International Journal of Health Care Quality Assurance

Evaluating health service quality: using importance performance analysis

Azar Izadi, Younes Jahani, Sima Rafiei, Ali Masoud, Leila Vali,
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Azar Izadi, Younes Jahani, Sima Rafiei, Ali Masoud, Leila Vali, (2017) "Evaluating health service
quality: using importance performance analysis", International Journal of Health Care Quality
Assurance, Vol. 30 Issue: 7, pp.656-663, https://doi.org/10.1108/IJHCQA-02-2017-0030
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IJHCQA
30,7
656
Received 6 April 2016
Revised 16 February 2017
Accepted 6 April 2017
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International Journal of Health
Care Quality Assurance
Vol. 30 No. 7, 2017
pp. 656-663
© Emerald Publishing Limited
0952-6862
DOI 10.1108/IJHCQA-02-2017-0030
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0952-6862.htm
Evaluating health service
quality: using importance
performance analysis
Azar Izadi
Faculty of Management and Medical Informatics,
Kerman University of Medical Sciences, Iran
Younes Jahani
Faculty of Health, Kerman University of Medical Sciences, Iran
Sima Rafiei
Faculty of Health, Qazvin University of Medical Sciences, Iran
Ali Masoud
Faculty of Management and Medical Informatics,
Kerman University of Medical Sciences, Iran, and
Leila Vali
Kerman University of Medical Sciences, Iran
Abstract
Purpose – Measuring healthcare service quality provides an objective guide for managers and policy makers
to improve their services and patient satisfaction. Consequently, the purpose of this paper is to measure
service quality provided to surgical and medical inpatients at Kerman Medical Sciences University (KUMS)
in 2015.
Design/methodology/approach – A descriptive-analytic study, using a cross-sectional method in the
KUMS training hospitals, was implemented between October 2 and March 15, 2015. Using stratified random
sampling, 268 patients were selected. Data were collected using an importance-performance analysis (IPA)
questionnaire, which measures current performance and determines each item’s importance from the patients’
perspectives. These data indicate overall satisfaction and appropriate practical strategies for managers to
plan accordingly.
Findings – Findings revealed a significant gap between service importance and performance. From the
patients’ viewpoint, tangibility was the highest priority (mean ¼ 3.54), while reliability was given the highest
performance (mean ¼ 3.02). The least important and lowest performance level was social accountability
(mean ¼ 1.91 and 1.98, respectively).
Practical implications – Healthcare managers should focus on patient viewpoints and apply patient
comments to solve problems, improve service quality and patient satisfaction.
Originality/value – The authors applied an IPA questionnaire to measure service quality provided to
surgical and medical ward patients. This method identifies and corrects service quality shortcomings and
improving service recipient perceptions.
Keywords Importance performance analysis, Service quality, Patient satisfaction
Paper type Research paper
Introduction
Improving service quality has become a major challenge for staff working in organizations
wanting to survive in competitive markets and meet service recipient expectations and
satisfaction (Sahney et al., 2006). Healthcare has a special importance among non-clinical
services owing to its uncertain nature. Healthcare staff need to develop and execute quality
improvement plans to succeed (Hekmatpou et al., 2010).
The authors thank Kerman University of Medical Sciences hospital staff for providing data. This paper
reports Research Project Number 100.259.
 Quality as a competitive advantage Evaluating
Quality gives a sustainable competitive advantage – a crucial factor in patient satisfaction health service
(Zarei et al., 2011), which ultimately increases referrals, service demand and hospital quality
reputation (Parasuraman et al., 1988). Providing high quality services leads to cost savings,
increases market share, profitability and service provider effectiveness (Kazemi and Fanudi,
2009; Wong and Shoal, 2002). That is why the hospital manager’s main mission is to provide
quality care for patients, meet their needs and expectations in a proper manner. Fulfilling 657
this important mission requires institutionalizing hospital quality (Sodani, 2012).

Service quality measurement

The most significant quality improvement step is to evaluate customer satisfaction and
discover their needs. In 1983, the National Organization of Health Services in the USA
passed a law requiring all healthcare centers to set plans based on patient views
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(Vingerhoets et al., 2001). Several studies on measuring hospital services quality and patient
satisfaction revealed many challenges, which emphasizes the need for continuous attention
to quality issues, keeping hospital managers informed about potential problems and to solve
them (Parand et al., 2014). Patient perception questionnaires are a common client-centered
measurement tool (Seidi et al., 2005). There are several service quality assessment models,
such as: Client Oriental Provider Efficient, Lot Quality Assurance Sampling, Criteria and
Standards of Quality, Statistical Process Control, SERVQUAL and Importance Performance
Analysis (IPA) (Mohebifar et al., 2016).

