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The 1st Workshop on Environmental Science, Society, and Technology IOP Publishing
Journal of Physics: Conference Series 1363 (2019) 012095 doi:10.1088/1742-6596/1363/1/012095
Service Quality Improvement by Using the Quality

Function Deployment (QFD) Method at the Government
General Hospital
Abdurrozzaq Hasibuan1*, Luthfi Parinduri1, Oris Krianto Sulaiman1,

Abdul Rahman Suleman2, Adek Khadijatul Z Harahap2, Masnilam
Hasibuan2, Frits Gerit John Rupilele3, Janner Simarmata4, Nuning
Kurniasih5, Achmad Daengs GS6 and Abdussakir7
1
Faculty of Engineering, Universitas Islam Sumatera Utara, Medan, Indonesia
2
Faculty of Computer Science, Universitas Victory Sorong, Sorong, Indonesia
3
Faculty of Economic, Universitas Graha Nusantara Padangsidimpuan, Indonesia
4
Universitas Negeri Medan, Medan, Indonesia
5
Faculty of Communication Sciences, Library and Information Science Program,
Universitas Padjadjaran, Bandung, Indonesia
6
Faculty of Economic, Universitas 45 Surabaya, Surabaya, Indonesia
7
Faculty of Science and Technology, Universitas Islam Negeri Maulana Malik
Ibrahim, Malang, Indonesia
*rozzaq@uisu.ac.id
Abstract. In the face of increasingly competitive competition in the hospital industry,

RSU managers are required to be able to develop strategies, policies or new
breakthroughs related to improving the quality of their services, through improving the
characteristics of hospital services, which focus on patient needs, so that the risk of
errors or discrepancies between service characteristics that are enhanced by what the
patient wants can be avoided or minimized. From the results of research conducted there
are 21 variables of patient needs from a health service at the Government General
Hospital (RSU). Whereas the patient's research on the service quality of the
Government Hospital is 1 variable that has fulfilled the needs of patients, namely that
they are satisfied with the quality of hospital services. Variable is the state and
completeness of modern medical facilities. Whereas for other variables there are gaps so
that they cannot meet patient expectations until the highest quality limit is very
satisfied, it is necessary to have a direction of improvement. To obtain the suitability,
the technique used to improve the characteristics of the service is the application of the
QFD method. The QFD method in this study is in the form of a quality service matrix at
the Government General Hospital.From the HOQ matrix, the service quality of the
Government Hospital is obtained from the input of the Government
Hospital/management that there are priority variables needed to improve their quality,
which is generally the patient's needs related to the recovery of patients, including the
knowledge and abilities of doctors, medicines the treatment given in the healing of
patients, the service of examination, treatment and care that is fast and precise,
guarantee of security and trust in the services provided and the completeness of the
readiness and cleanliness of the equipment used. So there are 33 service quality
characteristics prioritized for further improvement, with the main priority being patient
recovery
Content from this work may be used under the terms of the Creative Commons Attribution 3.0 licence. Any further distribution
of this work must maintain attribution to the author(s) and the title of the work, journal citation and DOI.
Published under licence by IOP Publishing Ltd 1
1. Introduction
The hospital is one type of industry that moves in the service sector. The offer provided consists
of a principal service accompanied by additional (complementary) services or supporting items.
In this category, the main offer is service, but during processing time, the service is related to
physical elements, such as food, drinks, facilities provided and so on.
With increasing public awareness of the importance of health problems, the services
provided by the hospital have received serious attention from the community and related
government agencies. The level of health of the population in a country reflects the country's
progress and prosperity. Therefore, the quality of services provided by a hospital as one of the
service industries engaged in health, should receive serious attention from consumers.
Consumers in this case are patients, who are critical enough to assess the quality of hospital
services[1].
One technique that can help hospital managers/leaders in developing plans for improving
their service characteristics in accordance with patients' desires is to use the Quality Function
Deployment (QFD) matrix method. QFD will translate what customers need (in this study the
hospital customers are patients) to what the hospital should produce. QFD allows hospitals to
prioritize customer needs, find innovative responses to these needs and improve processes to
achieve maximum effectiveness[2].
2. Research Objectives
a. Identifying the patient's needs for the quality of hospital health services.
b. Provide an overview to the RSU management/management to the extent that patients assess
the quality of hospital services at this time.
c. So that the RSU management/management can find out the main priorities of the variable
patient needs that are planned to be fulfilled or fulfilled, in relation to the planning process of
improving the quality of service to patients in the future and can find out the main priorities
of service characteristics that need to be further improved. in relation to realizing the
variables of patient needs that have been prioritized to be fulfilled or fulfilled in the future.
3. Theoretical Basis
The word quality has many different definitions and varies from conventional to strategic.
Conventional definition of quality usually describes the direct characteristics of a product, such
as performance (performance), reliability (reliability), easy to use (ease of use), aesthetics, and
so on. And according to the definition of strategic, quality is everything that is able to meet the
wants or needs of customers (meeting the needs of customers)[3].
In Din ISO 8402 the quality is defined as the totality of the form and characteristics of an
item or service, which contains at the same time an understanding of security or the fulfillment
of the needs of users [4]. Quality is often interpreted as customer satisfaction or conformance to
needs or requirements (conformance to the requirement). The definition of a product can be
tangible, intangible, or a combination of both. Thus there are three categories of products in
question, namely: (1) goods (goods), such as cars, computers, tires, etc .; (2) software
(software), such as computer programs, and (3) services (services), such as banking, insurance,
hospitals, and so on. Based on the definitions that have been raised about quality, both
conventional and more strategic, it can be concluded that basically this quality is always focused
on customers (customer focused quality). Thus products are designed, manufactured, and
services provided to meet customer needs, desires, and expectations, so that the product can
satisfy them.
In essence, business goals are to create and maintain customers [5]. In the Total Quality
Management (TQM) approach, quality is determined by the customer. Therefore, only by
understanding the process and customers can a company realize and appreciate the meaning of
quality. All management efforts in TQM are directed to one main goal, namely the creation of
customer satisfaction. Whatever management does will not do any good if it ultimately does not
2
result in increased customer satisfaction. The existence of customer satisfaction can provide
benefits [6], including:
a. The relationship between the company and its customers becomes harmonious.
b. Providing a good basis for repurchase.
c. Can encourage customer loyalty.
d. Establish a word of mouth recommendation that is beneficial for the company.
e. The company's reputation is good in the eyes of customers.
f. Earnings can increase.
4. Identify Customer Needs
The customer is the person who receives the results of the work of someone or a company, so
only they can determine the quality as what they are and only those who can convey what and
how they need. This is why the popular quality movement slogan reads "quality starts from the
customer" [7]. Every person in the company must work with internal, external, and customer
customers to determine their needs. In the TQM approach, customer needs are clearly identified
as part of product development. The goal is to exceed customer expectations, not just fulfill
them. For this reason, accurate information regarding customer needs and desires for the
products produced by the company is needed. Thus the company can understand well the
behavior of consumers in the target market, so that the company concerned can develop the
right strategies and programs in order to take advantage of the opportunities that exist, establish
relationships with each customer, and outperform its competitors [8].
The main key to identifying internal customer needs is continuous communication between
employees who are interrelated and dependent on each other as individuals, and between
departments that are interdependent as a unit. In this communication, each party conveys their
needs to the other party, so that mutual understanding and cooperation between individuals and
between departments within the company are involved. To encourage and facilitate such
communication, quality mechanisms, self-managed teams, inter-departmental teams and
improvement teams [9] can be used.
Continuous communication with external customers is also very important. One reason for
the need for continuous communication is that customer needs change over time and even
changes can take place very quickly. Through this communication the company can monitor any
developments and changes that occur. If this is not anticipated, the company can lose in
competition. The factors that led to the emergence of new customer needs were new
technologies, market competition, changes in tastes, social upheaval, and international
conflicts[10].
Satisfaction Referring to the Implementation of All Health Service Requirements
Here a measure of patient satisfaction is associated with the application of all health care
requirements. A health service is referred to as quality health services if the application of all
health care requirements can satisfy patients[11]. With this opinion, it is easy to understand that
the quality measures of health services are broad, because they include an assessment of patient
satisfaction regarding:
a. Availability of Health Services (Available)
b. Fairness of Appropriate Health Services
c. Continuity of Health Services (Continue)
d. Acceptance of Health Services (Acceptable)
e. Achievement of Health Services (Accessible)
f. Affordability of Health Services (Affordable)
g. Health Service Efficiency (Efficient)
h. Quality of Health Services (Quality)
Quality Function Deployment (QFD) Method
Quality Function Deployment (QFD) was first developed in 1972 by Mitsubishi’s Shipyard in
Kobe, Japan. The essence of QFD is a large matrix that will connect what the customer wants
3
(WHAT) and how a product will be designed and produced to meet the customer's desire
(HOW) [12].
The main focus of QFD is to involve customers in the product development process as early as
possible, where their needs and desires are used as the starting point of the QFD process [13]
And therefore the QFD is referred to as the voice of the customer. The underlying philosophy is
that customers will not be satisfied with a product, even if a product has been produced
perfectly, if they do not want or need it.
The QFD concept uses a detailed chart to translate quality perceptions into product
characteristics, which are then used as requirements for the engineering and production stages.
The basic design tool is a chart called House of Quality. The design begins with conducting
marketing research to determine specific product attributes that customers want from a
predetermined market segment, the relative importance of each attribute, and determining
customer perceptions of competing products and company products in each of the attributes.
Technical
Correlation
Technical Response
(Technical Requirement)
Customer Relationships (Impact of
Needs and Technical Response on Planning
Want Customer Needs)
Technical Matrix
Figure 1. House of Quality

