International Journal of Quality & Reliability Management

Hospital healthcare service quality, patient satisfaction and loyalty: An

investigation in context of private healthcare systems
Taqdees Fatima, Shahab Alam Malik, Asma Shabbir,
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International Journal of Quality & Reliability Management, Vol. 35 Issue: 6, pp.1195-1214, https://
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QUALITY PAPER Private

healthcare
Hospital healthcare service systems
quality, patient satisfaction
and loyalty 1195
An investigation in context of Received 27 February 2017
Revised 1 June 2017
private healthcare systems Accepted 22 June 2017

Taqdees Fatima
Management Sciences, COMSATS Institute of Information Technology,
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Islamabad, Pakistan
Shahab Alam Malik
Faculty of Management Sciences, Indus University, Karachi, Pakistan, and
Asma Shabbir
Management Sciences, COMSATS Institute of Information Technology,
Islamabad, Pakistan

Abstract
Purpose – The purpose of this paper is to explain the patients’ views towards private healthcare service
providers. The study focussed on hospital service quality and analysed the relative significance of quality
measurements in anticipating the patients’ satisfaction and loyalty. The mediating role of patient satisfaction
is assessed between quality of hospital healthcare services and patient loyalty.
Design/methodology/approach – A total 611 patients (both indoor and outdoor) participated in a
questionnaire survey from the six private hospitals of capital city, Islamabad, Pakistan. Data were analysed
through descriptive statistics, common method variance, reliability, correlation and regression in order to
investigate customer perceived service quality and how the quality of services stimulates loyalty intentions
towards private service suppliers.
Findings – Findings depict that private healthcare service providers are attempting to deliver well improved
healthcare services to their customers. Results confirmed that better quality of healthcare services inclines to
build satisfaction and loyalty among patients. The healthcare service quality aspects (i.e. physical
environment, customer-friendly environment, responsiveness, communication, privacy and safety) are
positively related with patient loyalty which is mediated through patient satisfaction.
Practical implications – Findings will help the hospital managers to articulate effective strategies in order to
ensure superior quality of healthcare services to patients. The study will induce hospital management to deliver
attentions towards the quality of private healthcare service systems and improvements towards the deficient
healthcare services. Furthermore, the study will present a clear picture of patient’s behavioural attitudes;
satisfaction and loyalty intentions towards the quality of healthcare services.
Originality/value – The study provides the views and perceptions of patients towards the quality of
healthcare services. The healthcare service quality dimensions, i.e., physical environment, customer-friendly
environment, responsiveness, communication, and privacy and safety were assessed. Hospital healthcare
service quality was examined in order to find out its effect on patient satisfaction and patient loyalty.
Keywords Pakistan, Loyalty, Customer satisfaction
Paper type Research paper

1. Introduction
International Journal of Quality &
In healthcare industry, the emergent of global competition inclines the patients more curious and Reliability Management
concerned regarding the provision of healthcare services. The increasing focus on health and the Vol. 35 No. 6, 2018
pp. 1195-1214
development of the senior citizen population have vigorously improved the health needs and © Emerald Publishing Limited
0265-671X
transferral of healthier lifestyle within the general population. The new enlargement in the DOI 10.1108/IJQRM-02-2017-0031
 IJQRM global competitive service environment has influenced the residential business, especially the
35,6 healthcare services. In this way, the healthcare associations have begun to emphasise on the
superior healthcare service quality, as day by day increased competition among hospitals
induces customers to make a best choice in selecting any hospital. Service quality is the most
vital key element regarding service suppliers to get upper hand, so it ought to be very much
enhanced and well measured (Lee and Yom, 2007). At the same time, better healthcare quality
1196 than counterparts provides businesses with a chance to distinct themselves in competitive
markets (Karatepe et al., 2005). At present, on account of expanded expectations for ordinary
eases and higher customer’s desires, it is obligatory for hospitals to give superior healthcare
services to the patients and to fulfil their requirements (Padma et al., 2010).
Over the last three decade, service quality and its outcomes are one of the rare topics in
services marketing literature which have received widespread academic research.
The demand for improved and better healthcare service quality has enlarged which leads
to build pressure towards supply side (i.e. service providers) and have become a difficult
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assignment for researchers, hospital administrators, government policymakers and