The IPA model

In the early service recipient satisfaction assessment models, the difference between patient
perceptions and expectations was regarded as a criterion to judge services quality; while
subsequent models such as IPA measure the relationship between importance (tangibility,
reliability, responsiveness, assurance, empathy, social accountability, service delivery
process and service organization) and patient perceptions about health provider
performance (Sherman and Sherman, 2000; Bani Asadi et al., 2011). Fathi et al. (2011)
mentioned that measuring existing performance to develop an appropriate strategy for
achieving the optimal level was a key element in quality assurance. When identifying
improvement priorities for resource allocation, it is essential to focus on corrective actions.
Khalifeh and Razavi (2012) declared that IPA is an efficient tool for prioritizing service
indicators, enhancing service quality and for addressing patient satisfaction. The model’s
growing importance in identifying system strengths and weaknesses, its efficiency in
determining priorities and improvement strategies, led to IPA’s application in various
research fields, including health, finances, information systems, education and e-learning. In
a study conducted to comprehensively identify factors related to supply chain relationships
in automobile companies and to improve trade relations between them, IPA was used.
Olfat and Barati (2013) believed that IPA could identify critical foci and consequently
concentrate resources to achieve improved performance. Measuring service quality among
inpatients is a priority, which can suggest appropriate opportunities for improving
healthcare services. Consequently, we aim to: analyze different quality aspects related to
healthcare services from the KUMS hospital patient viewpoint; and provide useful advice
for policy makers and hospital managers to improve service quality and efficiency.

Research question and method

This cross-sectional descriptive study was conducted in three KUMS training hospitals, 2015.
Patients (n ¼ 268) from surgical and medical wards were selected through stratified sampling.
The two inclusion criteria were: inpatient more than 24 hours; and over 18 years.
 IJHCQA Data collection involved a standard IPA model questionnaire with two parts: questions
30,7 regarding patient demographics such as sex, age, educational level and hospitalization
frequency; and 32 questions that measured patient expectations and perceptions regarding
eight service quality dimensions: tangibility ( five items); reliability ( four items); empathy
( four items); service delivery process ( five items); social accountability (three items);
service organization (three items); responsiveness ( five items); and assurance (three items).
658 A five-point Likert scale was used: 1 ¼ strongly disagree to 5 ¼ strongly agree. Face and
content validity were confirmed in previous studies (Bani Asadi et al., 2011). Questionnaire
reliability was confirmed in a similar study (Lotfee, 2009). Using patients’ expectations
regarding eight quality dimensions, we plotted a four-quadrant matrix on an X-Y coordinate
plane (Figure 1), which helped to classify study variables necessary for any improvement
strategy (Olfat and Barati, 2013; Anderson and Zwelling, 1996).
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Results
The sample patients’ profile reveals that:
• average age was 40 years;
• 54.1 percent were male;
• 9 percent were illiterate;
• 24.6 percent had diploma;
• 66.4 percent had higher educational degree;
• 66 percent were hospitalized in surgical and 33.9 percent in medical wards; and
• 55.5 percent had been hospitalized more than once (Table I).
The highest and lowest patients’ perceptions, respectively, belonged to assurance (3.0270.99)
and social accountability (1.9871.04). The highest and lowest expectations were tangibility
(3.5470.61) and social accountability (1.9170.92). Table II depicts patients’ perceptions and
expectations related to eight quality dimensions in three hospitals. In Hospital A, the highest

Importance
Quadrant II Quadrant I
High
Possible Overkill Keep Up the Good
Work

Performance
Quadrant III Quadrant IV
Low Priority Concentrate Here

Low

Notes: Quadrant I indicates high performance and importance - a

priority that needs immediate action; Quadrant II (high performance,
low importance) indicates that organization managers over-emphasized
related items; Quadrant III (low performance and importance) shows
that improvement is not needed; Quadrant IV requires immediate
Figure 1.
IPA matrix attention. Data were analyzed using SPSS 19
Source: Anderson and Zwelling (1996)
 Variable Frequency (n) %
Evaluating
health service
Sex quality
Female 130 48.5
Male 138 51.5
Age
18-28 80 29.8 659
29-39 66 24.6
40-50 55 20.5
51-61 37 13.8
W61 30 11.3
Hospitalization
Once 119 44.4
Twice 73 27.2
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More than twice 76 28.4