A quality house is a picture of a set of matrices that interact with one another, as shown in
Figure 1. Figure 1 can provide information about: (1) Customer needs in the form of customer
needs and desires of a product or service, (2 ) Technical response in the form of what and how
can be done by the company for this, (3) The influence of technical response on customer needs
(relationship) in the form of technical response to customer satisfaction, (4) Planning matrix, in
the form of methods for building strategies for customer satisfaction and comparing products or
services themselves to meet the needs of customers with competitors ) or negative influence
(contradictory), (6) Technical matrix (technical matrix) consists of determining technical
responses that contribute greatly to customer satisfaction, competitive assessments and
determining technical response targets based on the performance of technical responses from
competitors.
5. Research Methodology
Test Validity and Reliability
Correlation calculations for each variable with a total score using the "product moment"
correlation technique formula as follows:
n( XY )  ( X  Y )
r
  
n X 2  ( X ) 2 n Y 2  ( Y ) 2
Information :
X = Score of each variable
Y = total score of each respondent
N = Number of respondents\
The way to see the critical number is to look at line N-2 in the correlation table of the r-value,
for example for the significant level of 5%, N = 25 (df = 23), a critical value of r = 0.396 will be
obtained. so the variable will be declared valid if the value of r is greater than 0.396.
Validity and reliability testing is the process of testing the questions in a questionnaire, whether
the contents of the questions are valid and reliable. If the items are valid and reliable, it means
4
that the items can be used to measure the factors. The next step is to test whether the factors are
valid to measure the existing construct.
Table 1. Determination of the Sample Amount of Each Level

Level Inf. Number (%) Number of
of patients sample
1 VIP 200 20,00 20,00  20
2 Class I 227 22,70 22,70  23
3  320 32,00 32,00  32
Class I
4 Class II 169 16,90 16,90  17
5 Class III 84 8,40 8,40  8
Total 1000 100 100
The total value of the level of importance of a variable is calculated from the results of the
multiplication of the respondent's answer to the measurement scale (Likert scale). The Likert
scale value for the level of importance is as follows:
SP = Very Important = 5
P = Important =4
CP = Quite Important = 3
KP = Less Important = 2
TP = Not Important = 1
The total value of the service level of a variable is calculated from the multiplication of the
number of respondents with the measurement scale (Likert scale). The Likert scale value for the
service level is as follows:
SB = Very Good = 5
B = Good =4
CB = Good enough = 3
KB = Poor =2
TB = Not Good =1
The results of the processing of questionnaire data in sections I and II can be obtained by
showing the gap between the level of interest of patients and the level of service in the hospital.
This gap shows that hospital services on a variable needs are not in accordance with patient
expectations (level of importance). To find out this gap, the mode of importance and service
level of each variable is used.
Table 2. Total Value of Data on the Importance of Variables in Patient Needs

No Variable Patient Needs SP P CP KP TP TN
1 Complete and modern state and completeness of medical facilities 31 46 23 0 0 408
2 Patient inpatient room condition 50 35 15 0 0 435
3 Food quality 53 26 21 0 0 432
4 Completeness, readiness and cleanliness of the equipment used 43 43 14 0 0 429
5 Appearance of doctors and hospital nurses 56 37 7 0 0 449
6 Service procedures are not complicated 62 34 2 0 0 452
7 Accuracy of medical services provided to patients 59 40 1 0 0 458
8 Service schedules are implemented correctly 64 36 0 0 0 464
9 Inspection, treatment and care services that are fast and precise 62 38 0 0 0 462
10 Alertness of personnel in handling patients 64 35 1 0 0 463
11 Dexterity in handling patient complaints immediately 62 37 1 0 0 461
12 The doctor provides clear, precise & easy to understand information 65 32 3 0 0 462
13 Complete and modern health & support facilities and medical facilities 62 30 8 0 0 454
14 The skills of doctors and nurses at work 60 40 0 0 0 460
15 Attitudes of hospital doctors and nurses (hospitality, courtesy) 64 36 0 0 0 464
16 Ease of obtaining drugs 80 20 0 0 0 480
17 Medications that are given effectively in helping patients recover 82 17 1 0 0 481
18 Ease of contacting the hospital (by land or telephone transportation) 77 20 3 0 0 474
19 The doctor's willingness to give advice 86 12 2 0 0 484
20 The willingness of nurses to provide information 61 32 7 0 0 454
21 Visite is a routine doctor 48 48 4 0 0 438
Note: TN = Total Value of Interest
5
4
Modus Level of Imporrtance
3
Level of Servece
2
0
1 2 3 4 5 6 7 8 9 101112131415161718192021
Servace Variable Number
Figure 2. Gaps Between Patient Interest and Hospital Service Level.

6. Analysis
Application of QFD Method Efforts to Improve Service Quality of Government Hospitals
In the process of improving the quality of hospital services, not all variables of patient needs can
be met at once, but must be gradually and adjusted to planning priorities. This is due to the
limitations of the hospital, both in terms of funds, human resources, time, environmental
conditions, and so forth.
As a tool used to carry out the process of improving the quality of hospital services, the QFD
method is used. The application of the QFD method in this study only arrived at the first stage,
namely the stage of the formation of the House Of Quality (HOQ) matrix. In the process of
building a HOQ matrix. There are several steps that must be taken in the process of building the
HOQ matrix to improve the quality of RSU services. Based on the dimensions of quality used.
1. Tangible dimensions (physical evidence), the patient considers it very important for a
hospital service to pay attention to the condition of the patient's inpatient room, the quality of
the food served, the cleanliness and completeness of the equipment used and the appearance
of hospital doctors and nurses. In addition, patients assume that the state and completeness of
modern medical facilities are also important to note from a hospital service.
2. Dimension of Reliability (reliability), the patient considers it very important for the hospital
to pay attention to its non-convoluted service procedures, accuracy of medical services
provided to patients, accuracy of service schedules, and prompt and appropriate examination,
treatment and care services provided to patient.
3. Responsiveness Dimensions, each patient is looking forward to hospital services so that
personnel are quick in handling patients and handling patient complaints immediately.
4. Dimensions of Assurance, patients consider very important for hospitals for the accuracy of
medical services provided to patients, complete & modern health & support services and
medical facilities, the skills of doctors and nurses at work, attitudes of doctors and nurses
obtaining drugs and medicines that are given is very effective in helping healing patients,
because all these things are considered very important by the patient.
5. Emphaty dimension, the patient really hopes for a hospital service in order to really pay
attention to the ability of doctors and nurses in conveying information, routine visite
doctrine. In addition, patients also assume that the ease of contacting the hospital is also
important to note from a hospital service.
House of Quality Matrix Analysis Characteristics of RSU Service Services