therapeutic specialists to fulfil the needs of patients which helps to build satisfaction and
loyalty (Al-Borie and Sheikh Damanhouri, 2013; Ranaweera and Prabhu, 2003) however, it
calls for more expenditures to get the consideration of new patients rather than to retain
existing patients ( Kessler and Mylod, 2011). Loyalty is one of the important factors for
business success which can only be build and sustain through provision of better service
quality leading to improved satisfaction. All these improved provisions require effective
cost allocation and cost management strategies.
In terms of service providers, two forms of providers are operating specifically in
developing countries, i.e., public and private hospitals. Choosing the right hospital and
experienced physician are imperative reason to consider which suggestively influence a
patient’s treatment (Shabbir et al., 2016). Based on fact, public hospitals are funded by
government and attached by government rules and regulations while private hospitals offer
more personalised care and treatment to their patients. Private hospitals have more funds to
maintain the pool of patients and providing them best service quality than their
counterparts. Numerous comparative studies have suggested the differences in healthcare
services provided by public and private hospitals and results show that patient prefer to
visit private over public because of multiple factors such as improved technology, no
waiting list and delay in treatment, hygienic environment, more personalised care from
physician and nurses (Shabbir et al., 2016; Imran and Irfan, 2011).
In systems, where private hospitals are not funded by public financing, they are more
directing towards earning profits by focussing on service quality, so that patients search for
private care only because of perceptions of better facilities and excellence. Thus, the present
study addressing the gap by examining fact that if patients prefer to visit private hospitals
then which of the factors contribute and forces them to choose private hospitals over the
public ones. Studies have also confirmed that patients select private hospitals only because
of not satisfying the healthcare delivery provided by public providers. They compel to
spend more money in order to get desired service quality.
Currently, patient’s demands complete and exact information before availing any sort of
service by a specific healthcare association (i.e. private healthcare providers), based on the
reason if they are spending more money to treatments, patients become more curious and
expect supplement services to avail quality of services beyond their expectations, and
simply any occurrence of dissatisfaction tends to force them to move towards others
competitors (Ramsaran-Fowdar, 2009). Moreover, service quality is considered as a vital
element in promising patient general satisfaction and loyalty towards private hospitals
(Caruana, 2002). It is demonstrated that doctor and medical attendant both ought to focus in
the direction to enhance service quality ( Jakobsson and Holmberg, 2012).
 Manimay (2014) proposed that giving powerful training to attendants, specialists and Private
supporting staff on interpersonal abilities and viable correspondence stimulates patient healthcare
satisfaction. In private hospitals service quality advancements are mandatory in order to systems
accomplish commendable profile to expand loyalty along with patients (Atinga and Baku, 2013).
Zeithaml et al. (1996) proposed that at the time when service quality has affirmative evaluation,
it impacts the clients’ attractive behavioural expectations that reinforce their association with
the service supplier. Consequently the arrangement of service quality has a great significance to 1197
the administration of all service associations and hospital ought to especially be interested in
giving magnificent medical consideration, additionally concentrate on giving quality support to
their patients ( Johnson et al., 2006). From above discussion it is demonstrated that it has, and
remains, indispensably vital in the current competitive business sector that it is the utmost duty
of suppliers to build and maintain satisfaction, providing superior quality services and
considerable medical treatments through the better understanding of service quality as
characterised by the customers. This could only be possible if the service providers come to
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know and understand the perceptions and view of service users. Thus, present study tends to
focus on patients perception towards the provision of healthcare services.
Many empirical studies have examined the relationships among service quality, customer
satisfaction and loyalty in many service sectors. But the current study focus on the necessity to
address the healthcare service quality conditions provided by private sector hospitals
specifically from the context of Pakistan where the service providers will acquire an advantage
by understanding the service user’s behaviours and its effect on satisfaction and loyalty.

Research questions
Following questions are aimed to be addressed through this study:
RQ1. How healthcare service quality factors (i.e. physical environment, customer-friendly
environment, responsiveness, communication, and privacy and safety) could effect on
patient loyalty and patient satisfaction of private hospitals of Pakistan?
RQ2. Is patient satisfaction mediates the relationship between healthcare service quality
and patient loyalty?
RQ3. Is there any difference/gap in the quality of Healthcare service dimensions
(i.e. physical environment, customer-friendly environment, responsiveness,
communication, and privacy and safety)?
RQ4. How healthcare service quality dimensions (physical environment, customer-
friendly environment, communication, privacy and safety and responsiveness)
relate to patient loyalty?

Research objectives
Based on research questions, the study has following objectives:
• to examine the healthcare service quality conditions provided by private sector
hospitals of Pakistan;
• to investigate the relationship between Healthcare service quality dimensions
(i.e. physical environment, customer-friendly environment, responsiveness,
communication, and privacy & safety), patient satisfaction and patient loyalty;
• to find out the mediating role of patient satisfaction between healthcare service
quality and patient loyalty; and
• to examine the difference in the quality of healthcare service quality provided by
private sector hospitals of Pakistan.
 IJQRM 2. Literature review
35,6 2.1 Healthcare service quality and patient loyalty
Patient loyalty demonstrates the confirmed probability to connect in a specific conduct
(Oliver, 1980). Marketing literature proposes that client loyalty can be characterised in two
different ways ( Jacoby and Kyner, 1973). Primarily characterised loyalty as an attitude
(state of mind) and the second meaning of loyalty is behavioural. Distinctive sentiments
1198 make an individual’s general connection to a product, service, or association is characterised
as attitudinal loyalty (Fornier, 1994). While behavioural loyalty incorporates keeping on
obtaining services from a similar provider, expanding the scale as well as extent of a
relationship and willingness to recommend ( Yi, 1990). The behavioural perspective of
loyalty is just like as loyalty characterised in the service writing. Present study analysed
behavioural instead of attitudinal loyalty that has linked to customer satisfaction.
Customers normally build up a mind-set towards buying in light of an earlier service
experience. They additionally develop an attitude about whether to stay with or leave a
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service (Zeithaml, 2000). Zeithaml et al. (1996) grouped behaviour intentions are as
favourable and unfavourable loyalty: favourable into affirmative response, positive input,
recommending, staying committed and paying more, whereas unfavourable loyalty as
unconstructive reaction, changing to a new association, and doing less business with an
organisation. An eagerness to suggest, ready to visit again and constructive word of mouth
(WOM) aims can be considered as loyalty. Constructive WOM is turned out to be the most
grounded indicator for forming future conduct and attitude, which incorporates oral,
individual to-individual correspondence between a recipient and a communicator
(Buttle, 1998). Bigné et al. (2008) argues that a client who has a more grounded bond with
a particular supplier (e.g. faithful client) will pay higher costs for the value of product and
services given by that supplier. Zeithaml et al. (1996) use readiness to pay as a behavioural
intermediary for quality. A few studies explored service quality and satisfaction’s immediate
impact on loyalty. Discoveries reveal that service quality and satisfaction has an immediate
association with WOM (Ladhari, 2009; Hanzaee and Shojaei, 2011).
The association between service quality and loyalty can be taken as two structures; it
can be direct which communicates better service quality prompts to build customer loyalty
while the effect can be indirect, which communicates satisfaction has an intervening impact
between service quality and customers’ loyalty (Bou-Llusar et al., 2001). Parasuraman et al.
(1985, 1988), Zeithaml et al. (1996) and Boshoff and Grey (2004) have studied about various
endeavours which show the service quality is a predecessor to behavioural intensions.
The association between service quality and loyalty can be taken as two structures; it
can be direct which communicates better service quality prompts to build customer loyalty
while the effect can be indirect, which communicates satisfaction has an intervening impact
between service quality and customers’ loyalty (Bou-Llusar et al., 2001). Parasuraman et al.
(1985, 1988), Zeithaml et al. (1996) and Boshoff and Gray (2004) have studied about various
endeavours which show the service quality is a predecessor to behavioural intensions.
The present study is based on perceived HCSQ dimensions like physical environment,
customer-friendly environment, communication, privacy & safety and responsiveness. Though
dimensions of SERVQUAL have been authenticated in Indian context, it is expected that its
applicability will be influenced because of cultural differences of consumers (Amin and
ZahoraNasharuddin, 2013). Based on the literature, the study hypothesised that:
H1. Healthcare service quality is positively related with patient loyalty.