Education level
Illiterate 24 8.9
Under diploma 66 24.6
Diploma or upper degrees 178 66.5
Ward
Internal 91 33.9 Table I.
Surgery 177 66.1 Demographics

Quality Hospital A Hospital B Hospital C Total study sample

dimensions Importance Performance Importance Performance Importance Performance Importance Performance

Tangibility 3.567 0.62 2.97 0.8 3.67 0.5 1.97 0.9 3.477 0.6 2.97 0.74 3.57 0.6 2.67 0.85
Reliability 3.67 0.56 2.67 0.7 3.67 0.3 2.87 0.7 1.77 1.07 2.87 0.69 2.97 0.5 2.77 0.73
Responsiveness 37 0.69 2.537 1.03 2.97 0.7 1.97 1.1 3.027 0.5 2.47 1.06 2.97 0.6 2.37 1.08
Assurance 2.67 0.78 2.97 0.9 2.77 0.7 2.97 0.9 2.417 0.7 3.17 1.05 2.67 0.6 3.027 0.9
Empathy 2.87 0.84 2.57 0.9 2.77 0.8 1.827 1.07 2.87 0.6 2.57 1.01 2.87 0.7 2.37 1.02
Service delivery
process 3.27 0.79 2.57 0.9 1.97 1.0 1.877 1.07 3.17 0.6 1.77 1.1 2.77 0.8 2.037 1.05 Table II.
Accountability 1.927 0.7 2.47 1.03 1.97 0.98 1.77 1.01 1.97 1.01 1.77 1.08 1.97 0.9 1.97 1.04 Importance and
Service performance analysis:
organization 1.947 0.8 1.957 0.94 1.77 1.05 1.897 1.01 2.67 0.8 2.37 1.1 2.17 0.9 2.067 1.02 quality dimensions

and lowest perceptions were tangibility (2.9770.88) and service organization (1.9570.94).
In Hospital B, they were assurance (2.9170.97) and social accountability (1.7671.01) and in
Hospital C: assurance (3.1871.05) and service delivery process (1.7171.12). Comparing
patients’ expectations revealed that the highest and lowest means in Hospital A were reliability
and social accountability (1.9270.78); In hospital B: reliability (3.670.37) and service
organization (1.771.05) and in Hospital C: tangibility (3.4770.67) and assurance (1.7671.07).
Table III depicts the highest and lowest negative gaps: tangibility (gap score ¼ −0.91) and
service organization (−0.04). Only in two quality dimensions (assurance and social
accountability) were gap score positive (0.41, 0.07). The IPA matrix showed that in Hospital A,
social accountability and in Hospital C, reliability, were placed in Quadrant III. As this area
represents the least important aspects from patients’ viewpoint, service providers should
transfer resources to weak sectors. The keep-up-the-good work Quadrant captured empathy,
assurance, responsiveness, tangibility, reliability and service delivery quality dimensions for
Hospital A; assurance and reliability for Hospital B; empathy, assurance, responsiveness,
 IJHCQA tangibility and service organization for Hospital C. That is, hospitals have performed well on
30,7 these quality dimensions and must try to maintain their status. Patients in all three hospitals
mentioned service organization in quadrant keep-up-the-good work. Those in Hospital B
placed social accountability and service delivery in the low priority quadrant.
Although patients were dissatisfied with some quality dimensions, the little importance
given to them prevented managers from considering them in hospital improvement
660 programs. Finally, the concentrate here quadrant captured: empathy, responsiveness and
tangibility in Hospital B and service delivery process in Hospital C. Patients regarded such
attributes important, but were not satisfied with their performance, so that this area
called for special attention. In assessing overall hospital service quality, empathy,
service organization, assurance, responsiveness, tangibility and reliability were placed in
the keep-up-the-good-work quadrant, while social accountability and service delivery were
placed in the low priority area (Table IV ).
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Conclusions and recommendations

Measuring hospital service quality is an important strategy for managers wanting to
improve services. Measurement can be done through various instruments; we used IPA in
our surgical and medical wards. To identify and improve service quality shortcomings,
this approach along with service recipient perceptions can be helpful. The literature
confirmed our results; i.e., that there were statistically significant differences between
patient expectations and perceptions in almost all dimensions, confirming that efforts are
needed to achieve desired levels (Lotfee, 2009; Butt and de Run, 2003; Bakar et al., 2008;
Tabibi et al., 2012; Mohammadi and Shoghli, 2009). Hospital performance in different
quality dimensions did not comply with patient expectations. Thus, it is necessary to
focus on improvement models for the patients’ benefit first and consider their interests as
the prime healing encounter.