1. Planning Matrix Analysis
As a basis for making these decisions, there are 4 interval classes that will be used as criteria
to determine whether a need is "very important", "important", "important enough", or "less
important" for the planning focus. Decisions about the priority variables to be fulfilled are
those that meet the criteria of "important" and "very important". The values in the class
interval are in the form of the relative importance of the variable needs.
6
2. Identification of Service Characteristics
3. Identification of Levels of Relative Interest in
7. Conclusion
1. Patients can be grouped into 5 strata based on the type of treatment room, namely patients
who have felt the service to VIP, patients who have felt service in class I, patients who have
felt service in class I, patients who have felt service in class II, patients who have felt service
in class III.
2. Of the 21 variables used to improve the quality of public hospitals, there are 9 needs
variables as the main priority that needs to be improved, namely the knowledge/expertise of
doctors in determining medicines, skills/skills of doctors, appropriate treatment measures,
effective and efficient medical actions. speed of taking action/decision, completeness,
readiness and cleanliness of the tools used, personnel alertness in handling patient
complaints, personnel attention to patients, and the ability of doctors and nurses to behave,
providing clear, precise and easy to understand information.
3. In relation to the 9 priority variables needed to improve service quality there are 33 service
characteristics that need to be improved.
4. Facility service characteristics that need to be improved in realizing quality improvement
efforts are complete medical equipment and modren.
5. To support efforts to improve quality, personnel service characteristics must be improved.
The characteristics that need to be improved in this case are the quick handling of patients,
coming soon when needed, cultivating therapeutic communication with patients, being
friendly to patients, patience of personnel, proactively civilizing, and being fair with patients.
REFERENCES
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Addison – Wesley Publishing Company, 1995.
[3] S. Santoso, Buku Latihan SPSS : Statistik Parametrik. Jakarta: PT. Elex Media Komputindo, 2000.
[4] H. Umar, Riset Pemasaran dan Perilaku Konsumen. Jakarta: PT. Gramedia Pustaka Utama, 2000.
[5] A. Azwar, Pengantar Administrasi Kesehatan. Jakarta: Binarupa Aksara, 1996.
[6] F. Tjiptono, Total Quality Manajemen. Yogyakarta: Andi Offset, 2000.
[7] A. Azwar, Menjaga Mutu Pelayanan Kesehatan. Jakarta: Pustaka Sinar Harapan, 1996.
[8] S. Arikunto, Prosedur Penelitian : Suatu Pendekatan Praktek. Jakarta: PT. Rineka Cipta, 1996.
[9] D. S. Ermer and M. K. Kniper, “Quality Function Deployment for Quality Service Design,” J.
Total Qual. Manag., 1998.
[10] et al Dergibson, Sugiarto, Teknik Sampling. Jakarta: PT. Gramedia Pustaka Utama, 2001.
[11] F. Tjiptono, Prinsip-Prinsip Total Quality Service. Yogyakarta: Andi Offset, 1997.
[12] M. Singarimbun and S. Effendi, Metode Penelitian Survai. Jakarta: LP3ES, 1989.
[13] V. Gaspert, Penerapan Konsep-konsep Kualitas dalam Manajemen Bisnis Total. Jakarta: PT.
Gramedia Pustaka Utama, 1997.
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An application of quality function Quality

