SQ. Finally, the study
attempts to provide a comprehensive review of literature for Indian healthcare managers
and practitioners to enable them a better understanding of healthcare services and
implement them in their HCEs to achieve greater levels of patient satisfaction.
This paper although successfully achieves the set objectives, there are opportunities
for further research. Further in-depth investigation needs to develop and validate the HCE
model using SEM by gathering primary data through the survey of Indian HCEs like
multi-specialty, super-specialty, private nursing homes, government aided hospitals and
civil hospitals so that the quality of services could be improved and sustained by
achieving higher patients’ satisfaction level. An attempt should also be made to further
explore a more appropriate method of improving SQ level in Indian HCEs through a
comparative study of international standard criteria and/or awards to generalisability.

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