ISSN 0952-6862

Volume 21 Number 1 2008

Health Care Quality Assurance
Addressing the issues of management and quality
Patient satisfaction structures, processes and outcomes

International Journal of

International Journal of Health Care Quality Assurance
Patient satisfaction structures, processes and outcomes
Editors Keith Hurst and Kay Downey-Ennis

ISSN 0952-6862 Volume 21 Number 1 2008

Access this journal online ______________________________ Editorial advisory board ________________________________ Editorial __________________________________________________ Gearing service quality into public and private hospitals in small islands: empirical evidence from Cyprus
Huseyin Arasli, Erdogan Haktan Ekiz and Salih Turan Katircioglu ______

3 4 5



Measuring the three process segments of a customer’s service experience for an out-patient surgery center
Angela M. Wicks and Wynne W. Chin _____________________________


Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients
Brian A. Costello, Thomas G. McLeod, G. Richard Locke III, Ross A. Dierkhising, Kenneth P. Offord and Robert C. Colligan _________


Access this journal electronically
The current and past volumes of this journal are available at:
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The role of understanding customer expectations in aged care
Leib Leventhal _________________________________________________


Patient claims and complaints data for improving patient safety
Pia Maria Jonsson and John Øvretveit _____________________________


Evaluating hospital service quality from a physician viewpoint
Peter Hensen, Meinhard Schiller, Dieter Metze and Thomas Luger ______


The influence of service quality and patients’ emotions on satisfaction
Maria Helena Vinagre and Jose Neves _____________________________ ´


The relative importance of service dimensions in a healthcare setting
Rooma Roshnee Ramsaran-Fowdar ________________________________


CENTRE SECTION News and views __________________________________________ Recent publications ______________________________________

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The Netherlands Professor John Øvretveit The Nordic School of Public Health. Quality Management and Performance Measurement Research Unit. Belgium Dr Kristina L. Gibraltar Professor Dr Johannes Moeller University of Applied Sciences. Marketing Black School of Business. Gaucher Group Vice President Operations. Quality and Customer Satisfaction. 4 # Emerald Group Publishing Limited 0952-6862 . Allied Health Administration. Universidad Complutense de Madrid. Singapore Peter Wilcock Visiting Professor in Healthcare Improvement. Sweden Helen Quinn Senior Lecturer/Academic Lead for Internationalism. UK Professor Abdul Raouf Institute of Leadership and Management. St Bernards Hospital. AIAR. University of Strathclyde. Healthcare and Services Management. St Vincent’s Hospital.IJHCQA 21. King Saud Health Sciences University. 2008 p. School of Healthcare. Centre for Clinical Governance Research. Department of DMEM. School of Public Health. Faculty of Economics and Business Administration. Faculty of Health Sciences. Hamburg. UK Ales Bourek National Board of Medical Standards. 1. 21 No. Saudi Arabia Dr Karen Norman Director of Nursing and Patient Servcies. Pakistan Ulises Ruiz Faculdad de Medicina. Germany Max Moullin Director. UK 4 Dr Syed Saad Andaleeb Professor and Program Chair. Australia Ian Callanan Clinical Audit Co-ordinator.1 EDITORIAL ADVISORY BOARD Dr Waleed Albedaiwi Quality Management Advisor and Director. Czech Republic Professor Jeffrey Braithwaite Director. Guo Associate Professor. Spain Dr Keng Boon Harold Tan Ministry of Health. Ghent University. UK Dr Udo Nabitz JellinekMentrum. Ireland Ellen J. Penn State Erie. USA Professor Jiju Antony Strathclyde Institute for Operations Management. University of Hawaii’i-West O’ahu. Hawaii International Journal of Health Care Quality Assurance Vol. Wellmark Blue Cross Blue Shield of Iowa and South Dakota. Salisbury NHS Foundation Trust. University of Leeds. Sheffield Hallam University. USA Paul Gemmel Professor. Bournemouth University and Director of Service Improvement. Faculty of Medicine. University of New South Wales.