function
deployment and SERVQUAL deployment
approaches to enhance the service

quality in radiology centres
Shakiba Sadat Gavahi and Seyed Mohammad Hassan Hosseini Received 14 July 2021
Revised 15 December 2021
Shahrood University of Technology, Shahrood, Iran, and 5 March 2022
Arash Moheimani 20 April 2022
15 May 2022
Department of Information Systems, Supply Chain and Decision Making, Accepted 22 May 2022
NEOMA Business School, Mont-Saint-Aignan Cedex, France
Abstract
Purpose – Meeting the patients’ requirements as customers of the health care sector is crucially important as a
social responsibility. According to the resource constraints, only an efficient utilisation of health services can
provide that purpose. This study aims to develop a quantitative assessment framework for radiology centres as
a vital section in healthcare to translate the patients’ requirements into service quality specifications. This
would help to achieve quality improvement by emphasising the voice of customers.
Design/methodology/approach – A literature review is conducted to specify the service quality criteria and
the patients’ requirements related to healthcare and hospitals. Based on the experts’ opinions, these criteria and
requirements are later customised for the radiology centres. Moreover, the requirements are categorised into
five dimensions of SERVQUAL. The interrelations between service elements are also determined through
expert group consensus using Pearson correlation. Afterwards, by applying the QFD method, the relations
between the requirements and criteria are explored. Additionally, a customer satisfaction survey is executed in
Tehran public hospitals to prioritise these requirements and provide an importance-satisfaction analysis.
Findings – Based on the result of the case study, service elements are prioritised for improvement, and
practical suggestions are provided using the Delphi technique for quality improvement. In addition, a cause-
and-effect diagram is presented to highlight the improvement area and provide enhancement suggestions.
Originality/value – This study is the first empirical attempt to benefit from the VOC in evaluating and
enhancing the quality of service delivered to radiology patients. In doing so, the study applies a hybrid
approach of QFD and SERVQUAL as well as other tools to highlight the improvement area and provide
enhancement suggestions. The findings can be readily used by the practitioners.
Keywords Quality function deployment (QFD), Healthcare services, Radiology centres, SERVQUAL,
Patients’ requirements
Paper type Research paper
1. Introduction
For hospitals, providing services with an adequate level of quality is a moral responsibility as
well as a survival imperative, given today’s stiffly competitive market. In this way, healthcare
scholars have been focusing on the quality of medical care and strategies for possible
improvements to successfully adhere to the codes of conduct while securing their market
share. Like many other business areas, a primary concern of all hospitals and other medical
care organisations is customer satisfaction, which means the degree to which the patients are
content with the service they receive (Upadhyai et al., 2020). Accordingly, many studies have
been conducted to scrutinise the importance of service quality to better understand how to
satisfy and retain patients (Kamel and Mousa, 2021; Verma et al., 2022).
On the other hand, hospitals are the primary helpers to people during illnesses, disabilities Benchmarking: An International
Journal
and disasters, and because of this, the quality of services they provide concerns patients © Emerald Publishing Limited
1463-5771
(Bowers et al., 2015; Moheimani et al., 2021a). Therefore, the hospitals’ managers have to deal DOI 10.1108/BIJ-07-2021-0411
BIJ with several challenges to increase the quality of medical services according to the customers’
expectations (Deepu and Ravi, 2021; Moheimani et al., 2021b). This means that patients
themselves can say a lot, about what they receive in medical and what improvements can be
most beneficial to them (Srinivas et al., 2021). In other words, the required improvements and
positive changes needed in medical care systems should be based on the new understanding
of customers’ requirements (C.R.s). Such understandings can only be obtained by studying
the patients’ perspective, mainly known as listening to the voice of customers (VOC)
(Melander, 2020). Evaluating hospitals’ service quality based on VOC is hugely valuable since
it helps grasp what the patients undergo and what they deem unsatisfactory, providing first-
hand knowledge of what should be improved (Camg€oz-Akda g et al., 2013; Shukla et al., 2020).
Several methodologies have been introduced to utilise the patients’ perception of the service
quality to upgrade the hospitals’ performance (Camg€oz-Akda g et al., 2013; Pekkaya et al., 2019).
Meanwhile, the quality function deployment (QFD) technique is receiving increasing attention
in academic research and management to translate customer requirements into technical
characteristics (Alsaadi et al., 2018; Goharshenasan et al., 2022). This approach provides a
robust framework to translate the customer expectations to the system specifications. The
output of this approach identifies potential improvements in products and services to meet
customer expectations that ultimately lead to increased customer satisfaction.
The intangibility of the service sector increases its complexity, which makes it more
challenging to assess and manage quality. In the absence of tangible metrics such as crop
yield or production volume, it is perfectly reasonable for service providers to seek judgment
and improvement suggestions from the service recipients. Service quality, the so-called
SERVQUAL, is a well-known and effective procedure to capture the customers’ perception
and judgment to put to use for quality improvement purposes (Sulphey and Jasim, 2020).
SERVQUAL is a multi-dimensional model based on the expectancy-disconfirmation theory
that applies a five-dimensions questionnaire to collect the expectations and perceptions of
customers (Ali et al., 2018; Altuntas and Yener, 2012; Lacerda et al., 2021). Healthcare scholars
have employed this scale to enhance service quality by better understanding patients’
requirements and expectations (Altuntas and Yener, 2012; Gholami et al., 2016). In addition,
several studies have integrated the QFD and SERVQUAL methodologies to overcome their
respective limitations (Gonzalez, 2019; Lizarelli et al., 2021). Successful implementation of
QFD largely hinges on data collection and classification, and the customers’ requirement
aggregation and prioritisation processes can also face several obstacles (Lizarelli et al., 2021;
Deepu and Ravi, 2021). At the same time, several flaws, such as pursuing nonexistent
excellence, and non-generalizable gap analysis, can limit the application of the SERVQUAL
model (Sulphey and Jasim, 2020). It has been shown that integrating QFD and SERVQUAL
can successfully surmount these limitations (Camg€oz-Akda g et al., 2013; Lizarelli et al., 2021).
Another notable point is that the quality of medical services and the role and
responsibility of hospitals have such a close connection to human prosperity that renders
them too complicated and complex to be discussed generally. This is the main reason why
many studies have focused to only one sector of the hospitals, such as emergency, radiology,
or cardiology, rather than conducting an organization-wide analysis. This way, the focus will
be directed at the performance of a much simpler entity, allowing for a further in-depth and
detailed analysis with outcomes less susceptible to negligence and over-generalization
(Altuntas and Yener, 2012; Laberge et al., 2013; Verulava et al., 2018; Beegle et al., 2022).
In that regard, the radiology department is an essential part of healthcare with an
unparalleled impact on problem identification since it permits a gaze into a living body’s
interior without incision (Towbin et al., 2017; Zhang et al., 2020). Because radiology
departments are responsible for a significant part of diagnoses, numerous studies have
concentrated on their performance and assessed their level of service quality (Taner et al.,
2012; Towbin et al., 2017; Zhang et al., 2020; Santos and Rocha, 2022). Due to their vital role, it
is indisputable that the radiology departments’ service quality should be assessed, and as Quality
discussed before, VOCs are perfectly applicable to conduct such assessments. function
This study deploys the QFD technique and SERVQUAL model specifically in radiology
centres to translate the customer requirements of these departments into workable technical
deployment
characteristics. In that respect, customer requirements are determined through literature
review, expert comments, and relative clients. Public Tehranian hospitals that have a radiology
department are considered the research population. A survey questionnaire collects data from
target respondents, i.e. patients who recently received service from the radiology centres. Based
on this survey, we investigated the weights related to each customer expectation and evaluated
current satisfaction scores. Then a more accurate understanding of the relationship between
different patient’s expectations and the technical characteristics associated with them is
provided. Moreover, the relationships between service elements are determined through expert
group consensus and a Pearson correlation. Since an essential part of any study is the practical
implications, two other quality tools, namely the Importance-Satisfaction Analysis (ISA) and
cause-and-effect diagram (obtained from a Delphi consensus), are applied to highlight the most
critical weaknesses and provide service enhancement suggestions.
The outline of the paper is as follows. An introduction to this study was presented in
section 1. Section 2 is devoted to the survey of works related to this study. The research
methodology and steps of the study are illustrated in section 3. Section 4 presents the result of
the research. In section 5, the implications of the findings are discussed and some managerial
insights are provided. Finally, the conclusion, the study’s limitations, and some suggestions
for future studies are given in section 6.
2. Literature review
Many studies have focused on assessing and improving the quality of services in different
healthcare departments (Ali et al., 2018; Gonzalez, 2019; Soysa et al., 2018; Swain, 2019).
Scholars have employed various methods to measure the level of quality in these
departments. Some of the methods used for this purpose are 6δ(Bonilla et al., 2008; Frankel
et al., 2005; Rosier et al., 2020; Taner et al., 2012), Value Stream Mapping (VSM) (Camg€oz-
Akda g et al., 2018; Improta et al., 2018; Laberge et al., 2013; van der Sluijs et al., 2019; Swancutt
et al., 2017; Towbin et al., 2017), Plan-Do-Study-Act (PDSA) (Breckner et al., 2018; Gjolaj et al.,
2016; Lipshutz et al., 2008; Newcombe and Fry-Bowers, 2018), and ISA (Aeyels et al., 2018; Lee,
2016; Shieh, 2010; Shieh et al., 2019; Wu and Hsieh, 2012). One of the major methods that have
been repeatedly applied to assess the level of excellence in healthcare subdivisions is QFD
(Abdelsamad et al., 2018; Gremyr and Raharjo, 2013; Joshi and Bhargava, 2019; Luschi et al.,
2016; Rahimi et al., 2013). The QFD method was initially proposed in 1966 as an effective
customer-oriented technique for transforming customer requests into technical requirements
(T.R.s) for continuous product (or service) quality improvement (Vinayak and Kodali, 2013).
Although this technique was first proposed for quality improvement in manufacturing
industries, its application has been expanded in all manufacturing and service industries.
Healthcare and related centres that play a vital role in modern society’s quality of life and
social welfare have attracted increasing attention to improve service quality and provide
customers’ expectations (Bowers et al., 2015; Moheimani et al., 2021a). Many researchers
investigated QFD-based methods to enhance service quality in the healthcare sector. As an
introductory study, Radharamanan and Godoy (1996) used this methodology to improve
service quality in the healthcare system (Radharamanan and Godoy, 1996). Martins and
Aspinwall (2001) conducted a study in the UK, reviewing the QFD implementation problems
and then discussing a postal survey conducted to attain the “Voice of the User” and the “Voice
of the non-User”. They showed that QFD users regarded Behavioural Management as the key
to successfully applying the technique (Martins and Aspinwall, 2001). Rahman and Qureshi
(2008) developed the fuzzy QFD (FQFD) method to assess LIFENET Health customers’
BIJ spoken and unspoken needs to achieve the various objectives. These objectives included how
to decide optimum portfolio for health services strategically; how to assess competitors’
market position to reckon the market position of LIFENET; and how to set the revised target
to satisfy the customers’ demand and to fetch profit to fulfil managers’ mission and vision in a
competitive market (Rahman and Qureshi, 2008). Camg€oz-Akda g et al. (2013) described how
QFD methodology could translate customer expectations into quality characteristics in a
private healthcare setting. They also proposed an integrated SERVQUAL and QFD for
quality improvement in the healthcare sector (Camg€oz-Akda g et al., 2013). Gremyr and
Raharjo (2013) conducted a case study of a clinic in Sweden, reducing the time spent
prescribing medication by 20% using the QFD model and adding it to the time the doctor
spends with the patient (Gremyr and Raharjo, 2013). Vanteddu and McAllister (2014) used the
QFD to improve hospital services and rank influential factors in improving these services. By
defining 63 patient requests, such as ease of planning and parking, they prioritised 60
elements of service, and finally, the essential elements of service were addressed to improve
hospital services. The first two elements of these services are “average patient admission
time” and “average test time” (Vanteddu and McAllister, 2014). Lee et al. (2015) used the QFD
fuzzy logic in health services to improve the quality of services at a Singapore hospital and
presented an approach to support the decision-making process and monitor the process
performance to ensure its stability (Lee et al., 2015). Hashemi et al. (2015) used QFD to improve
the quality of chemotherapy unit services at Nemazee Hospital in Iran (Hashemi et al., 2015).
Ali Keshtkaran et al. (2016) applied the QFD technique to enhance the quality of the burn unit
services in Ghotbedin Hospital in Shiraz (Keshtkaran et al., 2016). Do gan and Akbal (2021)
conducted a study with an AHP-weighted QFD carried out in a pediatric hospital in Turkey to
determine pediatric patients’ expectations and how to meet their expectations (Do gan and
Akbal, 2021).
Another service improvement model is SERVQUAL, which has a good reputation for
evaluating the quality of service in hospitals (Ali et al., 2018). Priyono and Yulita (2017)
integrated the QFD with the Kano model and SERVQUAL to improve hospitals’ service
admissions. After determining the customer’s demands, they applied the Kano model to
analyse customers’ expectations and used the SERVQUAL model to determine the service
elements (S.E.s) (Priyono and Yulita, 2017). Fauziah et al. (2019) investigated service
improvement methods to examine the influences of pharmacy services’ quality based on five
quality dimensions of the SERVQUAL approach. They also used the QFD technique to
improve service quality using VOC. They provided proper gap analyses between customers’
perceptions and expectations and prioritised them in a hospital in Indonesia (Fauziah
et al., 2019).
Table 1 summarises previous research related to the present study. It is necessary to note
that the provided references are not all the available contributions in the literature but rather
a sufficient sample to reflect an apt image of the main focuses and the lacuna. As
demonstrated, numerous studies considered the quality of different medical services and
used various quality improvement methodologies. However, despite its utter importance, no
study has considered the customers’ expectations in radiology departments. To the best of
our knowledge, this is the first attempt to assess the radiology department’s service quality
with the powerful tools of QFD. Additionally, this method is reinforced by SERVQUAL,
which can resolve the shortcomings that the methods might have encountered if conducted
separately. Moreover, the study applies a Delphi panel to evaluate the findings and yield
information on improving the services. Delphi is a communication technique that has been
used numerous times to validate and interpret the result of QFD (Lee et al., 2017; Lo et al.,
2017). Thus, the present study contributes to the literature by pioneering the utilisation of
arguably the best VOC-based methodology available in radiology centres. Plus, it generates
an expert agreement on the best strategies to ameliorate the service deficiencies, and by doing
Department Methodology
References Emergency Cardiology ICU1 Radiology Etc. 6σ VSM QFD PDSA SQ2 ISA Etc
Frankel et al. (2005) U 3 +

Benitez et al. (2007) U + 3
Bonilla et al. (2008) U 3 +
Lipshutz et al. (2008) U 3 +
Shieh (2010) U 3 +
van der Meulen et al. (2011) U 3 +
Wu and Hsieh (2012) U + 3
Taner et al. (2012) U 3
Altuntas and Yener (2012) U + 3
Gremyr and Raharjo (2013) U + 3
Laberge et al. (2013) U 3
Rahimi et al. (2013) U 3 +
al Owad et al. (2014) U 3 +
Gholami et al. (2016) U 3
Lee (2016) U 3
Luschi et al. (2016) U 3
Gjolaj et al. (2016) U 3 3 +
White et al. (2017) U + 3
Towbin et al. (2017) U 3 +
Mulisa et al. (2017) U 3 +
Swancutt et al. (2017) U 3 +
Aeyels et al. (2018) U + 3 +
Digumarthy et al. (2018) U + 3
Newcombe and Fry-Bowers (2018) U 3
Camg€oz-Akda g et al. (2018) U 3
Breckner et al. (2018) U 3 +
Verulava et al. (2018) U 3
Improta et al. (2018) U 3 +
Abdelsamad et al. (2018) U 3 +
van der Sluijs et al. (2019) U 3 +
Tripathi et al. (2019) U 3 +
(continued )
function
Quality
deployment
improvement in
regarding quality
healthcare
Table 1.
Previous studies
BIJ
Table 1.
Department Methodology
References Emergency Cardiology ICU1 Radiology Etc. 6σ VSM QFD PDSA SQ2 ISA Etc
Joshi and Bhargava (2019) U 3 +

