International Journal for Quality in Health Care, 2018, 1–19

doi: 10.1093/intqhc/mzy125
Review

Review

Dimensions of service quality in healthcare:

a systematic review of literature
IRAM FATIMA1, AYESHA HUMAYUN2, USMAN IQBAL3,
and MUHAMMAD SHAFIQ1
1
Institute of Quality and Technology Management, University of the Punjab, Lahore, Pakistan, 2Department of
Public Health and Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical College and Shaikh Zayed
Postgraduate Medical Institute, Shaikh Zayed Medical Complex, Lahore 54700, Pakistan, and 3Global Health and
Development Department, College of Public Health, International Center for Health Information Technology
(ICHIT),Taipei Medical University, 250-Wu-xing St. Xinyi District, Taipei 11031, Taiwan

Address reprint requests to: Ayesha Humayun, Department of Public Health and Community Medicine, Shaikh Khalifa
Bin Zayed Al-Nahyan Medical College and Shaikh Zayed Postgraduate Medical Institute, Shaikh Zayed Medical
Complex, Lahore, Pakistan. Tel: +92 32 1434 3065; Fax: +92 42 9923 1159; E-mail: drayeshah@gmail.com, registrar@
skzmdc.edu.pk
Editorial Decision 21 April 2018; Accepted 22 May 2018

Abstract
Purpose: Various dimensions of healthcare service quality were used and discussed in literature
across the globe. This study presents an updated meaningful review of the extensive research
that has been conducted on measuring dimensions of healthcare service quality.
Data sources: Systematic review method in current study is based on PRISMA guidelines. We
searched for literature using databases such as Google, Google Scholar, PubMed and Social
Science, Citation Index.
Study selection: In this study, we screened 1921 identified papers using search terms/phrases.
Snowball strategies were adopted to extract published articles from January 1997 till December 2016.
Data extraction: Two-hundred and fourteen papers were identified as relevant for data extraction;
completed by two researchers, double checked by the other two to develop agreement in discrepan-
cies. In total, 74 studies fulfilled our pre-defined inclusion and exclusion criteria for data analysis.
Data synthesis: Service quality is mainly measured as technical and functional, incorporating
many sub-dimensions. We synthesized the information about dimensions of healthcare service
quality with reference to developed and developing countries. ‘Tangibility’ is found to be the most
common contributing factor whereas ‘SERVQUAL’ as the most commonly used model to measure
healthcare service quality.
Conclusion: There are core dimensions of healthcare service quality that are commonly found in
all models used in current reviewed studies. We found a little difference in these core dimensions
while focusing dimensions in both developed and developing countries, as mostly SERVQUAL is
being used as the basic model to either generate a new one or to add further contextual dimen-
sions. The current study ranked the contributing factors based on their frequency in literature.
Based on these priorities, if factors are addressed irrespective of any context, may lead to contrib-
ute to improve healthcare quality and may provide an important information for evidence-
informed decision-making.

Key words: SERVQUAL, healthcare service quality, dimensions of service quality, quality improvement

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
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 2 Fatima et al.

Introduction patient was the most appropriate to produce the best result that
could be reasonably expected by the patient, and whether those ser-
Service quality has been discussed and defined in literature by studies
vices were delivered with due attention to the doctor/patient rela-
like Parasuraman et al. [1]. Authors proposed service quality as ‘The
tionship.’ Aagja and Garg [19] stated hospital service quality as ‘the
degree and direction of discrepancy between consumer’s perceptions
discrepancy between patient’s or patient’s attendants’ perceptions of
and expectations.’ Cronin and Taylor [2] emphasized on service qual-
services offered by a particular hospital and their expectations about
ity in terms of ‘performance-only measures’ that are based only on
hospitals offering such services.’
consumers’ perceptions of performance of a service provider. These
Focusing on the idea of ‘measuring dimensions of service quality
definitions were broadly accepted, challenged and modified by many
in health care,’ this study attempts to systematically review and sum-
studies in different years with varied contexts. Studies formulated and
marize studies and synthesize evidence focused on the work of the
theorized various models to discuss the concept.
last 20 years.
Amongst them, one of the earlier and basic model describing the
aforementioned concept was of Gronroos [3]. Authors identified
three attributes of service quality named, functional quality, tech- Method
nical quality and image. Silvestro et al. [4] compared, contrasted
Reporting systematic review
and assimilated literature of Total Quality Management (TQM) per-
In order to collect significant information for the determination of
spectives in manufacturing and highlighted service quality to be evi-
hospital service quality dimensions in the literature so far, we have
dently influenced by manufacturing TQM. Influence of such
developed PRISMA statement, flow diagram and checklist. The pro-
participative and continuous organizational process may lead to
cesses involved steps like identification process, screening process,
organizational productivity and growth.
eligibility criteria and then the final selection of articles.
Focusing on generic models for service quality, Parasuraman
et al. [1] suggested a concise model to assess service quality within
an organization named SERVQUAL. This model was the continu- Identification process
ation of a previous model where so far 10 dimensions (Tangibility, Identification process includes selection of records using various
Reliability, Assurance, Responsiveness, Empathy, Communication, database searches and additional records through other sources.
Competence, Credibility, Courtesy and Security) were lessened to 5 Other sources include relevant studies recommended by experts.
dimensions (Tangibility, Reliability, Assurance, Responsiveness and
Empathy) with 97 items in former and 22 items in the later model.
Databases
Haywood-Farmer [5] described an ‘attribute service quality mod-
A systematic search using databases of ‘Google,’ ‘Google Scholar,’
el’ that was comprised of three basic attributes that are professional
‘PubMed,’ Scopus and ‘Social Science Citation Index’ (via Web of
judgment, physical facilities and processes, and behavioral aspects
Science) was carried out. Criterion of time duration selection was
where each attribute consists of several factors. The focus of this
based on the limited knowledge before 1997. Key terms were used
model was the provision of high-quality services as per preferences
for search purposes. Only titles were read and if found relevant,
and expectations consistently.
were included in the list along with search for gray literature and
Brogowicz et al. [6] synthesized a model of service quality focus-
discussion with experts for other sources. No language, publication
ing on three factors like company image, external influences and
type or year restriction was applied.
traditional marketing activities as the ‘attributes’ that effect technical
and functional quality expectations. Mattson [7] developed ‘Ideal
value model of service quality’ and presented ‘Value approach to Search terms/phrases
service quality modeling as an outcome of satisfaction process.’ It We used search terms ‘hospital service quality,’ ‘service quality mod-
focused to negative disconfirmation of customers by suggesting to el development in hospitals’ and ‘service quality assessment using
pay attention to cognitive processes of customer service concepts. patient’s perspective.’ We developed a Boolean search strategy after
Teas [8] suggested ‘Evaluated performance and normal quality consensus between researchers for PubMed incorporating truncated
model’ with the assumption that ‘perceived ability of the product to search terms and potential synonyms (Table 1).
deliver satisfaction can be conceptualized as the product’s relative This search strategy seems to be impractical for other databases.
congruence with the consumer’s ideal product features’. Similarly, In addition to that, for PubMed we applied a more sensitive filter
some other researchers like Dabholkar [9], Spreng and Mackoy that was developed by Terwee et al. [92] to better capture measure-
[10], Philip and Hazlett [11], Sweeney et al. [12], etc. proposed their ment instruments.
model in various service sector organizations. But the model that
has gained much support from researchers is Gap model and
Screening process
SERVQUAL suggested by Parasuraman, Parasuraman and Johnson
PRISMA guidelines were followed for the screening process, where
[1, 13, 14]. Gronroos [3] model has also gained much attention by
search results of databases were checked for duplicates using two
researchers though not to the extent as that of SERVQUAL so far
softwares; Mandalay and EndNote. All duplicates were removed.
[15] but found better in determining customer satisfaction when
Abstracts were read and full-texts were thoroughly studied.
consumers were actively involved in service delivery processes [16].
Similarly, in the particular context of healthcare, Donabedian
[17] defined service quality in hospitals as ‘The abilities to reach the Data extraction eligibility criteria
desired objectives using legitimate means,’ where the desired objec- We developed a standardized excel sheet for data extraction from
tives implied ‘the achievable level of health.’ While medical service selected studies. Eligibility criteria for research type includes either
quality has been argued by Fuentes [18], as ‘a multidimensional con- quantitative, qualitative or mixed methods having all kinds of obser-
cept reflecting a judgment as to whether the service performed for a vational and interventional studies. There was no sample size