readers will be surprised how Editorial 5 International Journal of Health Care Quality Assurance Vol. They used SERVQUAL – notably the instruments’ five dimension – to compare and contrast private and state hospital patient satisfaction. 1. dissects and develops SERVQUAL. a patient needs a lower limb amputation owing to smoking-related peripheral vascular disease. manuscript submissions and author downloads steadily increased in 2006-2007. and introduce a middle “process” segment. It is harder. processes and outcomes Two things prompted us to produce our second special issue this year. Ramsaran-Fowdar goes on to underline customer loyalty and retention’s importance and relevance to private healthcare – discussion that adds considerably to commentaries in the related articles we publish here. and we are fortunate to publish two private patient satisfaction-oriented studies.’s commentary. Wicks and Chin also concentrate on SERVQUAL but in USA outpatient surgery contexts. The second private patient oriented manuscript emerges from Ramsaran-Fowdar’s Mauritian study. They not only explore unusual elements such as patients’ perceptions after using both public and private hospitals but also they reveal SERVQUAL dimension differences between the two services. Readers also will benefit from the lessons Arasli et al. fascinating patient satisfaction issues emerge that are important for health service managers and practitioners. We wanted to address private and public patient satisfaction. to satisfy the patient because he or she does not want this course of action. therefore. They also spend time carefully explaining methods for modifying existing. A unique feature in Ramsaran-Fowdar’s article is her needs and wants’ section. Second. Her detailed psychometric explorations relate to both general and private healthcare. 5-7 q Emerald Group Publishing Limited 0952-6862 . Consequently. The authors remind us that service quality is one of the most important drivers behind customer attraction. The resulting Cypriot health service strengths and weakness findings are likely to make managers and practitioners worried or proud. 2008 pp. He or she needs to stop smoking to preserve the remaining limb. learned from their explorations into SERVQUAL’s psychometric properties. this issue’s authors not only revisit stalwart patient satisfaction debates but also explore new topics not often encountered in the literature. First. 21 No. Long-in-the-tooth patient satisfaction researchers know this minefield well. and her findings reveal that seven not five SERVQUAL quality dimensions are needed for Mauritian private health services. First. That is. although it might not be thought possible that new patient satisfaction insights can emerge. In short. patient satisfaction remains a popular author and reader topic. Unexpected findings also materialise such as staff social skills’ importance in patient satisfaction. valid and reliable patient satisfaction measures for use in different settings. Similarly. Ramsaran-Fowdar too unpicks. the eight manuscripts and 50 K words amount to a themed book containing novel elements on clearly what is an important and enduring quality assurance subject.Editorial Patient satisfaction structures. retention and loyalty. Arasli and his colleagues offer fascinating insights into Cypriot patient expectation and satisfaction. One particular sobering analysis for insurance-based healthcare managers and practitioners is the cost difference between: losing loyal patients. which usefully extends and develops Arasli et al. They concentrate on two existing SERVQUAL segments: expectations (or pre-process) and perceptions (or post process). and recruiting new ones.