2.2 Healthcare service quality and patient satisfaction

Premium service quality empowers hospital administrators to distinct the hospital and increase
a practical competitive favourable position and upgrade proficiency (Olorunniwo et al., 2006).
 Grönroos (1984) characterised perceived quality as an assessment procedure, where the Private
customer compares his/her expectations with his/her service observations. Hospital healthcare
service quality is the disparity between customer perceptions and their assumptions about systems
hospitals services (Aagja and Garg, 2010). In healthcare setting, patients are the essential
capital of hospital. Subsequently in order to satisfying and sustaining patients, healthcare
service quality has turned out to be reasonably more imperative (Arasli et al., 2008; Alhashem
et al., 2011). A few studies addressing patients’ judgment conducted in developing countries 1199
demonstrate that customers can assess service structure, procedure and result (Andaleeb, 2001;
Baltussen et al., 2002).
Literature has confirmed the relationship between healthcare perceived service quality
and patient satisfaction, shown direct relationship which expresses; more the remarkable
healthcare service quality, more prominent will be the patient satisfaction (Leisen Pollack,
2008; Bakan et al. 2014). Cronin and Taylor (1992) have also found a solid causal relationship
between the positive and general service quality and satisfaction. In addition, Badri
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et al. (2009) recognised that patients and their satisfaction are seen as the most basic point in
the organising, execution and appraisal of service delivery, additionally addressing the
requirements of patient and healthcare principles are very important towards
accomplishing high worth.
In healthcare settings, patient satisfaction is widely used to determine service quality.
Shabbir et al. (2016) has demonstrated the association between service quality and patient
satisfaction, result shown the positive association between healthcare service quality and
patient satisfaction. Patient satisfaction has also assessed by examining the difference
between perceived and expected service quality (Shabbir et al., 2017 Forthcoming). Positive
patient inclination will frame trust which can give positive judgments to the hospital
(Brennan, 1998). Chahal and Mehta (2013) and Naidu (2009) portrayed healthcare service
quality; patient satisfaction. Patient satisfaction serves as a medium between service quality
and behavioural intentions. Based on the literature, the study hypothesised that:
H2. Healthcare service quality is positively related with patient satisfaction.

2.3 Patient satisfaction and patient loyalty

Cronin et al. (2000) through their examination clarified that consumer satisfaction can give a
potential direct effect on customer loyalty. Positive patient inclination will frame trust which
can give positive judgments to the hospital (Brennan, 1998). Chahal and Mehta (2013) and
Naidu (2009), Shabbir et al. (2016) portrayed healthcare service quality and patient loyalty
are significantly interconnected in the literature. Cronin and Taylor (1992) and Dick and
Basu (1994) investigated that purchaser satisfaction is one of a few reasons for the
development of client loyalty. Chahal and Mehta (2013) observed that readiness to return to
the hospital and prescribing it to others is called as behavioural intensions. While client
loyalty (e.g. goal to repurchase, readiness to give a positive word) is characterised as a
function of consumer satisfaction (Kessler and Maylod, 1999). Based on the literature, the
study hypothesised:
H3. Patient satisfaction is positively related with patient loyalty.

2.4 Patient satisfaction as a mediator between healthcare service quality and patient loyalty
At a point when client is pleased with the product or service that time it is considered as
satisfaction. Satisfaction can be said as a positive reaction of people to a particular concentration
(shopper experience) that is resolved at a specific time (Shemwell et al., 1998). Satisfaction might
be a man’s sentiments of happiness or disillusionment in result for contrasting an item/service
perceived performance with its expectation (Kotler and Keller, 2009). Sometimes it turns out to
 IJQRM be extremely hard to satisfy everybody or decide satisfaction among gathering of people in light
35,6 of the fact that generally individuals have diverse judgments and expectations. At the same time
as patient satisfaction evaluation is critical for patient as well as for the healthcare association
too ( Johansson et al., 2002). Moreover, patient satisfaction is not just important toward the end of
the care; additionally it is indispensable for the underlying treatment choice (Brenan, 1995).
Patient satisfaction upgrades the image of hospital, which ultimately converts in
1200 expanded service utilise and market share (Saad Andaleeb, 1998). For healthcare suppliers,
customer satisfaction prompts to positive outcomes, for example, higher rates of patient
maintenance, positive verbal exchange and higher profit (Zeithaml, 2000). On very basic
level, patient satisfaction is a subjective judgment that outcomes from the examination of
healthcare associations and understood correlation of the actual performance with the
expectation of the people.
Healthcare service quality dimensions, i.e., physical environment, customer-friendly
environment, responsiveness, communication, and privacy and safety are tested to relate
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with patient loyalty if patient satisfaction mediates between their relationships. The
operational definition of constructs is given in Table I.
Patient satisfaction additionally impacts the rate of patient consistency with doctor
counsel and demands (Calnan, 1988). In this manner, satisfaction really influences the result
of medicinal practices. Thus, patient’s satisfaction evaluation has turned into an
indispensable piece of healthcare associations ( Reidenbach and McClung, 1999). Patient
satisfaction serves as a medium between service quality and behavioural intentions
(Shabbir et al., 2016). Cronin and Taylor (1992) and Dick and Basu (1994) investigated that
purchaser satisfaction is one of a few reasons for the development of client loyalty.
Moreover, Caruana (2002) deduced in his review that the relationship between service
quality and loyalty is mediated by patients’ satisfaction. Supported by literature, present
study is hypothesised:
H4. Patient satisfaction mediates the relationship between healthcare service quality and
patient loyalty.
H4a. Physical environments and patient loyalty is mediated by patient’s satisfaction.