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 Dimensions of service quality in healthcare: a systematic review of literature 3

Table 1 Generic search terms with Boolean connectors (with following review questions: ‘which dimensions of healthcare service
truncation) quality are measurable?’ and ‘what are service quality models used
to assess hospital service quality?’
Construct Boolean operator AND AND
Measurement Population Tool
instrument Data analysis
• Service Quality ‘Hospital*’ OR ‘Instrument*’ OR For better comparison of studies, an evidence table was manually
• Patient’s • Department • Tool* generated. The evidence table possesses author name, year, country,
Perspective • Care • Program* respondents, data collection method, sample size, data analysis
• Employee’s • Ward • Model* approach, sampling method and study design, model/tool/instru-
Perspective • Provider • Questionnaire* ment used to assess quality dimensions and finally dimensions of ser-
• Survey* vice quality measured through these models in each study. All
• Measur* dimensions were listed as codes and these codes were categorized
• Assess*
and then themes/patterns were extracted out of these codes followed
• Factor*
by content analysis.
• Compar*
• Method*
• Develop* Selection of articles
In PUBMED, the symbol ‘*’ denotes the preceding word combined with Primarily, basic characteristics of included studies were collected
any letters to follow, e.g. ‘Method*’ reflects ‘Methods,’ ‘Methodology,’ (author and year, country, study design, respondents, survey adminis-
‘Methodologies,’ etc. tration, etc.) based on the data extraction sheet. Secondly, detailed
information on the determination of service quality dimensions, devel-
opment of measurement instruments and their psychometric properties
restriction and no restriction of quality measurement technique or were obtained. These properties were concerned with item generation
model used, however, it was emphasized that they must determine and response scales, thus, testing for psychometric properties (reliabil-
quality dimensions in their respective studies. The development of ity, validity and scoring) and domains of respective instruments.
this sheet was informed by criteria for the assessment of measure-
ment instruments as given below in Sections 2.4.1 and 2.4.2 and by
quality improvement theory. Findings
This study was uncircumscribed to studies adopting specific meth-
odological approach, nor did it confine to only empirical studies.
Inclusion criteria Out of 214, 74 studies extracted reported service quality dimensions
Studies were selected if they complied with each of the following cri- across the globe as presented in Fig. 1. While observing sampling
teria: focusing on measuring dimensions of service quality of health- technique, the largest number of studies were included in ‘Others’
care or hospitals; discussing models/instruments/tools used for category presenting inadequately discussed sampling technique.
measuring service quality in healthcare/hospitals; addressing devel- Convenience sampling was on second and simple random sampling
opment or application of a measurement tool/model/instrument and on third. Sampling techniques used in 74 eligible studies are shown
referring to the hospital setting or healthcare. Only original research in Fig. 2.
papers and case studies were included. We used snowball strategies Figure 3 depicts design of studies used in qualitative synthesis of
to screen reference lists of relevant, eligible studies. After completing study. The category ‘others’ has the highest studies that showed
list of articles with relevant titles from all sources, researchers designs that were not clearly stated, while on second number cross-
removed duplicates. Papers were screened using pre-defined inclu- sectional studies were conducted.
sion and exclusion criteria. We found that 36(48.64%) studies performed factor analysis, 30
(40.54%) studies did descriptive statistics only, while rest of the
Exclusion criteria studies executed regression analysis (10.81%) as shown in Fig. 4.
We excluded studies that did not mention precise sampling tech- Sample size of ≥500 respondents was taken in 14(18.91%) studies
nique adequately, review papers and perspectives that addressed whereas rest of 60(81.1%) studies possess ≤500 as given in Fig. 5.
improvement models not targeted at the healthcare sector, studies Moreover, 61(82.43%) studies collected data via questionnaire
highlighting hospital performance, data on quality outcomes rather as survey tool, 3(4.05%) studies conducted focus groups and 9(12.2
than regarding systems and strategies for measuring quality, quality %) studies performed interviews while the rest of them used direct
and safety studies targeting small individual strategies such as observation and hospital records as presented in Fig. 6.
improving hand hygiene practices as well as studies based on quality In Table 2, we observed most commonly used dimensions and it
measurement strategies that did not assess their implementation was found that reliability and responsiveness were vital contributing
using specific evaluation tools. factors in 44(59.5 %) studies, empathy and assurance has been con-
sidered as a causative factor in 43(58.1 %) studies while tangibility
in 23(31.1%) studies. It is because ‘Tangibility’ is synonymically
Research team used as tangibles in 19(25.7%) studies, physical environment and
The research team was comprised of four researchers (academicians infrastructure in 4(5.4%) studies, respectively, physical appearance
as well as consultants). Two of them collected, selected, analyzed in 01(1.35%) study and physical cure and others in 3(4.05%) stud-
and then classified published articles on measuring service quality in ies. If collectively considering all these tangible associated factors, it
hospitals. The other two investigators resolved identified discrepan- is the highest contributing factor 54(72.9%) to improve the hospital
cies by consensus agreement. We selected research papers using the service quality needed, described in overall 74 studies.