Because some patients completed the patient satisfaction questionnaire ten years after answering the MMPI. Specifically.1 6 relatively unimportant empathy seems to be in the patients’ rankings. Moreover. the authors concentrate on two enduring and stable personality characteristics – pessimism and hostility. and readers will emphasise with the case study family. The author argues that elderly care services and user expectation and satisfaction are complex owing to the aged patients’ vulnerability – particularly their retribution and reprisal fears. despite lower satisfaction scores. satisfaction and emotions. Readers familiar with customer satisfaction literature know that health service researchers usually borrow from industry and commerce. Might it be possible that patient behavioural and emotional characteristics are equally if not more important satisfaction drivers? The Mayo study. Readers should find their method explanation and discussion educational. Unusually. Their customer-provider framework and the way they dissect patient expectation and satisfaction are also useful. However. The authors extracted almost 1. which they modify to fit local culture. Their premise is that we should not assume patient satisfaction or dissatisfaction (as healthcare outcomes) naturally follow healthcare structures and processes. Portuguese patient service expectation. He concentrates on elderly patient and elderly care service stakeholder expectation and satisfaction. It showcases poor service structures. Leventhal’s bitter-sweet article is a lesson to service providers. a secondary analysis of archived information.. patient satisfaction is a complex and multi-factorial healthcare outcome. a study we hope to publish later. Clearly. they are just as likely to recommend a provider to family and friends.300 patients that answered both questionnaires. Discussion around SERVQUAL’s history and development reinforces discussion elsewhere. the authors finish with arguments for modifying their patient satisfaction measure for non-health use. Intriguingly. the Mayo team are following-up this study with a separate analysis about which patient types are likely to respond to patient satisfaction questionnaires. they argue that these two behaviours are more tangible during patient-physician contact – another reason for concentrating on these two personalities. their warnings about adopting of-the-shelf patient satisfaction studies without adjusting them to suit local culture are salutary. elderly patients’ children) influences on face-to-face care become clear. In short. In common with other authors in our special issue. Vinagre and Neves’ related project connects.g. government accreditation agencies’) and bottom-up (e. process and outcomes. among other things.g. Moreover. . Readers may not be surprised to learn that pessimistic and hostile patients are less likely to rate care higher. which is often used in consumer research but infrequently if hardly ever used in patient satisfaction studies. Leventhal uses a case study to illustrate his arguments. the authors tie SERVQUAL data with a range of patient emotion scores from the Differential Emotional Scale II. the top-down (e. combines Minnesota Multiphasic Personality Inventory (MMPI) and patient satisfaction data. other stakeholder pressures cannot be ignored.IJHCQA 21. However. Readers will not find many finer examples of analysts borrowing broader (expectation and disconfirmation) theories and models and using them to explore and explain healthcare structures. It is good that healthcare research and development leads the way! We are also fortunate to publish the Mayo team’s and the Vinagre-Neves’ ground-breaking patient satisfaction studies.. processes and outcomes when statutory healthcare services are not up to the mark. their starting point is SERVQUAL.

one dataset shows incidents tripling in 25 years. the implications for practitioners and managers are clear. readers will benefit from the authors’ thorough and clear method section. clinician response rates are notoriously poor and unfortunately the authors were victims. For example.e. Westbrook. and despite the low “turn-out”. 7 was authored by Jeffrey Braithwaite. 20 No. was authored by Mary T. What is known. Mary T. For example. Specifically. In common with other articles in this special issue. completed an intriguing study and report. 20 No. Christine Jorm and Rick A. Iedema. Nevertheless. Hensen and his German co-authors. Referrer behaviour is tangibly observable but variations remain unexplained. the picture is complex since patient complaints in another database levelled in comparison. comparing complaints and claims information shows that the true adverse event frequency may be underestimated. They concentrate on “internal customers” (fellow health service professionals) rather than “external customers” (patients). for example. the eight articles include helpful reference lists that should arm patient satisfaction researchers and writers with a valuable resource. Debbi Long. Plainly. provider clinicians have a strong positive image about their services. 21 No. important findings emerge. Rowena Forsyth. is worrying. published in the same issue. Not only are complaints and claims results explored and explained but also important methodological issues are painstakingly aired as a warning to researchers analysing similar fields. for example. In short. questionnaire surveys in this context are always on thin ice. The authors revisit information stored in three complaints and claims databases. Unperturbed. the paper “Promoting safety: longer-term responses of three health professional groups to a safety improvement programme”. Jeffrey Braithwaite. Comparing referring physician (i. while referrers’ perceptions are less upbeat. 7) and it would pay to read their work in a patient safety context. Debbi Long. Merely benchmarking within and between countries and feeding back results. Travaglia. Joanne F. Travaglia. Mallock. Christine Jorm and Marjorie Pawsey. however. Stakeholder analyses are paramount therefore. Patient commendations are a strong theme in the article and interestingly. Rick Iedema. attitudes and practice” published in Vol. Joanne F. . However. the stakeholders and gatekeepers) with provider clinician (hospital core staff) service quality perceptions proved fascinating. Keith Hurst Editorial 7 Erratum We would like to point out that the paper “Are health systems changing in support of patient safety? A multi-methods evaluation of education. 1 materials’ range and depth makes it an essential text for the library shelf. Vol. Finally. Also. is educational if not instrumental for improving service quality.Jonnson and Øvretveit’s article could just as easily sit in our Patient Safety special issue (Vol. Peter Nugus. Another feature readers will notice in this issue is the range of countries included. For example. Nadine A. they offer explanations and solutions to poor response rates. Jonnson and Øvretveit’s work is groundbreaking in several ways. Westbrook. Like other articles here. geographically remote patients are less likely to recommend a service to family and friends.