Variables Operational definitions

Patients satisfaction Refers to determining patient’s content for the services that they are receiving from
healthcare e.g. well-timed, well-organised, and patient-centred delivery of quality
healthcare
Physical environment Refers to physical facilities, infrastructure, hospital functions, medical apparatus,
medical staff’s cleanliness and environmental peacefulness, vital for the patient’s
health condition
Customer-friendly Refers to hospital staff’s dedication to giving a friendly environment, advanced
environment quality and merciful care
Communication It is about keeping customers all around up to date, recognising and listening to
their issues. e.g. advising by staff and specialists ought to comprehend the patient’s
issue or his/her ailment
Privacy and safety Keep away from or reducing to acceptable limits, actual or potential harm from
healthcare is defined as privacy and safety
Responsiveness Screen and bring issues to light of how and in which environment individuals are
dealt when looking for healthcare and maintain a specific attention on biased
Table I. treatment connected with societal position
Operational definitions Patient loyalty Refers to frequent utilisation of service when the patient has a positive attitude
of variables toward the service or hospital providing the service
 H4b. The relationship between customer’s friendly environment and patient loyalty is Private
mediating by patient’s loyalty. healthcare
H4c. The relationship between communication and patient loyalty is mediating by systems
patient’s loyalty.
H4d. The relationship between privacy and safety and patient loyalty is mediating by
patient’s satisfaction. 1201
H4e. Responsiveness and patient loyalty is mediated by patient’s satisfaction.

2.5 Healthcare service system in Pakistan

Being a developing country, Pakistan is also striving to improve the healthcare system
within the country. Most of the people are compelled to choose private healthcare
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providers just because of poor healthcare services provided by their counterparts.

Patients are bound to spend additional money just to acquire better healthcare treatment
and to save their lives and time. In this case, patients come up with greater expectations in
their mind and then based on those expectations, they evaluate the services provided by
hospitals. Studies have been carried out related to healthcare services specifically from
Pakistan, demonstrates that public hospitals are lagging behind private hospitals and
how healthcare service quality could affect the satisfaction and loyalty intentions of
patients (Shabbir et al., 2016, Imran et al., 2017; Nasim et al., 2014). Private hospitals are
providing superior service quality in terms of physical environment, fair admission
procedures, behaviour of hospital staff, and quality of physicians and nurses. Numerous
comparative studies have been carried out in order to investigate the relationship between
healthcare service quality, satisfaction and loyalty. However, in order to address the
question that on which factors patients prefer to visit private hospitals than their
counterparts and how they assess the quality of healthcare services and that could affect
their loyalty and satisfaction is needed to explored further. Thus, present study is
examining the effect of healthcare service quality, satisfaction and loyalty from private
sector hospitals of Pakistan.

3. Theoretical framework
Various studies have accomplished to determine a connection between healthcare services
and patient satisfaction (Alhashem et al., 2011), healthcare service quality and behavioural
intentions (Naidu, 2009). At the same time healthcare service quality and patient loyalty is
mediated by patient’s satisfaction while patient loyalty is active as end result (Shabbir et al.,
2016). According to the undertaken research framework (Figure 1), the relationship flanked
by healthcare service quality, patient satisfaction and patient loyalty has been inspected.

Healthcare Service Quality

1. Physical Environment
2. Customer-Friendly Environment
3. Communication Patients Patients
Satisfaction Loyalty
4. Privacy and Safety
5. Responsiveness

Figure 1.
Theoretical framework
 IJQRM Healthcare service quality aspects like physical Environment, customer-friendly
35,6 environment, communication, privacy and safety and responsiveness act as antecedent to
the patient loyalty. Patient satisfaction is mediating the link between healthcare service
quality and patient loyalty while patient loyalty acts as end result.

4. Research methodology
1202 4.1 Population frame
Population frame is comprised of the considerable number of people or things with
indistinguishable attributes in regard to the outcomes have to be drawn. Total population
includes private hospitals all over Pakistan in order to find out healthcare service quality
conditions. Based on the research question, study tends to narrow down the scope towards
the hospitals which are situated in twin cities of Islamabad and Rawalpindi. Among private
hospitals situated in these cities, only six hospitals were chosen based on their size,
popularity, and large numbers of patients visit (three hospitals from each city).
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Hospitals were selected based on purposive sampling technique keeping in mind the size
and reputation of hospitals, as patients visit these private hospitals because of multiple
factors; when they do not want to visit public hospitals or not satisfied with their quality;
when doctors from other city/village recommended them to visit the specific hospital; or
when they already visited there and found the quality better than others.
In these hospitals, as per permission of administration, following wards were allowed for
data collection, general medical, gynaecology, surgery, and cardiology.