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 4 Fatima et al.

Records identified through database

searching (7,370,000) Additional records identified

Identification
through other sources
Google, Google Scholar, Scopus, PubMed,
Science Citation Index Medline

Duplicates removed
Abstracts Screened
Screening

(n = 1921)

Records Excluded
(n = 1707)

Full text articles assessed for

eligibility (n = 214)
Eligibility

Articles excluded
with reasons = 140
Studies included in qualitative
synthesis (n = 74)
Included

Studies included in quantitative

synthesis (n = 0)

Figure 1 Flow chart identifying, screening and selecting eligible studies for systematic review from January 1997 till December 2016.

60
48
50

40

30

20
12
9
10
2 2 1
0
Simple Stratified Systematic Convenience Purposive Others
Random Random Random Sampling Sampling
Sampling Sampling Sampling

Figure 2 Sampling type of studies used for qualitative synthesis.

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 Dimensions of service quality in healthcare: a systematic review of literature 5

50
45 42

40
35
30 25
25
20
15
10
4
5 2 1
0
Cross sectional Case Studies Case Series Quantitative Others
study Research Designs

Figure 3 Study designs of studies used for qualitative synthesis.

40
36
35
30
30

25

20

15
8
10

0
Descriptive Statistics Regression Factor Analysis

Figure 4 Data analysis approach of studies used for qualitative synthesis.

16
14 14
14 13 13
12
12

10 8

0
0–100 101–200 201–300 301–400 401–500 More than 500

Figure 5 Sample size (no. of respondents) of studies used for qualitative synthesis.

Discussion academics, practitioners, researchers, policy makers and decision

makers to assess service quality within an organization [93]. ‘Many
Service quality models applied in hospitals
scholars used already developed RATER model’ while some other
Healthcare services are unique in identifying new challenges.
researchers used ‘Parasuraman’s Gap model’ in their studies to
Concentrating on these challenges proactively have engaged
measure service quality in hospitals as shown in Table 3.

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 6 Fatima et al.

70
61
60

50

40

30

20
9
10 3 1 1
0
Questionnaire Focus Group Interview Direct Hospital Record
Observation

Figure 6 Data collection METHOD of studies used for qualitative synthesis.

Table 2 Year-wise systematic search of eligible articles [57]; Shemwell and Yavas [87] ‘developed new models with new
attributes’ as shown in Table 4.
Year Total articles Matched articles Discarded Lee and Kim [94] developed a model using structural
searched with terms/keywords articles equation modeling to assess healthcare service quality named
HEALTHQUAL and identified empathy, tangible, safety, efficiency
2016 162 19 144
2015 360 42 318
and improvements of care service and shed new discernments about
2014 188 34 154 their relative importance. They compared type of patient treatment
2013 182 35 147 (inpatients, outpatients and emergency room) in both patients and
2012 142 17 125 the general public in order to improve hospital service quality and
2011 126 11 115 operational efficiency [101]. This model is considered using patient’s
2010 102 07 95 perspective, employee’s perspective and the accreditation institu-
2009 80 03 77 tion’s perspective. We assume that study could not be generalized as
2008 80 08 72 it was limited to one hospital only and more research is needed to
2007 70 05 65
validate the model in a number of hospitals with varied sectors and
2006 68 03 65
cultures. The model also lacks predictive validity test for certain
2005 54 06 48
2004 62 03 59
constructs.
2003 62 02 60 Bediwan and Efendi [95] employed a qualitative approach in
2002 52 02 50 order to contribute new dimensions in literature of service quality.
2001 42 06 36 They found responsiveness, value, technical, access, interpersonal,
2000 36 04 32 tangibles and outcome. These dimensions need to be empirically val-
1999 27 01 26 idated. Findings of model were different from that of typical model
1998 16 03 13 introduced by Parasuraman et al. [1, 13]. We feel that by customiz-
1997 9 03 06 ing this service quality model to necessities and uniqueness of hos-
Total 1921 214 1707
pital service may enrich the hospital service quality literature.
Sumaedi et al. [96] hypothesized a multilevel healthcare service
quality model in Jakarta and identified three primary dimensions:
named healthcare service outcome, healthcare service interaction and
Some of the researchers argued that ‘RATER model have some healthcare service environment. First, two dimensions possess three
serious problems’ like ‘factors that did not load on their respective sub-dimensions each, i.e. waiting time, medicine and effectiveness and
dimensions,’ [85] ‘five component scale structure was not supported soft interaction, medical personnel expertise, hard interaction, respect-
[97, 64] five factor model has a poor fit’ [98, 99]. Therefore, research- ively, while the last dimension possess two sub-dimensions: equipment
ers such as Nadi et al [20] added ‘physical appearance,’ Yamoah condition and ambient condition. This model proved to be stable veri-
et al. [66] supplemented ‘affordability,’ Untachai and Zarei et al. fied against respondents’ gender, age and income.
[28, 42] both appended ‘cost,’ Kara et al. [62] proposed ‘courtesy,’ Untachai [42] proposed a second-order factor model for hospi-
Jabnoun et al. [63] put ‘administrative responsiveness and supporting tals in Thailand. In this study, authors argued service quality to be
skills,’ Andaleeb et al. [50] added ‘communication and bakhsheesh’ one-dimensional construct because it has direct causal influence on
Tucker et al. [100] introduced ‘caring,’ ‘communication’ and ‘out- five attributes reliability, cost, tangible, empathy and response. The
come’ while Cheng et al. [55] augmented new dimensions like ‘access- model operationalized these five latent variables by 17 manifest vari-
ibility and affordability,’ respectively, to SERVQUAL. ables acting as reflective indicators. This determined that patients
Other researchers such as Lee and Kim [94]; Budiwan and assess hospital service quality with five basic dimensions but they
Efendi [95]; Sumaedi et al. [96]; Untachai [42]; Rakhmawati et al. view overall service quality as a higher-order factor that appre-
[41]; Aagja and Garg [34]; Chahal and Kumari [35]; Dagger et al. hended implication mutual to all dimensions.