These are: empathy. Additionally. Kowloon. Eastern Mediterranean University. 8-23 q Emerald Group Publishing Limited 0952-6862 DOI 10.htm IJHCQA 21. Turkey 8 Received 21 December 2005 Revised 13 April 2006 Accepted 1 June 2006 Erdogan Haktan Ekiz School of Hotel and Tourism Management. Eastern Mediterranean University. food and the physical environment. The instrument contained both service expectations and perceptions questions.The current issue and full text archive of this journal is available at www. There is considerable lack of literature with respect to service quality in public and private hospitals. Originality/value – The hospitals need to organize training sessions based on the critical importance of service quality and the crucial role of inpatient satisfaction in the health care industry. since job satisfaction leads to customer satisfaction and loyalty. Research results revealed that the various expectations of inpatients have not been met in either the public or the private hospitals Research implications/limitations – At the micro level. 2008 pp. 1. Turkey Abstract Purpose – The purpose of this research is to develop and compare some determinants of service quality in both the public and private hospitals of Northern Cyprus. Gazimagusa – (North) Cyprus. Findings – This study identifies six factors regarding the service quality as perceived in both public and private Northern Cyprus hospitals. hospital administrations need to gather systematic feedback from their inpatients. Keywords Customer services quality. Hong Kong. including other dimensions such as hospital processes and discharge management and co-ordination may provide further insights into understanding inpatients’ perceptions and intentions. who have recently benefited from hospital services in Famagusta. Future studies should include the remaining regions in Cyprus in order to increase research findings’ generalizability. The Hong Kong Polytechnic University. Hospital managers should also satisfy their Cyprus. were selected to answer a modified version of the SERVQUAL Instrument.1 Gearing service quality into public and private hospitals in small islands Empirical evidence from Cyprus Huseyin Arasli School of Tourism and Hospitality Management. relationships between staff and patients. 21 No. Additionally. the lack of management commitment to service quality in both hospital settings leads doctors and nurses to expend less effort increasing or improving inpatient satisfaction. Famagusta – (North) Cyprus. and Salih Turan Katircioglu Department of Banking and Finance. 454 respondents.1108/09526860810841129 . professionalism of staff. Private hospitals. Patients.emeraldinsight. Hospitals. New East Ocean Center. Public sector organizations Paper type Research paper International Journal of Health Care Quality Assurance Vol. giving priority to the inpatients needs. establish visible and transparent complaint procedures so that inpatients’ complaints can be addressed effectively and efficiently. Design/method/approach – Randomly. Faculty of Business and Economics.