Nainggolan (2019) U 3 +
Shieh et al. (2019) U + 3
Al Hroub et al. (2019) U 3 +
Lu et al. (2020) U 3 +
Rosier et al. (2020) U 3 +
This Study U 3 + +
Note(s): 1: Intensive Care Unit, 2: SERVQUAL, 3: Main technique, +: Supplementary technique
so, helps the related establishments to close the gap between what is required and how it can Quality
be achieved. function
deployment
3. Research methodology
As stated previously, this study’s main objective is to identify and understand the patient
expectations of the radiology departments using the QFD technique to improve their
satisfaction. The QFD technique is a valuable tool to understand customer requirements. The
proposed approach utilises a House of Quality (HoQ) matrix as the main tool of QFD to
identify the relations between patient expectations as C.R.s and the services’ elements as S.E.s
quantitatively. House of quality is built upon two principal components: the VOC and voice of
engineer (VOE), embodied in C.R.s and S.E.s, respectively and the correlations between them
are investigated. An ISA is also conducted to determine the status of C.R.s. The Delphi
method is then used to provide recommendations for improving C.R.s with reference to the
S.E.s affecting them.
Figure 1 shows the structure of the HoQ. Section A contains customer needs and
requirements. Section B contains a description of the service that needs to be developed.
Section C contains the computations for weighting Section A. Section D contains the
correlations of Section B. Section E contains the judgment on the strength of the relationship
between each element of Sections A and B. Finally, Section F includes the ranking of
Section B.
This paper’s proposed methodology is known as action research developed in the medical
field. We applied this action research in radiology departments for the first time. All the data
collected from the departments under study was provided using a participant-observer
format. Therefore, construct and internal validity and reliability are much stronger than in a
typical case study.
Figure 2 demonstrates a schematic diagram of the steps of the study. As illustrated, the
related studies are first reviewed to provide the initial C.R.s and S.E.s. Later, 15 experts,
including university professors, hospital officials and radiologists, were selected and briefed
about the process to form the study’s expert group. Afterwards, the questionnaires were put
together and handed out to patients regarding their opinion about the importance of the C.R.s
and how satisfied they were with the services. At the same time, the connections between the
S.E.s were established through the experts’ judgement. Then, based on the questionnaire’s
results and the S.E.s’ connections, the HoQ is constructed. Subsequently, the S.E.s are
prioritised, the ISA is performed, and the Delphi method is applied to derive practical
solutions, presented in a cause-and-effect diagram.
D. Correlation
B. Service elements (HOWs)
A. Customers’ C. Weight of
requests customers’
E. Relationship matrix requests
(WHATs)
Figure 1.
F. Priority of service elements HoQ matrix
BIJ Review and acquaintance
Review the related study with the process
Forming expert group
Identify the customers of the service Identify services elements by

and their expectations or needs for the literature review and experts' opinion
service with questionnaire, experts'
opinion and literature review
Determining weight of each Patients’ Determining the Relationship

requirements and prioritizing them between service elements
Determining the relationship between customers’

requirements and service elements through expert
group and constructing the HoQ
Service elements priorities by

their importance rating formula
Assessing the customers’

satisfaction
Forming the importance-

satisfaction matrix to identify
requirements with low
satisfaction and high importance
Figure 2. Providing improvement

The steps of the suggestions using cause-and-
proposed methodology
effect technique
According to the research methodology mentioned earlier, the main steps of this study are
explained in the following:
3.1 Identifying customers, determining and collecting C.R.s

The research was conducted at public hospitals in Tehran to translate the customer
expectation and needs in radiology departments. Reliable sources were first studied to
identify patients’ expectations as customers, and the items related to the radiology Quality
departments were determined. Then, experts’ opinions and interviews with patients finalised function
these cases, as shown in Table 2, and matrix A of HOQ is completed.
deployment
3.2 Identifying S.E.s
By investigating the existing literature and consulting the experts, we have identified 23 S E s
in the radiology departments that affect the services’ quality and acceptability. Table 3
presents the S.E.s, constructing the B matrix of the HoQ.
3.3 Prioritising patients’ requirements

In this stage, patients’ requirements were prioritised according to their total mean scores by
questionnaire to attain the C.R.s weights. The questionnaire consisted of 5 demographic
questions, and 24 questions of patients’ importance with each of the C.R.s. The items were
scored by a five-point Likert scale (extremely important 5 5, very important 5 4, moderately
important 5 3, slightly important 5 2, low importance 5 1), and items scored less than 3 were
removed. The statistical population was 3,500 people, and 346 people were chosen as a sample
size based on the Morgan table. Participants were selected randomly by using simple random
Code Needs and requirements Ref.
CR1 The general atmosphere in the radiology department Camg€oz-Akda

g et al. (2013)
should be nice and clean
CR2 There should be enough parking space Camg€oz-Akda g et al. (2013)
CR3 Comfortable radiology department with good heating Keshtkaran et al. (2016), Gonzalez (2019)
and cooling and ventilation system of the unit and Priyono and Yulita (2017)
CR4 Enough equipment and an adequate number of Keshtkaran et al. (2016) and Camg€oz-
radiologists Akdag et al. (2013)
CR5 Modern equipment with High quality Keshtkaran et al. (2016)
CR6 Accuracy of the radiologist and provide the best Hoe (2007)
diagnosis possible Gonzalez (2019)
CR7 The neat appearance of the staff Priyono and Yulita (2017)
CR8 Allocate appropriate space for the radiology department Experts’ opinion
due to the special condition of its patients
CR9 Easy to access Gonzalez (2019)
CR10 Provide services as promised Priyono and Yulita (2017)
CR11 Service schedules are implemented correctly and less Hasibuan et al. (2019) and Akram et al.
waiting time (2018)
CR12 Patient’s privacy protection Keshtkaran et al. (2016)
CR13 Helpful when customers need assistance Priyono and Yulita (2017)
CR14 Quick appointments for emergency patients Experts’ opinion
CR15 Accurately informs customers about the radiologists’ Priyono and Yulita (2017)
timetable
CR16 Speed in receiving results Hoe (2007)
CR17 Fast responses to any phone questions Priyono and Yulita (2017)
CR18 Accurate responses to any enquiries Priyono and Yulita (2017)
CR19 Obtain feedback from patients Moores (2006)
CR20 Cost of the services Hoe (2007)
CR21 Be covered by patient insurance Gonzalez (2019)
CR22 Friendly and polite to patients Priyono and Yulita (2017) and Camg€oz-
Akdag et al. (2013) Table 2.
CR23 24-hour access to services Moores (2006) Customers’ requests in
CR24 Be sensitive and able to identify the specific needs of Priyono and Yulita (2017) the radiology
customers departments
BIJ Code Service elements Ref
SE1 Hygiene and cleanliness of hospital and waiting room Camg€oz-Akda g et al. (2013) and Priyono and
Yulita (2017)
SE2 Organising a timetable of services for patients Priyono and Yulita (2017)
SE3 Using a computerised system Priyono and Yulita (2017)
SE4 Staff capabilities and their readiness and speed Priyono and Yulita (2017) and Gonzalez
(2019)
SE5 Staff dress Priyono and Yulita (2017)
SE6 Behaviour and attitude of staff and radiologist with Keshtkaran et al. (2016) and Camg€oz-Akda g
patients et al. (2013)
SE7 Training related to healthcare knowledge and Priyono and Yulita (2017) and Camgoz-
technical personnel Akdag et al. (2018)
SE8 Appropriate air condition Keshtkaran et al. (2016)
SE9 Taking measures to help poor patients with hospital Keshtkaran et al. (2016)
cost payments
SE10 Immediate attention and effective service Akram et al. (2018)
SE11 Appointment duration Camgoz-Akdag et al. (2018)
SE12 Customer care Gonzalez (2019)
SE13 Handle patients’ problems and complains Lee et al. (2015)
SE14 Remote communication channels Experts’ opinion
SE15 The comfort of the waiting room and rooms’ Priyono and Yulita (2017) and Gonzalez
environment (2019)
SE16 The number of equipment Keshtkaran et al. (2016)
SE17 The quality of the equipment Keshtkaran et al. (2016)
SE18 The number of the reception staff Keshtkaran et al. (2016)
SE19 Flexible schedule Gonzalez (2019)
Table 3. SE20 Scheduler speed and knowledge Gonzalez (2019)
Services’ elements in SE21 Accuracy and quality of reports Hoe (2007)
the radiology SE22 Reporting speed Camgoz-Akdag et al. (2018)
departments SE23 Radiologist Experience Camgoz-Akdag et al. (2018)
sampling. Finally, matrix C of HoQ is constructed. The calculation of C.R.1 weight is

explained in the following as an example:
345 people participated, of which 109 voted for extremely important, 160 voted for very
important, 60 voted for moderately important, 16 voted for slightly important, and 1 voted for
low importance. Therefore:
109ð5Þ þ 160ð4Þ þ 60ð3Þ þ 16ð2Þ þ 1ð1Þ
Weight of CR1 ¼ ¼ 4:04
346
3.4 Relationship between S.E.s