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 Table 3 Summary of selected studies on measuring hospital service quality

Dimensions of service quality in healthcare: a systematic review of literature

Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

South Asia
Nadi et al. [20] Iran Patients Questionnaire 600 Descriptive Statistics Simple Random Sampling Empathy, Physical Appearance,
Responsiveness, Assurance
and Reliability
Jandavath&Byram (Chennai) Inpatients Questionnaire 493/500 CFA Systematic random Assurance, Tangibility,
[21] India sampling Reliability, Responsiveness,
Empathy
Mallikarjuna [22] Mandya Patients Interviews/ hospital 60/80 Descriptive statistics, Non-probability sampling Tangibles, Reliability,
record ANOVA (Convenience Responsiveness, Assurance,
sampling) Empathy
Pouragha&Zarei Iran Outpatients Questionnaire 500 Descriptive statistics/ Cross sectional/ Accessibility, Appointment,
[23] Pearson’s correlation/ Systematic random Perceived waiting time,
multivariate regression method Admission process, Physical
method environment, Physician
consultation, Information to
patient, Perceived cost of
services
Marzban et al. [24] Iran Outpatient Questionnaire 211/260 T-test, Paired t-test, Cross sectional Tangible factors, Assurance,
Friedman test Responsiveness, Empathy, and
Reliability
Aghamolaei et al. Iran Patients Questionnaire 96 Wilcoxon and Kruskal- Multistage cluster Assurance, Tangibility,
[25] Wallis tests sampling method/cross Reliability, Responsiveness,
sectional study Empathy
Ajam et al. [26] Iran In door patients Questionnaire 100 Descriptive statistics and Simple random sampling Assurance, Tangibility,
two-sample t, Pearson Reliability, Responsiveness,
correlation and Empathy
ANOVA tests
Kazemi et al. [27] Tehran, Iran In patients Questionnaire 190/250 EFA, CFA, SEM Quantitative survey Assurance, Tangibility,
research design Reliability, Responsiveness,
Empathy
Zarei et al. [28] Iran Patients Questionnaire 983 Descriptive statistics Cross sectional study Tangibility, Reliability,
Responsiveness, assurance,
courtesy and empathy.
Irfan et al. [29] Pakistan Patients Questionnaire 369/500 SEM Convenience sampling Assurance, Tangibility,
Reliability, Responsiveness,
Empathy
Kumar et al. [30] Mysore, Patients Questionnaire 185 one sample t test and Simple random sampling Tangibles, Reliability,
Karnataka, regression analysis Responsiveness, Assurance,
India Empathy
Mekoth et al. [31] India Patients Interview 209 EFA & Regression Not Provided physician quality, clinical staff
analysis quality, nonclinical staff
quality, and waiting time

Table continued

7
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 Table 3 Continued

8
Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

Chakravarty, [32] Pune Bed peripheral, Questionnaire 99 Descriptive analysis Cross sectional study Assurance, Tangibility,
OPD patients Reliability, Responsiveness,
Empathy
Senarat & Sri Lanka Patients Interview 120 CFA Cross sectional study interpersonal aspects, efficiency,
Gunawardena [33] competency, comfort, physical
environment, cleanliness,
personalized information, and
general instructions

South Asia
Aagja & Garg [34] India Patients or their Questionnaire 200 CFA Convenience sampling Admission, medical service,
attendants method overall service, discharge
process, and social
responsibility.
Chahal&Kumari India Indoor patients Questionnaire 400 CFA, Proportionate-stratified Physical environment quality,
[35] random sampling Interaction quality, Outcome
quality
Narang [36] India Patients Self-administered 500 EFA Cross sectional Health personnel and practices,
Questionnaire health care delivery, Human
personnel practices and
conduct, Adequacy of
resources and services
Nekoei-moghadam Iran Patients Questionnaire 385 Descriptive statistics, Cross sectional Tangibles, Reliability,
& Amiresmaili [37] Paired T-test Responsiveness, Assurance,
Empathy
Akter et al. [38] Bangladesh Patients Mailed questionnaire 100 Gap Analysis, one sample Convenience sampling Responsiveness, Assurance,
t-test Communication, Discipline,
Bakhsheesh
Hensen et al. [39] Afghanistan Patients Direct observation, Exit 11 316 Descriptive Analysis Quantitative survey Cleanliness, staff courteous and
Interview research design respectful, skills and abilities
of health workers, explaining
the illness while doing their
job, Explanation of treatment,
Availability of medicine
prescribed Cost of visit,
Privacy
Duggirala et al. India patients mail questionnaire 100 CFA Cross sectional Infrastructure, personal quality,
[40] process of clinical care,
administrative processes,
safety indicators, over all

Fatima et al.
experience of medical care,
social responsibility

Table continued

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 Table 3 Continued

Dimensions of service quality in healthcare: a systematic review of literature

Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

East Asia
Rakhmawati et al. Indonesia Patients Questionnaire 800 Factor analysis Convenience sampling/ The quality of healthcare
[41] cross-sectional study delivery, The quality of
healthcare personnel, The
adequacy of healthcare
resources, The quality of
administration process
Untachai [42] Thailand Patients Questionnaire 445 EFA, CFA Cross sectional, random Response, Empathy, Cost/
sampling Assurance, Reliability,
Tangible
Yousapronpaiboon Thailand Out Patients Questionnaire 400 CFA Cross sectional Tangibility, Reliability,
& Johnson [43] Responsiveness, Assurance,
Empathy
Kim & Han [44] Daejon, Korea Hospital employees Questionnaire 198/230 Multivariate ordinary Convenience sampling Assurance, Tangibility,
least squares regression Reliability, Responsiveness,
Analysis Empathy
Butt & Run [45] Malaysia Patients Questionnaire 340/400 means, correlations, Random sampling Tangibility, Reliability, Empathy,
principal component Responsiveness, Assurance,
and CFA
Laroche et al. [46] South Korea Out patients Questionnaire, focus 557/600/3 CFA Case study Physician concern, Staff concern,
group interviews Convenience of care process,
Tangibles
Lin et al. [47] Taiwan Patients Questionnaire 1250 Regression Analysis Self-administered, Cross Tangibles, Reliability,
sectional survey Responsiveness, Assurance,
Empathy