4.2 Sample size and selection

The sample size was calculated according the rules given by Nunnally (1978) as he states that
sample size ought to be multiplied by 10 to the aggregate number of items and thus the
aggregate number of items was 42 which are multiplied by 10 equivalents to 420. Keeping in
view the said rule, researcher tried to gather maximum sample size and gathered the sample
of 611 respondents. Both admitted patients and OPD (outdoor patients) were approached for
participation in survey. Among admitted patients, only those patients were chosen who had
stayed more than 2-3 days in a specific hospital as only they were able to correctly evaluate
the quality of healthcare services that lead to depict satisfaction and loyalty. To address
the level of loyalty intentions, only those outdoor patients were selected who had visited the
hospital more than two times, as they profoundly encountered the nature of hospital services.
Total 650 questionnaires were distributed (420 to admitted patients and 230 to outdoor
patients). Less number of questionnaires was distributed among outdoor patients as they
were less in numbers as compared to admitted patients, primarily because of the eligibility
condition applied that only those who have visited that particular hospital more than twice
will participate. A final sample of 611 respondents was used for data analysis (381 Indoor
patients and 230 Outdoor patients).

4.3 Measures
The study has adopted the scale from existing literature in which service quality, customer
satisfaction and loyalty items were adopted from Kondasani and Panda (2015)
study and these items were taken from the previous studies (Parasuraman et al., 1988;
Boulding et al., 1993; Taylor and Baker, 1994; Youseff et al., 1995; Lam, 1997; Andaleeb, 2001;
Sower et al., 2001; Sureshchandar et al., 2002; White and Yu, 2005; Olorunniwo et al., 2006;
Bigné et al., 2008; Aagja and Garg, 2010).
Physical environment is the independent variable of this research. This instrument
contains nine items for measurement. Customer-friendly environment was measured
through six-items scale. Communication was measured along with five items. Privacy and
 safety contained four items for measurement and responsiveness was also measured with Private
four items. Satisfaction is mediating variable for this study and was measured with five healthcare
items; dependent variable loyalty also had five items. systems
4.5 Demographics of participants
In Table III members’ outline exhibits that the information was taken from 611 respondents.
Table comprised of demographic results like age, gender, education and income level of 1203
respondents. Results indicate that there are 297 male which equals to 48.6 per cent while
314 were female members showing 51.4 per cent of total respondents. As indicated by the age
aggregate outcome; 8.2 per cent members were under 15 years which demonstrates the most
minimal rate among all others. There were 49.3 per cent members were between 16-30 years,
31.1 per cent were between 31-50 years and 11.5 per cent members whose ages were above from
50 years. Education matrix of respondents demonstrates that 5.4 per cent respondents were
having zero education which demonstrates the most reduced rate among others, 18.8 per cent
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were not exactly or equivalent to Matric, 18 per cent having the education equal to intermediate,
36.3 per cent were bachelors which demonstrates the most elevated rate among all and
21.4 per cent respondents were having capability equivalent to master or above education.
Monthly income matrix shows the income range of respondents. It demonstrates
6 per cent respondents’ salary was not exactly or equivalent to Rs 15,000, 35 per cent
respondents gained between Rs 16,000-30,000, 44 per cent respondents earned between
Rs 31,000 and 50,000, which demonstrates most elevated rate among all. In all, 14.6 per cent
respondents gain above Rs 50,000 or above. Further details are available in Table III.
Table II includes the sample statistics of the study, which includes the details of inpatients
population and size such as number of beds available, number of beds concerned and total
number of respondents, and outpatient’s population. Further details are given in Table III.

5. Research findings
5.1 Reliability, common method variance, and descriptive results
Table IV depicts the results of α reliability. All the scores are above 0.7, thus, yielding good
reliable scores (Bland & Altaman, 1997). According to mean score results, highest mean score
is of communication (4.13) and lowest of responsiveness (3.94). In order to check common

Rawalpindi Islamabad

Hospitals A B C A’ B’ C’ Total

Inpatients population and sample

No. of beds
available 220 320 195 250 200 200 1,385
No. of beds
concerned 180 195 100 180 150 120 925
No. of
respondents 71 80 44 70 68 48 381

Outpatient’s population and sample

No. of patients 154 190 185 250 200 180 1,159
Respondents 41 40 42 43 34 30 230

Total sample
Sample In.p out.p In.p out.p In.p out.p In.p out.p In.p out.p In.p out.p 381
71 41 80 40 44 42 70 43 68 34 48 30 +230 ¼ 611 Table II.
Note: Hospital names are kept secret on account of obscurity Sample Statistic
 IJQRM Variables f %
35,6
Gender
Male 297 48.6
Female 314 51.4
Age
1204 15 year or less 50 8.2
16-30 year 301 49.3
31-50 year 190 31.1
51 year and more 70 11.5
Education
Matriculation or less 115 18.8
Intermediate 110 18.0
Bachelors 222 36.3
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Masters or above 131 21.4

Uneducated 33 5.4
Monthly Income
Rs15,000 or less 37 6.1
Rs16,000-30,000 214 35.0
Table III. Rs31,000-50,000 271 44.4
Demographical results Above Rs50,000 89 14.6

Variables 1 2 3 4 5 6 7

1 Physical environment 1
2 Customer friendly 0.347** 1
3 Communication 0.299** 0.506** 1
4 Privacy and safety 0.264** 0.446** 0.344** 1
5 Responsiveness 0.196** 0.361** 0.244** 0.415** 1
6 Satisfaction 0.320** 0.418** 0.352** 0.562** 0.393** 1
7 Loyalty 0.271** 0.413** 0.340** 0.509** 0.429** 0.676** 1
Table IV.
Correlation Mean 4.00 4.12 4.13 4.04 3.94 4.04 4.00
coefficients, reliability, Standard deviation 0.491 0.490 0.613 0.582 0.631 0.567 0.572
mean and standard α reliability 0.740 0.739 0.846 0.743 0.738 0.802 0.749
deviation results Note: **Correlation is significant at the 0.01 level (two-tailed)

method variance, Harman’s single factor test was applied by adding all variables into a single
factor and constrained that there is no rotation. Results showed that new common latent factor
explains variance of 24.03 per cent which is less than threshold of 50 per cent and thus
showing that there is no issue of common method variance (Podsakoff et al., 2003).