In the next stage, the relationships between S.E.s were determined through the opinions of the
expert group and Pearson correlation. The relationships were specified in five levels: strong
negative relationship, weak negative relationship, weak positive relationship, strong positive
relationship, and cells were left blank when there was no relationship. Finally, matrix D of
HOQ is constructed.
3.5 Relationship between C.R.s and S.E.s

The radiology departments have to set customised priorities due to limited resources.
The most suitable options to the most important expectations of patients need to be identified.
In this part of the research, the method used by Ali Keshtkaran et al. (2016) is taken, and
the relationships between C.R.s and S.E.s were determined through expert group consensus.
The expert group consisted of university professors, radiologists and hospital directors. Quality
Firstly, the expert group members provided individual responses, then discussed different function
responses to find the most suitable one. The relationships were determined in four levels,
including no relationship (0), weak relationship (1), medium relationship (3), and strong
deployment
relationship (9). At last, matrix E of HoQ is completed.
3.6 Service elements priorities

In this stage, the service elements’ priorities were determined by their importance rating,
which is obtained from the (1) formula:
X
Importance rating of a service elements ¼ ðimportance rating of patients’
requirements * relationship value patients’
requirements and the service elementsÞ
(1)
The importance rating of S.E.1 is calculated as an example:

Importance rating of a S:E1 ¼ ð9 * 4:04Þ þ ð0 * 3:96Þ þ ð0 * 3:4Þ þ ð0 * 4:68Þ
þ ð0 * 4:76Þ þ ð0 * 4:66Þ þ ð0 * 3:58Þ þ ð0 * 4:52Þ
þ ð0 * 4:34Þ þ ð0 * 3:70Þ þ ð0 * 4:70Þ þ ð0 * 3:76Þ
þ ð0 * 3:20Þ þ ð0 * 4:54Þ þ ð0 * 3:12Þ þ ð0 * 4:56Þ
þ ð0 * 4:40Þ þ ð0 * 3:62Þ þ ð0 * 3:08Þ þ ð0 * 4:62Þ
þ ð0 * 4:60Þ þ ð0 * 4:14Þ þ ð0 * 4:28Þ þ ð0 * 3:22Þ
¼ 36:36
At the end of this stage, matrix F of HoQ is constructed.
3.7 Assessing the customers’ satisfaction

In the questionnaire that we used to prioritise Patients’ Requirements and asked them to give
a score on a five-point Likert scale on the importance of each C.R., we also asked patients to
give a score on their satisfaction with each C.R. in the radiology departments.
3.8 Importance-satisfaction analysis

The satisfaction and importance of each item are generally obtained by asking customers
directly. This model is illustrated in Figure 3. The two axes on the matrix represent
Satisfaction (vertical) and relative importance (horizontal). The quadrants are designated as
surplus (low importance, high satisfaction), excellent (high importance, high satisfaction),
unimportant (low importance, low satisfaction), and to be improved (high importance, low
satisfaction). Improvement strategies are based on the area in which each quality attribute is
placed (Chen et al., 2020).
4. Result
The HoQ matrix is completed and is presented in Figure 4. Patients’ requirements
are classified according to the five dimensions of the SERVQUAL model: tangibility,
BIJ Satisfaction
1. Surplus area 2. Excellent area
Mean
3. Careless area 4. To be improved area
Figure 3.
Importance -
satisfaction matrix Importance
Mean
reliability, responsiveness, assurance and empathy. As it can be spotted in Figure 4, the

importance ratings, the relations between C.R.s and S.E.s, and the interrelations between
S.E.s are presented, and the C.R.s and S.E.s are prioritised. The weights of the C.R.s are
calculated and range from 3.08 to 4.76. The S.E.s importance indices are also calculated and
range from 28.46 to 234.68. In addition, the C.R.s are classified based on the SERVQUAL
dimensions and their respective importance and satisfaction score according to the patients.
This would ease the service quality evaluation and accentuate the radiology departments’
strengths and weak spots based on the SERVQUAL framework, further clarifying the
current service level and assisting the managers’ policymaking processes.
Figure 5 demonstrates this classification. The maximum difference between the importance
and satisfaction is observed in the tangibility, responsiveness, and reliability, respectively. In the
following, the C.R.s and S.E.s are ranked based on their respective computed priority, as shown
in Table 3, and a more in-depth evaluation of the results is suggested.
The ranking of the C.R.s and S.E.s highlights the customers’ most essential requirements
and the most effective components of the services that the radiology departments provide.
According to Table 4, S.E.12, i.e. “customer care” is the most practical S.E and S.E.3, i.e. “using
a computerised system” is outnumbered by the other S.E.s. As for the C.R.s, even though
prioritisation points out the patients’ most fundamental expectations, more scrutiny is
required to determine the aspects that the radiology departments should reinforce. The
reason is that the prioritisation reveals specifically what type of services the patients believe
to be necessary, yet it does not indicate the level to which those services are delivered. On that
account, the importance - satisfaction analysis is provided to inspect how the patients’
different expectations are answered and what angle the radiology departments should take to
meet the demands more successfully.
Figure 6 highlights the survey results of the importance and customer satisfaction of each
C.R. As the result shows, the C.R.s are distributed in the four quadrants of the importance -
satisfaction matrix (see Figure 3). The importance-satisfaction rating is based on the concept
that the organisation will maximise overall patients’ satisfaction by emphasising
improvements in those service categories where satisfaction is relatively low, and the
perceived importance of the service is relatively high. The radiology departments’ strategy
for the C.R.s of each category should be uniquely different because these demands are being
fulfilled unevenly.
The first quadrant, i.e. the surplus area, consists of C.R. 24, 13, 10, 15, 18, 1, 12 and 7. These
are the expectations being addressed sufficiently in the patients’ eyes. Nonetheless, due to
their low importance, they cannot lift the patients’ assessment of the department very high. In
Strong Positive Relationship
Quality
Weak Positive Relationship function
Strong Negative Relationship deployment
Weak Negative Relationship
Service elements
Importance rating
Weight
Patients'
SE10
SE11
SE12
SE13
SE14
SE15
SE16
SE17
SE18
SE19
SE20
SE21
SE22
SE23
SE1
SE2
SE3
SE4
SE5
SE6
SE7
SE8
SE9
Requirements
CR1 14 9 0 0 0 0 0 0 3 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 4.04
CR2 15 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 3.96
CR3 20 0 0 0 0 0 0 0 9 0 0 0 3 0 0 9 0 0 0 0 0 0 0 0 3.4
CR4 3 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 9 0 0 0 0 0 1 0 4.68
Tangibility
CR5 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 9 0 0 0 0 0 0 4.76
CR6 4 0 0 0 9 0 0 3 0 0 0 3 0 0 0 0 0 1 0 0 0 9 0 9 4.66
CR7 19 0 0 0 0 9 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 3.58
CR8 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4.52
CR9 11 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 4.34
CR10 17 0 1 0 0 0 0 0 0 0 1 1 3 0 0 0 3 0 1 0 0 1 3 0 3.70
Reliability
CR11 2 0 9 1 0 0 0 0 0 0 1 3 1 0 0 0 0 0 0 3 9 0 0 0 4.70
CR12 16 0 0 1 0 0 0 0 0 0 0 0 9 0 0 3 0 0 0 0 0 0 0 0 3.76
CR13 22 0 0 1 1 0 1 3 0 0 1 0 9 1 0 0 0 0 1 1 1 0 0 0 3.20
CR14 8 0 0 0 0 0 0 0 0 0 9 0 1 0 0 0 0 0 0 9 0 0 0 0 4.54
CR15 23 0 9 1 0 0 0 0 0 0 0 0 1 0 9 0 0 0 1 0 0 0 0 0 3.12
Responsiveness
CR16 7 0 0 3 9 0 0 0 0 0 3 0 1 0 0 0 0 0 0 0 0 0 9 1 4.56
CR17 10 0 0 0 9 0 1 3 0 0 3 0 3 0 9 0 0 0 9 0 3 0 0 0 4.40
CR18 18 0 0 0 9 0 0 9 0 0 3 0 3 0 0 0 0 0 0 0 1 0 0 0 3.62
CR19 24 0 0 0 0 0 0 0 0 0 0 0 3 9 0 0 0 0 0 0 0 0 0 0 3.08
CR20 5 0 0 0 0 0 0 0 0 9 0 0 1 0 0 0 0 0 0 0 0 0 0 0 4.62
CR21 6 0 0 0 0 0 0 0 0 9 0 0 3 0 0 0 0 0 0 0 0 0 0 0 4.60
Assurance CR22 13 0 0 0 0 0 9 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 4.14
CR23 12 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 4.28
Empathy
Figure 4.
CR24 21 0 0 0 1 0 9 3 0 0 1 0 9 1 0 0 0 0 0 0 0 0 0 0 3.22 HoQ for the problem
SEs Importance index 36.36 74.08 28.46 161.58 32.22 73.84 79.02 47.48 55.02 93.42 67.3 234.68 30.92 72.02 41.88 53.22 47.5 49.62 58.16 62.32 45.64 56.82 46.5
at hand
other words, the C.R.s of this quadrant are overly satisfied, which makes them more critical
since the surplus in efforts and allocation of resources could be clues of underachievement in
productivity. These are also could prove pivotal in cost reduction analyses. The second
quadrant, i.e. the excellent area, contains C.R. 6, 22, 16, 5, 9 and 23. These demands are both
imperative and adequately satisfied. In fact, these demands could be considered the strengths
of the radiology departments, and policies should be placed to ensure maintaining their
current quality levels.
The next section is the careless area, which contains C.R. 2, 19 and 3, which are neither
important nor satisfied according to the matrix, hence doing little to elevate the patients’
judgments. Their low satisfaction rate also shows that not many resources and energy are
spent in this area, and therefore it can be considered an allowed overlook. The last quadrant,
BIJ i.e. to be improved area, includes C.R. 11, 17, 4, 20, 14, 8 and 21. These are the aspects that the
patients consider crucial but unsatisfying. Therefore, this area is the priority for attention and
enhancement and perhaps contains the most vital requirement factors to successful quality
improvement. Due to their significance and determinative nature, the C.R.s of this quadrant
are analysed more closely.
At this juncture, the relationships between the fourth quadrant’s C.R.s and S.E.s, which
affect them, are explored. There are seven C.R.s, including “service schedules are
implemented correctly and less waiting time”, “fast responses to any phone questions”,
“enough equipment and an adequate number of radiologists”, “cost of services”, “quick
appointments for emergency patients”, “allocate appropriate space for the radiology
department due to the special condition of its patients”, and “be covered by patient
insurance”. Table 5 summarises these factors and displays their respective importance and
100
Satisfaction Importance
80
60
40
20
Figure 5. 0
Satisfaction and
importance of the five
dimensions of
SERVQUAL
Prioritisation of C.R.s Scores Prioritisation of S.E.s Scores
C.R.5 4.76 S.E.12 234.68