South Asia
Rohini & India Patients Self-administered 500 EFA, ANOVA Stratified random Tangibles, Reliability,
Mahadevappa [48] Questionnaire sampling Responsiveness, Assurance,
Empathy
Rao et al. [49] India Patients Interview 2480 EFA Convenience Sampling Medicine availability, Medical
information, Staff behavior,
Doctor behavior, Clinic
infrastructure
Andleeb [50] Bangladesh Residents of Dhaka Interviews, Survey 300, 207/216 multivariate and Random sample, stage- Responsiveness, Assurance,
City who had questionnaire univariate ANOVA wise area sampling was Communication, Discipline,
utilized hospital combined with Bakhsheesh
services in the Systematic sampling.
past 12 months.
East Asia
Li et al. [51] China Patients Questionnaire 3071/3201 Factor analysis, one way Cross sectional Assurance, Tangibility,
ANOVA and Reliability, Responsiveness,
Regression Empathy

Table continued

9
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 10
Table 3 Continued

Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

Handayani et al. Indonesia Management Interviews and 23 high level Entropy method Qualitative and Human resources, process, policy
[52] officers, questionnaire management quantitative study and infrastructure.
academicians and officers, 2
patients academician of
public health
and computer,
297 patients

East Asia
Rose et al. [53] Malaysia Patients Questionnaire, interview 493, 20 Factor analysis, Multiple Convenient Sampling Social support, Patient
Regression education, Technical,
Interpersonal, Amenities
/Environment, Access/waiting
time, Cost, Outcomes, Overall
quality
Sohail [54] Malaysia Patients Mailed to respondents 150/1000 EFA, CFA Not Provided Tangibles, Reliability,
Responsiveness, Assurance,
Empathy
Lim & Tang [55] Singapore Patients Questionnaire 252/300 Reliability tests Convenience sampling Tangibles, Reliability,
Responsiveness, Assurance,
Empathy, Accessibility and
affordability
Lam [56] Hong Kong Patients Questionnaire 82/84 Factor Analysis Not Provided Assurance, Tangibility,
Reliability, Responsiveness,
Empathy
South East Asia
Dagger et al. [57] Australia Patients Focus group, mail 1333 EFA, CFA Cross-sectional Interpersonal quality, technical
questionnaire quality, environment quality,
administration quality
Western Asia
Al Fraihi & Latif Saudi Arabia Outpatients Questionnaire 306 CFA, one way analysis of Cross sectional Assurance, Tangibility,
[58] (Dhahran) variance test. descriptive study/ Reliability, Responsiveness,
convenience sampling Empathy
technique
Zaim et al. [59] Turkey Patients Questionnaire 265/400 Factor analysis, logistic Not Provided Tangibility, reliability,
regression model Responsiveness, assurance,
courtesy, and empathy.

Western Asia
Bakar et al. [60] Turkey Inpatient/out Questionnaire 472/550 Student t-test, the Mann- Random sampling Tangibility, Reliability, Empathy,

Fatima et al.
patient Whitney U-test, and Responsiveness, Assurance,
Pearson’s correlation

Table continued

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 Table 3 Continued

Dimensions of service quality in healthcare: a systematic review of literature

Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

Taner & Antony Turkey Out patients Questionnaire 200 Descriptive statistics Not Provided Tangibility, Reliability,
[61] Responsiveness, Competence,
Credibility, Security, Access,
Communication, Cost,
Understanding
Kara et al. [62] Turkey Patients Questionnaire 139 EFA, SEM Quantitative survey Tangibility, Reliability,
research design Responsiveness, Assurance,
Courtesy, Empathy
Jabnoun&Chaker UAE Inpatients Questionnaire 205/400 Factor analysis Random Selection Empathy, Tangibles, Reliability,
[63] Administrative responsiveness
and Supporting skills
North Africa
Mostafa [64] Egypt Patients Questionnaire 332 patients from Factor analysis Cross sectional survey Human performance quality,
12 hospitals human reliability, facility
quality
West Africa
Amole et al. [65] Nigeria Patients Questionnaire 326/420 Test of Consistency Purposive sampling Staff communication and
technique reliability, Assurance, Output
quality, Hospital environment
Mensah et al. [66] Ghana Outpatients Questionnaire 400 EFA and multiple Cross sectional survey Tangibles, Reliability,
regressions Responsiveness, Assurance,
Empathy and Affordability
Baltussen et al. [67] Burkina Faso Patients Questionnaire 1081 EFA Not Provided Health personnel practices and
conduct, Adequacy of
resources and services, Health
care delivery, Financial and
physical accessibility of care

South Africa
Fowdar et al. [68] Mauritius Patients Questionnaire 257/750 Factor and reliability Cross-sectional Tangibility/image, Reliability/
analysis quantitative research, fair and equitable treatment,
Convenience sampling Responsiveness, Assurance/
empathy, Core medical
services/ professionalism/skill/
competence, Equipment and
records, Records of medical
history
Jager&pooly [69] Pretoria, In- and out-patients Interview 583 non-parametric test Random Selection Assurance, Tangibility,
South Reliability, Responsiveness,
Africa Empathy
South America
Rosha et al. [70] Brazil Postoperative Questionnaire 116 Wilcoxon test & Shapiro- Cross sectional,
patients Wilk test. observational study