5.2 Correlation results

Correlation coefficient results are given in Table IV. All the correlation results are positive at
significance level of 0.01. The correlation results between healthcare perceived service
quality aspects proposed that the maximum correlation is between communication and
customer-friendly environment (r ¼ 0.506, po 0.01) while the lowest correlation is between
responsiveness and physical environment (r ¼ 0.196, p o0.01) and both lowest and highest
values are indication of moderate positive relationship between them.
Correlation among healthcare service quality and patient loyalty proposed the foremost
correlation held between privacy and safety and patient loyalty (r ¼ 0.509, po0.01) in addition
 to the minimum correlation among physical environment and patient loyalty (r ¼ 0.271, Private
po0.01) so mutual correlation confirms the positive moderate relationship between them. In healthcare
addition to the correlation between healthcare service quality and patient satisfaction proposed systems
the most surprizing correlation is between privacy and safety and patient satisfaction (r ¼ 0.562,
po0.01) and the least correlation between physical environment and patient satisfaction
(r ¼ 0.320, po0.01) which demonstrates the direct positive relationship between them. As well
as the value of correlation between patient satisfaction and patient loyalty is (r ¼ 0.676, po0.01) 1205
which demonstrates that there is a direct positive relationship between them.

5.3 Regression results

5.3.1 Effect of healthcare service quality on patient satisfaction and/between patient loyalty.
In Table V, Model-1 explains the individual effect of HCSQ dimensions like physical
environment ( β ¼ 0.075, po0.05), customer-friendly environment ( β ¼ 0.120, po0.01),
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communication ( β ¼ 0.096, p o0.05), privacy and safety ( β ¼ 0.312, po0.001) and

responsiveness ( β ¼ 0.218, po0.001), all variables have a positive significant effect on
patient loyalty. The Model 2 shows the individual effect of HCSQ dimensions like physical
environment ( β ¼ 0.125, p o 0.001), privacy and safety ( β ¼ 0.391, p o 0.001) and
responsiveness ( β ¼ 0.148, po0.001) customer-friendly environment ( β ¼ 0.099, po0.01) and
communication ( β ¼ 0.094, po0.01) have a significant positive effect on patient satisfaction.
The Model 3, shows the relationship between patient satisfaction and patient loyalty, depicting
a significant positive effect of patient satisfaction on patient loyalty ( β ¼ 0.676, po0.01). Hence,
the mentioned results provide support for the hypothesis from H1 to H3.
5.3.2 Mediating effect of patient satisfaction between healthcare service quality and patient
loyalty. Model-4 in Table V explains the mediating effect of patient satisfaction between individual
HCSQ dimensions and patient loyalty. Results suggest that patient satisfaction fully mediates the
relationship between physical environment and patient loyalty ( β ¼ 0.012, pW0.05), customer
friendly and patient loyalty ( β ¼ 0.070, pW0.05), communication and patient loyalty ( β ¼ 0.049,
pW0.05), while privacy & safety and patient loyalty ( β ¼ 0.115, po0.01) and responsiveness
and patient loyalty ( β ¼ 0.143 po0.001), showing patient satisfaction partially mediates between
these relationships. The results provide the support for all hypotheses that patient satisfaction
partially mediates the relationship between HCSQ dimensions and patient loyalty ( β ¼ 0.506,
po0.001). Thus, result provides the strong support for acceptance of H4 and H4a-e.

Model-1 Model-2 Model-3 Model-4

IV-DV IV-MV MV-DV (IV+MV-DV )
Independent variables β t-value β t-value β t-value β t-value

Physical environment 0.075* 2.116 0.125*** 3.633 0.012 0.378

Customer-friendly 0.120** 2.891 0.099* 2.455 0.070 1.923
Communication 0.096* 2.488 0.094* 2.497 0.049 1.441
Privacy and safety 0.312*** 8.039 0.391*** 10.368 0.115** 3.117
Responsiveness 0.218*** 5.917 0.148*** 4.130 0.143*** 4.399
Satisfaction 0.676*** 22.663 0.506*** 13.846
F 66.599*** 78.005*** 513.594*** 104.948***
R2 0.355 0.392 0.458 0.510
Adjusted R2 0.350 0.387 0.457 0.506
Durbin Watson 1.666 1.838 1.801 1.773 Table V.
Notes: Dependent variable: loyalty. Mediating variable: satisfaction. V, independent variables; DV, Model summary of
dependent variable and MV, mediating variable. *po 0.05, **p o0.01, ***p o0.001. regression analysis
 IJQRM 5.4 Ranking of healthcare services
35,6 Table VI shows the ranking of services in both ascending and descending order
(mean scores). “Customers are feeling safe in their interaction with staff” got the highest mean
scores (4.28) and “hospitals providing confidentiality” as well received the good quality mean
scores (4.26). Results indicate that due to fine services from the hospital administration,
patients have a comfortable relation with the staff. Two items; “Hospitals are well equipped
1206 with necessary medical equipment” and “doctors give adequate information” having same
mean scores (4.25). It shows that all private hospitals have all necessary tools and equipment
for treatment. “Physicians are willing to listen and answer questions” (4.22) which indicates
that patients can convey his/her problem comfortably and doctors listen and understand them
in convenient way. “Sufficient staff available in hospital” and “hospitals are not misusing
customer’s information” got the mean scores (4.18) indicate all hospitals have enough staff to
serve patients as well hospital doesn’t use customer information wrongly. “Give prompt
services to customers” (4.16), “department and division are easily recognised” (4.14) and
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“hospital personal explains the discharge process” (4.13).