C.R.11 4.70 S.E.4 161.58
C.R.4 4.68 S.E.10 93.42
C.R.6 4.66 S.E.7 79.02
C.R.20 4.62 S.E.2 74.08
C.R.21 4.60 S.E.6 73.84
C.R.16 4.56 S.E.14 72.02
C.R.14 4.54 S.E.11 67.30
C.R.8 4.52 S.E.20 62.32
C.R.17 4.40 S.E.19 58.16
C.R.9 4.34 S.E.22 56.82
C.R.23 4.28 S.E.9 55.02
C.R.22 4.14 S.E.16 53.22
C.R.1 4.04 S.E.18 49.62
C.R.2 3.96 S.E.17 47.50
C.R.12 3.76 S.E.8 47.48
C.R.10 3.70 S.E.23 46.5
C.R.18 3.62 S.E.21 45.64
C.R.7 3.58 S.E.15 41.88
C.R.3 3.4 S.E.1 36.36
C.R.24 3.22 S.E.5 32.22
Table 4. C.R.13 3.20 S.E.13 30.92
Prioritisation of the C.R.15 3.12 S.E.3 28.46
C.R.s and S.E.s C.R.19 3.08
4.28 Quality
CR7
function
4.08 CR12 deployment
CR1
3.88
CR18
CR23
3.68 CR15 CR9
CR16 CR5
3.48 CR22
CR10
CR6
SaƟsfacaƟon
CR13
3.28 CR24 CR3
CR21
3.08
CR8
CR14CR20
2.88
CR19 CR4
2.68
CR17
2.48 CR11
2.28
Figure 6.
CR2 The importance–
2.08 satisfaction matrix of
3.08 3.28 3.48 3.68 3.88 4.08 4.28 4.48 4.68 4.88 the C.R.s in the
radiology departments
Importance
satisfaction scores. The S.E.s that affect each C.R. are specified as “effective S.E.s”, and in
view of comprehensiveness, the correlations between these S.E.s are also factored in as
“related S.E.s”. For the sake of brevity, only the strongest relationships in matrices D and E
are considered here. This would help produce a timelier and more reliable conclusion.
In order to validate the findings, Table 5 is presented to the expert group. The group were
initially asked to offer opinions about the accuracy of the findings. Each expert was requested
to give a score from 1 to 5 to the consistency, reliability and rationality of the findings, making
the maximum possible score equal to 75. The survey’s final score was 69, which means the
experts consider the results 92% reliable. In the second round, the Delphi method is deployed
to provide practical, strategic solutions for enhancing the patients’ experience and judgement
4th quadrant Importance Satisfaction

C.R.s score score Effective S.E.s Related S.E.s
C.R. 11 4.70 2.40 S.E.2 S.E.20 S.E.3 S.E.19

C.R. 17 4.40 2.50 S.E.4 S.E.14 S.E.2
S E.18 S.E.3 S.E.10
C.R. 4 4.68 2.74 S.E.11 S.E.16 S.E.2 S.E.11 S.E.16 S.E.22
S.E.23
C.R. 20 4.62 2.86 S.E.9 S.E.12
C.R. 14 4.56 2.88 S.E.10 S.E.19 S.E.18 S.E.20 Table 5.
C.R. 8 4.52 2.94 – – The details of the
C.R. 21 4.60 3.10 S.E.9 S.E.12 fourth quadrant’s C.R.s
BIJ of the department with regard to the fourth quadrant C.R.s. In several rounds, the experts
gave suggestions about how the unsatisfied C.R.s could improve. Each expert gave their tips
about each C.R separately. Afterwards, seven anonymous lists of suggestions focusing on the
seven C.R.s were assembled and presented to the experts. The experts were asked to rank
the suggestions and offer new suggestions if new ideas struck. The experts also highlighted
the recommendations they thought of as certified or poor. This way, the suggestions are
modified, and the most pragmatic ones are specified. This process continues until all the
suggestions are rated as certified. The result of this analysis produces a cause-and-effect
diagram, as presented in Figure 7.
5. Discussion
This section considers the implications of the findings and aims to specify how the study’s
outcomes are helpful. In the following, the theoretical and practical implications of the
findings are given to clarify their applicability and the benefits, and a comparative analysis is
conducted to reflect the study’s compatibility with previous contributions.
5.1 Theoretical implications
This study proposed an integration of the QFD and SERVQUAL methods to indicate the
system characteristics affecting patients’ requirements in the radiology department.
The proposed approach employs the QFD methodology as the primary technique to
C.R.14: Quick C.R.4: Enough C.R.11: Service

appointments equipment and schedules are
for emergency an adequate implemented
patients number of correctly and
radiologists less waiting
Deployment of task
organising software
Designing in-service Taking advantage of both Implementing an
programs to enable staff with younger and experienced online appointment
skills to ace in urgency schedulers and specialists booking system
situations to maximise efficiency
and effectiveness
Constructing separate entrance door
orr Adopting patient
and allocating sizable waiting prioritising systems based
rooms to the radiology departments Economic assessment of
on urgency and severity to
increasing the number
shorten waiting times
staff and equipment
C.R.8: Allocate Improvement in
appropriate space patients’
for the radiology experience and
departments due to judgment of the
the special Instalment payment plans radiology
condition of its or prompt payment Analysing and departments
patients discount, especially for optimising staff number
patients who come in
Provide patients’ access Strengthening staff ability
regularly due to their
to counsellors to enroll in in creating effective
physical condition
healthcare plans communication with the
patients
Cooperative collaboration
with health insurance Partner with in-house non- Implementing and
companies to mitigate commissioned advisers improving remote
payment conditions communication channels
Figure 7.
The cause-and-effect
diagram for the C.R.21: Be C.R.17: Fast
C.R.20: Cost of
radiology departments’ covered by patient responses to any
the services
quality improvement insurance phone questions
gather VOC in the radiology department for the first time. The SERVQUAL analysis is used Quality
to support the method, which broadens the understanding of QFD findings and covers some function
of its major shortcomings, as discussed earlier (see Section 2). The ISA analysis is also
employed to obtain additional patient-based knowledge about the balance of importance and
deployment
satisfaction among the C.R.s. This joint analysis, although not novel, is pioneered in the
radiology department by the present study and uncovers new aspects of the radiology
departments’ strengths, weaknesses and their patients’ expectations.
5.2 Practical implications