Table continued

11
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 Table 3 Continued

12
Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

Interpersonal quality, technical

quality, environment quality,
administration quality
European Union
Purcarea et al. [71] Romania Female patients Questionnaire 208/1000 Factor analysis Cross sectional Tangibles, Reliability,
Responsiveness, Assurance,
Empathy
Raftopoulos [72] Greece Patients Questionnaire 212 Pearson correlation Cross sectional study Nurse’s technical and
coefficient, chi-squared interpersonal Competence,
test, t-test Physician’s interpersonal
competence, Physician’s
technical competence,
Structure characteristics
Karassavidou et al. North Greece Patients Questionnaire 137 EFA Cross sectional Human aspect, Physical
[73] environment and
infrastructure, Access
Raposo et al. [74] Portugal Patients Self-administered 414 CFA Partial Least Squares path Staff, Facilities, Medical care,
Questionnaire modelling (PLS) Nursing care

Arasali et al. [75] Cyprus Family members self-administered 454/650 EFA judgmental sampling or empathy, giving priority to the
who have questionnaire respondents purposive sampling inpatients needs, relationships
benefitted from between staff and patients,
healthcare professionalism of staff, food
facilities within 2 and the physical environment
years
Fuentes [76] Spain Patients Self-administrated 170 Factor Analysis Cross sectional Tangibles, delivered services
questionnaire relating, process of
performance
Angelopoulou et al. Greece Patients Telephonic interview 40 (20 from each Paired t-test Convenience sampling Professional competence and
[77] sector) interpersonal skills for both
physicians and nurses, cost of
medical care, surroundings
(temperature, noise,
decoration), quality of food
and administrative services
offered
Vandamme & Belgium Patients Questionnaire 70 EFA Not Provided Tangibles, Medical
Leunis [78] responsiveness, Assurance-1,
Assurance-II, Nursing staff,
Personal beliefs and values

Fatima et al.
Table continued

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 Table 3 Continued

Dimensions of service quality in healthcare: a systematic review of literature

Author name/Year Country Respondents Data collection tool Sample size Data analysis approach Sampling method/study Dimensions Identified
design

United Kingdom
Wisniewski [79] Scotland Patients Questionnaire 51 Descriptive statistics Not Provided Tangibility, Reliability,
responsiveness, Assurance,
Empathy
Kilbourne et al. UK & USA Nursing home Questionnaire 195 SEM, CFA Cross sectional Tangibles, Reliability,
[80] residents (147 Responsiveness and Empathy
females and 48 factors
males)
Curry & Stark [81] UK Nursing home Postal self-administered 153/257 Descriptive analysis Case study Assurance, Tangibility,
residents questionnaire Reliability, Responsiveness,
Empathy
Tomes & Ng [82] UK Patients Questionnaire 128 EFA Not Provided Empathy, Relationship of mutual
respect, Dignity,
Understanding of illness,
Religious needs, Food,
Physical environment
Youssef et al. [83] UK Patients Questionnaire 174 Descriptive statistics Not Provided Tangibles, Reliability,
Responsiveness, Assurance,
Empathy
Gabott & Hogg UK Patients Mail questionnaire 2000 EFA Cross-sectional Range of services, Empathy,
[84] Physical Access, Doctor
specific, Situational,
responsiveness
Other Europe
Lee [85] Ukraine People who got Questionnaire 214/218 Factor Analysis Not Provided Support from hospital,
treatment Reliability and Assurance,
Responsiveness and Empathy
USA
Sower et al. [86] USA Patients Focus group, Multiple, 663 EFA Not Provided Respect and caring, Effectiveness
Questionnaire and continuity,
Appropriateness, Information,
Efficiency, Effectiveness-meals,
First impression, Staff diversity
Shemwell & Yavas USA Patients Questionnaire 218 CFA Not Provided Search attributes, Credence
[87] attributes, Experience
attributes
Zifko-Baliga & US Patients Questionnaire 529 EFA Not Provided Professional expertise, Validation
Krampf [88] of patient belief, Interactive
communication, Image,
Antithetical performance,
Interactive caring, Professional

Table continued

13
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 14 Fatima et al.

Physical cure, Emotional cure,

reliability, Perspicacity, Skills,
Rakhmawati et al. [41] developed public health center service

Amenities, Billing procedure

Reliability, Responsiveness,

Reliability, Responsiveness,
Responsiveness, Assurance,

Responsiveness, Assurance,
quality model in Indonesia with 24 indicators having 4 dimensions

efficiency, Individualized
that are ‘the quality of healthcare delivery, the quality of administra-

Assurance, Tangibility,

Assurance, Tangibility,
Tangibles, Reliability,

Tangibles, Reliability,
Dimensions Identified
tion process, the quality of healthcare personnel and the adequacy
of health care resources.’ The model met the criteria of discriminant
and convergent validity. The research was conducted in public
health centers only leaving room for implication of findings to pri-

Empathy

Empathy

Empathy

Empathy
vate sector health centers. Therefore, in order to generalize model
better sampling method and study design-based study is required for
future perspectives.
Chahal and Kumari [35] developed modified hierarchical
Sampling method/study

approach model introducing three primary dimensions: interaction

quality, physical environment quality and outcome quality. Authors

Random sampling
announced their significant relationship with four service perform-
Factor Analysis
Not Provided

ance measures that include waiting time, patient satisfaction, patient

Pilot study

loyalty and image. The model depicted high degree of convergent

design

validity, content validity and discriminant validity. The model is

restricted to a government hospital only, therefore, possesses the
limitation to be generalized in private sector hospitals. As this study
was conceptualized in a developing country, therefore, it is needed
Data analysis approach

to be empirically tested in developed countries as well.

Aagja and Garg [34] developed a scale termed as public hospital
Two-tailed t-test /

Factor Analysis

service quality (PubHosQual) with five dimensions named ‘admis-

sion, medical service, overall service, discharge process and
ANOVA

EFA, CFA

social responsibility.’ This diagnostic tool possesses dimensions of

SEM

SERVQUAL and some other dimensions that varied from the

SERVQUAL ones. Author compared reliabilities and validities of
both scales and found 0.72–0.86 and 0.58–0.89, respectively. The
study concentrated on only one multi-specialty public hospital in
Study 2–227
Study 1–116

developing countries like India where area catchment of the popula-

Sample size

tion was predominantly from lower-middle to middle-income social

147/200

346/966

class. Therefore, developed instrument can be tested for validity in

443

varied cultural contexts.