These results demonstrate that patients do not wait when they are looking for
healthcare. They enjoy services at the appointed time. In hospitals various sections and
departments are categorised separately so that patients do not feel any ambiguity to
identify them. Further details are given in Table VI.
Table VI also indicates the scores of those services which hospitals are failed to provide
properly and greater part of patients are not satisfied. Condition of canteen got overall
lowest mean scores (3.53) which shows patients are not well facilitated with services
provided by cafeterias. “Hospital located in safe and secured place” (3.80) indicates patients
are not satisfied with the location of hospitals regarding security. “Doctors and staff handle
peak hospital traffic” (3.83) specifies patients are not properly handled and do not get
quality services during rush hours. “Hospital staff and public can be easily differentiated”
(3.88) shows patients are unable to differentiate the staff of hospital. “Materials related to
outpatient services are visually appealing” (3.90). “Staff has a warm and caring attitude” got
mean scores (3.91). “Customers feel safe in the hospital premises” (3.93) indicates staff
doesn’t have professional attitude towards patients. “Staff are courteous” (3.94) shows
behaviour of staff is usually rude. The time it took to meet doctor is not too long (3.99)
illustrates people have to wait due to huge number of patients. Medical staff effectively

Descending order M M Ascending order

Customers made to feel safe in their interaction with 4.28 3.53 Hospital canteen is good
staff
Hospital provides confidentiality 4.26 3.80 Hospital located in safe and secured place
Hospital is well equipped with all necessary medical 4.25 3.83 Doctors and staff handle peak hospital
equipment traffic
Doctors give adequate information on treatment 4.25 3.88 Hospital staff and public can be easily
differentiated
Physicians are willing to listen and answering 4.22 3.90 Materials related to outpatient services are
questions visually appealing
There are sufficient staff available in the hospital 4.18 3.91 Staff have a warm and caring attitude
Hospital not misusing customer’s information 4.18 3.93 Customers feel safe in the hospital premises
Gives prompt services to customers 4.16 3.94 Staff are courteous
The different departments, divisions and labs are 4.14 3.99 The time it took to meet doctor is not too
Table VI. easily recognised long
The ranking of Hospital personnel explain the discharge process to 4.13 4.00 Medical staff effectively listening to patient
healthcare services the patient and family requests/problems
 listening to patient requests/problems (4.00) demonstrates medical staff is not much Private
cooperative with patients. healthcare
Hence, the results depicts patients prefer to visit private hospitals because of good staff systems
interaction, hospital confidentiality, latest technology, physician’s more concern towards
patients’ needs and provide extra time to them, well equipped labs and well explained and
managed discharge procedures. While other mean scores, shows that if patients spend lots if
money in their treatment from private healthcare providers, they tend to form more 1207
expectations and after experiencing services, if they are not satisfied with the provided
services, they get dissatisfied and unhappy towards the condition of hospitals outdoor
places, i.e., cafeteria, parking, etc.

6. Discussion
Current study examines the research question, i.e. the effect of healthcare service quality
factors influence the patient’s satisfaction that aides in constructing loyalty intentions in
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hospitals of Pakistan. As study aim was measuring the patients view with respect to the
quality of healthcare service aspects like physical environment, customer-friendly environment,
communication, privacy and safety and responsiveness as well as effect of perceptions on
patients’ satisfaction and loyalty intentions. Study is descriptive in nature and aim of the study
was to explore the research questions and information was gathered from private hospitals to
quantify the perceptions of patients whether patients are satisfied/loyal or not.
The association among healthcare service quality and patient loyalty is related with each
other as demonstrated by results and it indicates that hospital will construct loyalty goals of
patient if the healthcare service quality provided by hospital in an appropriate manner.
Healthcare service quality and patient satisfaction is also positively related with each other
which provide indication of patient satisfaction as a resultant of better service quality. Patient
satisfaction and patient loyalty is related with each other which conclude that satisfaction
helps to build loyalty among patients thus patient satisfaction and loyalty have direct
relationship. The outcomes are stable with the earlier studies that HCSQ is absolutely related
with patient loyalty (Wu et al., 2008; Li et al., 2011; Chahal and Mehta, 2013) and patient
satisfaction (Raftopoulos, 2005; Badri et al., 2009; Naism et al., 2014). Patient satisfaction is
positively related with patient loyalty (Elleuch, 2008; Chahal and Kumari, 2010) and patient
satisfaction mediates the association among HCSQ and patient loyalty (Dagger and Sweeny,
2007; Mpinganjira, 2011; Aliman and Mohamad, 2013; Shabbir et al., 2016).
Moreover, result shows that in private sector hospitals, the healthcare service quality
aspect, i.e. physical environment has found the good interpreter of patient loyalty and a
strong predictor of patient satisfaction. It shows that in private sector hospital’s physical
facilities, infrastructure, hospital functions, medical apparatus, devices and instruments,
medical staff appearance etc., are well maintained and hospital’s management focus on
neatness, hygiene and environmental calmness, which are indispensable for the patient’s
healthcare condition.
Customer-friendly environment is also a forecaster of customer satisfaction and loyalty
because hospital staff behaviour provides a friendly environment. It shows that the private
hospital staff gives services at client favoured times and private hospital staff is more
worried about treatment times. Private division hospitals make conceivable two-sided
communication. They keep clients very much informed, recognise and listening to their
issues in a perceptive and convincing way. Specialists endeavour to comprehend the
patient’s issue or their ailment and after that patients ready to clearly explain his/her
issue/ailment. For the reason communication is an indicator of patient’s satisfaction and
loyalty as well. Privacy and safety has also found a strong predictor of both patient’s
satisfaction and loyalty. It shows in private division of Pakistan, hospitals endeavour to
stay away from or decrease real or potential damage from healthcare and lessen
 IJQRM antagonistic occasion’s danger. Last dimension of service quality responsiveness is also a
35,6 solid indicator of patient’s satisfaction and loyalty. It appears that hospitals especially
concentrate on out of line treatment relate with social position.