Service Service
Hospital Tangibility Reliability Responsiveness Assurance Empathy process Accountability organization

A −0.66 −1 −0.47 0.3 −0.3 −0.7 0.48 0.1

Table III. B −1.7 −0.8 −1 0.2 −0.88 −0.03 −0.2 0.19
Hospital quality C −0.57 1.1 −0.62 0.69 −0.3 −1.4 −0.2 −0.3
dimensions Total −0.9 −0.2 −0.6 0.42 −0.5 −0.67 0 −0.04

Matrix quadrants A B C Total

I. Keep up the good Empathy, assurance, Assurance, Empathy, Empathy, assurance,

work responsiveness, reliability assurance, responsiveness,
tangibility, reliability, responsiveness, reliability, tangibility,
service delivery tangibility, service service organization
process organization
II. Possible overkill Social accountability – Reliability –
III. Low priority Service organization Social Social Social accountability,
accountability, accountability service delivery
service delivery process
process, service
organization
Table IV. IV. Concentrate here – Empathy, Service delivery –
Hospitals in the responsiveness, process
IPA matrix tangibility
 In our study, the highest and lowest gaps were tangibility and service organization, Evaluating
indicating that hospitals were not clean, and did not have adequate and modern medical health service
equipment. Other studies do not support our findings; i.e., that the smallest gap between quality
patient perceptions and expectations was tangibility (Mohammadi and Shoghli, 2009;
Bahadori et al., 2014; Lee and Yom, 2007). Zarei et al. (2012) found that the largest gap was
tangibility. Furthermore, the positive gaps: assurance and social accountability confirmed
that hospitals had optimal performance in these areas. In fact, staff were a skilled workforce 661
familiar with modern medicine, who served patients politely and respectfully. Through
matrix analysis, results showed that to maintain a competitive advantage, staff in Hospitals
B and C should pay more attention to empathy, responsiveness, tangibility and service
delivery. Therefore, resources can be allocated to either improve quality dimensions:
keep-up-the-good-work or resolve the main weaknesses; i.e., concentrate here, from the
patients’ view point. Wu et al. (2010), studying Spanish services, revealed that tangibility,
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assurance and reliability, found that keep-up-the-good-work reflects importance and at the
same time acceptable performance.
Other findings also emphasized that perceived hospital service quality was mainly
dependant on the tangibility dimension (including physical environment, equipment,
payment process and cleanliness) confirming that the highest patient expectations were
related to tangibility. Results reported in similar studies confirmed our results; i.e., patients’
perceptions were mainly affected by environment and physical evidence than core
services such as medical care ones (Parasuraman et al.,1985; Grönroos, 1990; Boshoff and
Gray, 2004). Vandamme and Leunis (1993) found that tangibility and assurance were the
most important dimensions that explained hospital service quality. Sohail (2003), in his
study, declared that patient expectations were mainly dependent on modern equipment,
cleanliness and the facility’s visual appeal (Sohail, 2003).
Importance performance analysis enables hospital and health care organization
managers to better understand patient perceptions and expectations. It is a user friendly
and an inexpensive application. Using an X-Y coordinate plane, with four-quadrant matrix,
results can be plotted so that each point indicates the quality dimensions’ strengths and
weaknesses. Results can also help decision makers to improve service quality and patient
satisfaction through emphasizing service recipients’ perceptions in each quadrant. In fact,
to solve healthcare problems, improve quality and patient satisfaction, healthcare managers
should focus on patient viewpoints about different quality dimensions and act on their
comments. Our study’s main limitation is that data were mainly from three training
hospitals affiliated to Kerman Medical Sciences University, which may not represent the
Iranian population. Therefore, further studies are recommended to confirm our findings and
help generalizing them to the entire population. To expand IPA evaluation from a narrower
patients’ perspective, we suggest cross-matching importance and satisfaction levels using
both service recipient and service provider viewpoints.

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Corresponding author
Leila Vali can be contacted at: vali1386@gmail.com

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