Lee [102] has studied SERVQUAL conceptualization to measure
hospital service quality in developing countries and suggested four
Mailed questionnaire/

factors solution. The major contributing factors to evaluate service

Data collection tool

quality include ‘modern facilities,’ ‘being able to trust doctors,’

Postal survey

‘employees getting adequate support from the hospital,’ ‘willingness

Questionnaire

Questionnaire

Questionnaire

to help patients’ and ‘being dependable.’ The stability of those fac-

tors is evidenced by scale’s reliability. The author criticized
SERVQUAL due to lack of contextual stability.
A hierarchical model of health service quality was suggested by
Dagger et al. [57], for determining health service quality. A qualita-
tive study was conducted in two different healthcare contexts: oncol-
ogy clinics and a general medical practice with three diverse field
Respondents

studies of healthcare patients. In this study, authors found nine sub-

Patients

Patients

Patients

Patients

dimensions that were introduced from four primary dimensions.

The primary dimensions were interpersonal quality, technical qual-
ity, environmental quality and administrative quality. The sub-
dimensions included interaction, operation, expertise, atmosphere,
relationship, outcome, tangibles, timeliness and support. The study
Country

also explained the impact of service quality on service satisfaction

USA

USA

USA

and behavioral intentions.

US

Shemwell and Yavas [87] developed a scale using second-order

confirmatory factor analysis using sector-specific conceptualization
McAlexander et al.
Author name/Year
Table 3 Continued

Taylor & Cronin

of hospital service quality. This model provides two concrete bene-

Mangold [91]

fits of problem analysis at the abstract level and then its conceptual-
Zwelling [89]
Anderson &

Babakus &

ization to provide strategic direction for problem-solving. We feel

that the information obtained from the scale might be useful at indi-
[90]

vidual attribute level, that means management or consultant may

[2]

identify an area of problem-solving at the individual question.

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 Dimensions of service quality in healthcare: a systematic review of literature 15

Table 4 Evidence from literature about service quality dimensions Mekoth et al. [31], Aagja and Garg [34], Chahal and Kumari [35],
with or without SERVQUAL Narang [36], Duggirala et al. [40] in India.
Pouragha and Zarei [23] determined accessibility, appointment,
Research variables Typologies in literature
perceived waiting time, admission process, physical environment,
Studies that used SERVQUAL to Al Farihi and Latif [58]; Amole physician consultation, information to patient, perceived cost of ser-
measure healthcare service et al. [65]; Li et al. [51]; vices as dimensions of hospital service quality. Mekoth et al. [31]
quality Marzban et al. [24]; Aghamolaei identified physician quality, clinical staff quality, non-clinical staff
et al. [25]; Mensah et al. [66]; quality and waiting time as new dimensions for hospital service
Kazemi et al. [27]; Purcarea et al. quality. Aagja and Garg [34] suggested admission, medical service,
[71]; Kumar et al. [30]; Irfan
overall service, discharge process and social responsibility as deter-
et al. [29]; Yousapronpaiboon
minants of service quality in hospitals.
and Johnson, [43]; Zarei et al.
Chahal and Kumari [35] used structural equation modeling and
[28]; Butt and Run [45]; Fowdar
et al. [32]; Jager and Pooly [69]; suggested physical environment quality, Interaction quality and out-
Taner and Antony [61]; Mostafa come quality as attributes of hospital service quality. This study
[64]; Curry and Sinclair [68]; unveils the fact that interaction quality is more significant than atti-
Lam [56]; Anderson and tude, behavior and process quality. All dimensions identified collect-
Zwelling [81]; Babakus and ively put way forward for the patient satisfaction and loyalty. These
Mangold [91] dimensions being tactical, short-run oriented and radically altered
Studies that added dimensions in Nadi et al. [20]; Kim and Han [44]; can be turned into reality with existing financial resources. Narang
SERVQUAL Baker et al. [60]; Arasali et al.
[36] determined health personnel and practices, healthcare delivery,
[75]; Lee [85]; Jabnoun and
human personnel practices and conduct, adequacy of resources and
Chaker [63]; Andleeb [50]; Lim
services as factors for hospital service quality. The study brings into
and Tang [55]
Studies that calculated perception Mallikarjuna [22]; Aghamolaei consideration a patient’s opinions necessary for effective and incre-
minus expectation score (quality et al. [26]; Purcarea et al. [72]; mental change, improvement in healthcare processes, systems and
gap) using SERVQUAL Chakravarty [32]; Butt and Run overall organization. Moreover, study draws attention of policy
[46]; Curry and Sinclair [69]; makers and healthcare providers towards immediate and urgent
Lim and Tang [56]; Lam [57] response to the measured perceived service quality for improving
healthcare services. Infrastructure, personal quality, process of clin-
ical care, administrative processes, safety indicators, overall experi-
Hospital service quality dimensions in varied nations ence of medical care, social responsibility are conceptualized as
Perception-based service quality is highly culture-centric. Studies determinants of hospital service quality by Duggirala et al. [40].
conceptualized in western culture do not reveal patient’s beliefs,
thoughts and self-concepts as that of in Asian culture. These con-
cepts are extremely important in the assimilation of a patient’s
Service quality dimensions in developed countries
experience of illness and expectations, and perceptions of accessible
As described in Table 5, in developed nations like European coun-
healthcare services. Self-believes can enormously affect the quality of
tries including the USA, UK and EU, Australia or China, mostly
physician–patient relationship and of medical visit too.
researchers adopted the SERVQUAL model but a few like
Studies such as Donthu and Yoo [103] reported that highly col-
Vandamme and Leunis [78] from Belgium reported tangibles, med-
lectivist and power distant countries exhibit low level of service
ical responsiveness, Assurance-1, Assurance-II, nursing staff, per-
quality expectations. They pointed that short-term oriented culture
sonal beliefs and values, Arasali et al. [75] in Cyprus determined
demanded low service quality in comparison to long-term oriented
empathy, giving priority to inpatient needs, relationship between
counterparts and cultures of developing nations like India where ser-
staff and patients, professionalism of staff, food and physical
vice quality exhibit cost as differentiating strategy.
environment.
Service quality being an elusive construct in nature possesses
Raftopoulos [72], Karassavidou et al. [73] and Angelopoulou et al.
challenges related to its measurement for both academicians and
[77] though being from Greece yet identified varied dimensions that
practitioners while focusing on diversified cultures. The dimensions
include professional competence and interpersonal skills for both physi-
that seem to be valid or applicable in one country may not be
cians and nurses, cost of medical care, surroundings (temperature,
applicable to service context of another [104]. The number of ser-
noise, decoration), quality of food and administrative services offered;
vice quality dimensions depends on the type of services being offered
human aspect, physical environment and infrastructure, access; and
within the facility [105]. Therefore, various researchers studied hos-
nurse’s technical and interpersonal competence, physician’s interper-
pital service quality in both developing and developed nations and
sonal competence, physician’s technical competence and structure char-
suggested varied dimensions as given below.
acteristics respectively. Raposo et al. [74] from Portugal proposed staff,
facilities, medical care, nursing care using Partial Least Squares (PLS)
path modeling.
Service quality dimensions in developing countries Gabott and Hogg [84] using highest respondents of survey
Across the globe, studies on hospital service quality as given in reported range of services, empathy, physical access, doctor specific,
Table 2 determined various attributes to bring change in hospital situational, responsiveness as dimensions of service quality in the
services. Majority of researchers in developing nations like Iran, UK but Tomes and Ng [82] identified empathy, relationship of
Pakistan, Bangladesh, India, etc. have exploited already developed mutual respect, dignity, understanding of illness, religious needs,
scale and its dimensions except Pouragha and Zarei [23] in Iran, food and physical environment despite sharing the same culture.