Based on the study findings, the radiology departments have 23 S E s in which the most
effective one is “Customer care”. This means that customer care has the most influential role
in shaping the patients’ judgement about the quality of service. In other words, the most
important element of service in radiology departments is being careful and attentive towards
the patients because it has the strongest correlation with their requirements. In addition, the
patients also have 24 main requirements classified based on the SERVQUAL model stages. It
is shown that the most impactful requirement is the modernity and efficiency of the devices
and apparatuses, which means that the radiology managers will best answer the patients’
needs if they provide them with up to date and high-quality machines (see Table 4). The result
also highlighted the maximum difference between satisfaction and importance in three
dimensions of SERVQUAL: tangibility, responsiveness, and reliability, on which the
responsiveness also has the lowest level of satisfaction (see Figure 5).
Moreover, the ISM model divided the patients’ requirements into four categories and the
“to be improved” category is suggested as the attention priority. Seven requirements are
placed in the mentioned category: “Service schedules are implemented correctly and less
waiting”, “Fast responses to any phone questions”, “Enough equipment and an adequate
number of radiologists”, “Cost of the services”, “Quick appointments for emergency patients”,
“Allocate appropriate space for the radiology department due to the special condition of its
patients”, “Be covered by patient insurance”. Among the requirements, the requirement
“Service schedules are implemented correctly and less waiting” ranked the highest among the
“to be improved” requirements as it has the highest importance score and the lowest
satisfaction score. This requirement is also significantly affected by the service elements
“Organising a timetable of services for patients” and “Scheduler speed and knowledge”
(see Figure 6 and Table 5). These requirements are heavily discussed through a Delphi
method, and suitable recommendations are provided on how to improve the radiology
departments’ quality level according to each need. Finally, a cause-and-effect diagram is
presented, which summarises the suggestions (see Figure 7).
To sum up, this study discovers the important factors that greatly affect the service
quality in radiology departments and, by doing so, helps the radiology managers in detecting
what can be the cause of low performance or the key to improvement. These factors are
introduced by the ranking of S.E.s and C.R.s, as well as by classifying the C.R.s and finding
the most decisive group of patient expectations. This study also proposes its own practical
approaches to overcome the weaknesses and boost performance. These suggestions are
manifested in the form of a cause-and-effect diagram along with the suggestions provided in
the diagram and can benefit the managers as a prescriptive tool to improve the service level of
the radiology departments.
5.3 Comparative analysis

In order to perform a comparative analysis, two studies about the quality of service in radiology
departments are briefly introduced to compare their results with the present study’s results.
This aims to evaluate this study’s compatibility with the previous contributions. In the first
study, Mulisa et al. (2017) used a stratified sampling technique to perform an institution based
BIJ cross-sectional study among 321 radiology patients. The authors measured the patients’
satisfaction using SERVQUAL which consisted of seven dimensions: accessibility, quality of
radiological service, courtesy of radiology staff, the existence of good communication with the
service provider and desk worker, physical environment and privacy technique. They also
utilised several logistic regressions to identify independent factors that influenced patients’
satisfaction with radiological services. Based on the study’s results, the level of education of the
patients, their occupation and the waiting time have the most influence on their satisfaction
with the services. The authors conclude that the reason for the gap between the satisfaction of
more educated and less educated patients’ needs further discussion, and provide two
recommendations: A. An increase in attention and care towards patients. B. shortening the
waiting times. In the second study, Camg€oz-Akda g et al. (2018) employed VSM to view the
general condition and the problems of the radiology department and benefited from an HoQ to
prioritise the problems. The authors emphasized shorter waiting times and delays by indicating
that the application of IoT will decrease the duration of writing and giving a report to a patient,
and will reduce the time they have to spend in hospitals corridors. They also suggested that
new technological devices and equipment are imperative to increasing patient satisfaction.
Table 6 compares the results of the two studies with the present study. It can be seen that
minimising the length of time the patients are forced to await the procedure is suggested in
both studies. This item is equivalent to the requirement “Service schedules are implemented
correctly and less waiting” in the present study, which is established as the highest priority
for improvement based on the ISM analysis. This study also discovers the service elements
that affect this requirement and addresses the ways it can be improved through a Delphi
consensus. With regards to other recommendations, customer care and the modernity of the
equipment are both emphatically advised in Mulisa et al. (2017) and Camg€oz-Akda g et al.
(2018) studies, respectively.
6. Conclusion
Rested on the fact that the medical services hold an essential responsibility in determining the
life expectancy and increasing social well-being in today’s society, the current study seeks to
identify and broadcast the needs and demands of customers to the medical decision-makers.
Therefore, we aimed to assess and improve the quality of services of the radiology
departments, which is an integral part of the health service. In this regard, the radiology
departments’ patients are identified as customers, and the components of the services
provided by mentioned departments for their customers are the object of the research.
The purpose of the effort was to form a framework by which the customers’ demands could
help revise and improve the radiology departments. Quality function deployment is a widely
approved and effective methodology in extracting the customers’ demands and is enhanced
with the SERVQUAL model to be applied in this study to comprehend the radiology patients’
wishes and needs on a deeper level. This leads to the weaknesses of the discussed
departments more efficiently. This framework can help managers identify strengths and
weaknesses by translating customer voices throughout the product or service chain.
References Recommendations for improvement in radiological services
Mulisa et al. (2017) An increase in attention and care towards patients

A decrease in waiting times
Camg€oz-Akda
g et al. (2018) Shorter waiting times
Table 6. New technological devices
Comparison of results This study Service schedules are implemented correctly and less waiting
with two related Customer care
studies Modern equipment with High quality
This study is carried out in public hospitals in Tehran by identifying and analysing the Quality
expectations of patients and elements of the radiology departments to evaluate and improve function
the quality of services, and appropriate improvement priorities are obtained. It is expected
that by exercising the results, the level of quality of services provided will increase and
deployment
ultimately lead to higher patient satisfaction.
This study faced several limitations. One of the main limitations is the dependency of the
proposed method on inaccurate and subjective data when translating the customers’ voices.
Plus, the importance-satisfaction model also relies upon subjective judgements. Therefore, in
the future, methods and tools could be considered that deal with imprecise data to formulate
more uncertainty and reflect real-world situations more sharply. Besides, future research
could focus on prioritising the provided solutions and recommendations to determine which
course of action has precedence and could more effectively lead to quality improvement.
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Corresponding author
Seyed Mohammad Hassan Hosseini can be contacted at: sh.hosseini@shahroodut.ac.ir
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Service Quality Improvement by Using the Quality

Abdurrozzaq Hasibuan1*, Luthfi Parinduri1, Oris Krianto Sulaiman1,

Abstract. In the face of increasingly competitive competition in the hospital industry,

Figure 1. House of Quality

Table 1. Determination of the Sample Amount of Each Level

Table 2. Total Value of Data on the Importance of Variables in Patient Needs

Figure 2. Gaps Between Patient Interest and Hospital Service Level.

House of Quality Matrix Analysis Characteristics of RSU Service Services

An application of quality function Quality

approaches to enhance the service

Frankel et al. (2005) U 3 +

Joshi and Bhargava (2019) U 3 +

B. Service elements (HOWs)

Forming expert group

Identify the customers of the service Identify services elements by

Determining weight of each Patients’ Determining the Relationship

Determining the relationship between customers’

Service elements priorities by

Assessing the customers’

Forming the importance-

Figure 2. Providing improvement

3.1 Identifying customers, determining and collecting C.R.s

3.3 Prioritising patients’ requirements

Code Needs and requirements Ref.

CR1 The general atmosphere in the radiology department Camg€oz-Akda

sampling. Finally, matrix C of HoQ is constructed. The calculation of C.R.1 weight is

3.4 Relationship between S.E.s

3.5 Relationship between C.R.s and S.E.s

3.6 Service elements priorities

The importance rating of S.E.1 is calculated as an example:

At the end of this stage, matrix F of HoQ is constructed.

3.7 Assessing the customers’ satisfaction

3.8 Importance-satisfaction analysis

1. Surplus area 2. Excellent area

3. Careless area 4. To be improved area

reliability, responsiveness, assurance and empathy. As it can be spotted in Figure 4, the

Assurance CR22 13 0 0 0 0 0 9 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 4.14

Prioritisation of C.R.s Scores Prioritisation of S.E.s Scores

C.R.5 4.76 S.E.12 234.68

4th quadrant Importance Satisfaction

C.R. 11 4.70 2.40 S.E.2 S.E.20 S.E.3 S.E.19

C.R.14: Quick C.R.4: Enough C.R.11: Service

5.2 Practical implications

5.3 Comparative analysis

References Recommendations for improvement in radiological services

Mulisa et al. (2017) An increase in attention and care towards patients

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