6.1 Practical implication

This study has contributed as an explanatory model for healthcare association that measures
1208 the impression of patients with respect to healthcare service quality, furthermore measure the
level of satisfaction and loyalty intentions. Consequently, this study is valuable to healthcare
providers; in the meantime it can be productive for business association. Also, the study adds
to existing literature by providing understanding and learning about the healthcare services
and the factors, which can influence service quality, how it has developed and measured.
Additionally, the study highlights that it will be exceptionally successful that private
healthcare association’s emphasis on each element which can deliver prompt satisfaction.
Pakistan hospital ought to concentrate on huge measurement of service quality that the
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patients gave constructive response with respect to their satisfaction and loyalty.

6.2 Limitation and future research

There are certain limitations associated with this research that need to be addressed.
Further study could be outline to test characteristics of service quality, by utilising other
strategy for data gathering, i.e. interviews and experimental research to see which of them
will be more viable. Also future study could be expected to test similar factors in other
service sector. Furthermore applying the model to different hospitals in different cities may
give distinctive or additional helpful results. Researcher has led quantitative study while in
future qualitative study will give more in-depth knowledge. The present study has just
centred on private hospitals, however, future studies can be done that will gauge the
perception and additionally desires of both public and private hospitals’ patients with the
same or other healthcare service quality dimensions addressed in this study. The present
study incorporated the mediating role of patient satisfaction, while future studies could
focus on hospital image and price factor with respect to healthcare service quality.
The effect of healthcare service quality is taken on patient loyalty while future studies could
focus on other outcome variables and also incorporate other healthcare service quality
dimensions; doctors and nurses’ professionalism, price and appointment producers, etc.

6.3 Conclusion
Conclusion provide clear understanding about healthcare service quality conditions in private
sector hospitals of Pakistan and how private hospitals are trying to provide better quality
services and contributing an affirmative role with a specific end goal to attract and sustain the
customers. Different studies justifying the findings of our current study; Mostafa (2005)
proposed the private hospitals are conveying healthcare services in Egypt in better way with
improved quality of services. Correspondingly, the patient admires more prominently the
healthcare services towards private hospitals in Bangladesh (Andaleeb, 2000). Furthermore,
contradicting studies also directed the better quality of services is provided by public sector
hospitals than their counterparts with respect to Pakistan but these results are entirely diverse
with other studies (like Andaleeb, 2000, 2001; Mostafa, 2005; Shabbir et al., 2016; Shabbir et al.,
2017; forthcoming) justifying the private hospitals in Pakistan are trying better endeavours
when contrasted with the public hospitals.
Outcome of this study demonstrates that private hospitals tend to provide more
concentrating on their patient’s requests and creating themselves with a specific end goal to
give highest healthcare facilities to the patients. From the outcomes discussed above,
likewise demonstrated that in private hospitals, all the staff are meant to give care to their
 patients, giving clean solid and client well-disposed environment to the patients, powerful Private
communication, productively going to patient calls, accessibility of specialist and healthcare
convenient working hours for clients inside the hospital and advancement of an input systems
system. Private hospitals provide endeavours towards perpetual change in the procedures,
framework and gave constantly quality of healthcare service to their patients. Findings
recommend that better quality of healthcare services help in building satisfaction and
loyalty intentions in light of the fact that a reliable client will always make positive WOM. 1209
In addition, the hospital managers are focussing on patient oriented strategies as patients
are the honest resource of an organisation to build a clear picture of profitability and
authority. Results additionally recommend that the relationship between patient loyalty and
healthcare service quality aspects like physical environment, customer friendly,
responsiveness, communication and privacy and safety is mediated by patient satisfaction.

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1213
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About the authors

Taqdees Fatima is an MS Scholar at the Department of Management Sciences, Faculty of Business
Administration, COMSATS Institute of Information Technology (CIIT), Pakistan. Her research
interests are service quality in healthcare.
 IJQRM Dr Shahab Alam Malik is Professor/Dean of Faculty of Management Sciences in Indus University,
35,6 Karachi, Pakistan. He obtained his PhD Degree in Management Science and Engineering with
specialisation in Total Quality Management from the Harbin Institute of Technology (HIT), Harbin,
China and an MBA from Hamdard University, Islamabad. His research interests are TQM, Service
Quality, HRM, and education. Dr Shahab Alam Malik is the corresponding author and can be contacted
at: shahabmaliks@gmail.com
Asma Shabbir is serving as a Lecturer in Department of Management Sciences, Faculty of Business
1214 Administration, COMSATS Institute of Information Technology (CIIT), Attock Campus, Pakistan. She
did her MS in Human Resource Management from COMSATS Institute of Information Technology
(CIII), Islamabad. Her research interests are service quality in healthcare and she has publications in
International Journal of Quality and Reliability Mangement.
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