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 16 Fatima et al.

Table 5 Service quality models for hospitals used in eligible articles

Author and year Model Respondents/test Scale used Measurement of service quality addressed
audience through

Lee and Kim [93] HEALTHQUAL 368 Patients and 389 Factor analysis Empathy, Tangibles, Safety, Efficiency and
public respondents Degree of improvements in care service
Budiwan and Hospital Service Quality 15 Informants, Recorded, transcribed Technical, Interpersonal, Tangibles, Access
Efendi [94] indepth interviews and then analyzed and Responsiveness, Value and Outcomes
Sumaedi et al. [95] Healthcare Service 154 Respondents Factor analysis Healthcare Service Outcome, Healthcare
Quality Service Environment, Healthcare Service
Interaction
Rakhmawati Service quality model 800/Patients Factor analysis Quality of healthcare delivery, Quality of
et al. [41] for PHC healthcare personnel, Adequacy of
healthcare resources and Quality of
administration process
Untachai [42] Second-order factor 445 Respondents Factor analysis Reliability, Tangible, Response, Cost and
structure Model Empathy
Aagja and Garg PubHosQual 201 Respondents Factor analysis Admission, Medical service, Overall service,
[34] Discharge, Social responsibility
Chahal and Kumari Health Care Service 400 In-door patients Regression analysis Physical environment quality, Interaction
[35] Quality quality, Outcome quality
Dagger et al. [57] Model of Health Service 28 Participants, 7 per Qualitative analysis Interpersonal quality, Technical quality,
Quality focus group from Environment quality and Administrative
clinics quality
Shemwell and Hospital SQ model 218/300, Patients Factor analysis Search, Credence, Experience
Yavas [87]

Shemwell and Yavas [87], Sower et al. [86] and Zifko-Baliga
and Krampf [88] also shared the same US culture but suggested var-
ied dimensions like search attributes, credence attributes and experi-
ence attributes; respect and caring, effectiveness and continuity,
appropriateness, information, efficiency, meals, first impression, staff
diversity and professional expertise, validation of patient belief,
interactive communication, image, antithetical performance, inter-
active caring, professional efficiency, individualized reliability, per-
spicacity, skills, physical cure, emotional cure, amenities and billing
procedure.
This systematic search of literature of developed and developing
countries combined evidence and analyzed the diversity in dimen-
sions found in their work. Contextual elements encouraged
researchers of these studies to develop their own tools or to modify
the existing ones by adding dimensions and sub-dimensions import-
ant in their socio-demographic, cultural and geo-political context.
We found a range of dimensions from most used to least used and
this diversity can be utilized for further research.
This study has the advantage of being able to review articles
based on hospital service quality using PRISMA guidelines to bring
out an overview of quality articles. PRISMA has been proved as
instrumental for both qualitative and quantitative synthesis of
reviews, but the current review is focused on qualitative synthesis
only. After searching multiple times, we suggest that the current
study is the first systematic review on the stated topic using
PRISMA guidelines with qualitative synthesis. A future research is in
need to map out a frame for section assessment as well as to classify
articles into certain categories according to individuals’ quality and
also conduct quantitative synthesis using meta-analysis.
One of limitations of this review includes inaccessibility of few
databases in Pakistan and in Universities where the researchers
worked, like, CINHAL, EBSCO and EMBASE. For some papers, we
could find the abstract or title but not full text and some were in dif-
ferent languages. Time frames like one from 1997 to 2016 also
could be a limitation as 2017 was not included and neither was any
data prior to 1997. Though we assume that before 1997, a discrete
knowledge had been available focused on hospital service quality
dimensions and some studies are not immediately open access avail-
able if published in 2017–2018 year.
Recommendations emerged after this review includes the need of
hospital service quality measuring contextual dimensions reported in
literature. Such as tangibility, that is found to be one of the import-
ant contributing factors amongst all studies. Therefore, if it is appro-
priately assessed and addressed in hospitals, they probably be able
to ensure better and much improved services to their stakeholders
especially consumers.
Conclusion
Evidence synthesized from this review concludes that SERVQUAL is
the most commonly used model for healthcare service quality meas-
urement along with the limited use of other models. Healthcare
quality is found to be multidimensional with many different sub-
dimensions added in different studies based on their specific context-
ual need. Similarly, SERVQUAL is also the most common model
used in assessing hospital service quality in developing countries.
This comprehensive review will guide both managers and research-
ers in adopting measurement tools and techniques/models for their
context looking through a broader framework. In addition to that,
current findings encourage further exploration and addition of con-
textual dimensions of service quality in changing scenarios of health-
care delivery in developing countries.
Acknowledgements
Authors are thankful of Higher Education Commission, Pakistan for Funding
PhD project of First Author, during which period this review had been
conducted.

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 Dimensions of service quality in healthcare: a systematic review of literature
Conflict of Interest
Dr U.I. is the Editor of IJQHC.
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