simultaneously. This might be true for the private institutions. There has been a great deal of service quality assessment research conducted on different industries. education. understanding inpatients’ evaluations of their hospital service quality performance can help to improve existing health care system output in general and. such as a clear ¨ definition of quality service or dimensionality (Gronroos. 2001. 1990). heterogeneity. Moreover. there is no scientific empirical evidence to indicate that public hospital staff attitude is the same as their private counterparts.e. There is a generalization that service organizations. on the other hand. Valdivia and Crowe. at the same time. hospitals. It is also assumed that those inpatients. the number of satisfied inpatients and.. 1993. a hospital.. Therefore. Defining service quality is complex and necessary for any measurement effort. has functioned in terms of outcomes like service quality over several years (Labarere et al. inseparability and perishability. therefore. Cronin and Taylor. have to deal with several service product characteristics such as intangibility. Hasin et al. 1997) in the USA and European healthcare sectors.. high risks exist for the private hospitals whilst offering their services in a highly competitive environment dealing with human health. Tomes and Ng. since their structure and functioning are different. require a sustainable. like their counterparts. competitive advantage and. Within the fast developing health care industry. A strong link has been found in the literature between service quality. 1992. more attention should be given to the service quality improvement issues. Uzun.. 1985. Contrary to the above stereotyping in the literature. less attention has been paid to the comparative assessment of service quality in public and private hospitals. 2002). i. This feedback could also be used in their overall service quality improvement effort in the industry. Lim et al.. 2004). The health care expenditures equated to 9. State hospitals. 1996. Kara et al. are under public and government pressure in which these two stakeholders push them to understand inpatient needs and expectations and to provide a value added service quality. therefore. Labarere et al. It is currently acknowledged that service quality measurement can be used to understand how well a service organization. 2005. 2003). 2005. Service quality. consequently.9 percent) in the world GNP (World Development Indicators.4 and Private 3. as hospital service quality improves.3 percent of the world Gross Domestic Product (GDP) in the year 2000. However. however. 1990). which have experienced services from both hospitals over a specific period. has become the focus of considerable attention in respect of satisfying and retaining customers in the service industry (Spreng and MacKoy. inpatient satisfaction and practitioner loyalty (Pakdil and Harwood. 1990.. 1999). since the competition is unavoidable for them within the free market economic system. However. Reichheld and Sasser. Although several scales have been developed and tested to measure service quality (Parasuraman et al. health and so forth contributed 66.. including those in health care.Introduction The share of services such as tourism. the authors could not come to any common conclusion on a conceptualization of service quality and customer satisfaction issues.3 percent (Public 5. Vandamme and Leunis. which involves sensitive decision making and extensive service provision in comparison to other services. could provide valuable feedback that serves to identify the variations in both types of organizations in terms of their service provision. 2004. 1995. 2001. It has also been claimed that. loyalty increases in such a way that these inpatients may play an active role in the positive “word of mouth” business and may exert re-purchase intention and thus reduce organizational costs. may enhance service quality of specific healthcare processes (Meehan et al. far superior to other organizations. Yi. many government hospitals are blamed and Service quality in public and private hospitals 9 . and the situational factors in different industries.

67. which has examined the service quality differences by collecting data from users of both types of hospital within a specified time period. The remaining institutions are also controlled by the government. 1998. no empirical research exists to our knowledge on service quality. 2002). Arasli and Ahmadeva. Anderson. Franck et al. 2003. less is known about service quality differences between public and private hospitals (Jabnoun and Chaker. also stated that: The Ministry does not deny these ongoing problems especially in respect of the inadequate staffing levels and the lack of well established security systems in hospitals (Kibris Newspaper. is to assess and compare service quality in the Northern Cyprus public and private hospital sector. 1995. The present study’s findings may also provide hospital managers and government authorities with useful guidelines. the Doctors’ Coalition Minister. The authors primarily stated that both the public and private hospital administrations have little or no concept of systematic data collection about inpatient needs. Camilleri and O’Callaghan. 2005). 2005). lack of medical equipment and instruments. and inpatient complaints. claimed that the sector’s quality and standard are suffering from a lack of structure as well as from employing poorly qualified. the former Minister of Health and Social Affairs. They found that. disinterested staff and limited opportunities for patients to choose the doctors they want (Kibris Newspaper.. Arasli and Ahmadeva. 2004. kitchen and service sections (Kibris Newspaper. we can conclude from our personal observations. Withanachchi et al. He also stated that changing circumstances require an urgent major change. service quality.1 10 criticized today for their lack of speed owing to the inflexibility of their traditional hierarchal structures in respect of their quality improvement (Tountas et al. unprofessional personnel. 2005. Cyprus hospitals’ service quality using a public opinion survey. although private hospitals conditions are better than those of their public counterparts. The foremost aim of this study. there are nine public and 52 private hospitals.. Poor service quality has been identified as a problem for many years.IJHCQA 21. medicine and facilities. For example. therefore. Celal. Study context Healthcare services are carried out by both public and private institutions in Northern Cyprus. predominantly in legislation. The contribution of this study to the relevant literature. for the first time. 2005). that several ongoing quality problems exist in Northern Cyprus healthcare. In other words. the health care challenges. is two fold. This introductory section provides a brief description of the service. as well as the conceptual relationship between . 2004). their proposed model also provided indicators for overcoming these problems by employing a total quality management (TQM) approach. the Public Personnel Association Head. Jack and Phillips. First. corroborated by the above statement. poor service quality and of low priority given to the inpatients’ needs. Specifically. both are still suffering from a degree of low quality equipment.9 percent) belong to public hospitals (Arikan. Just one year later. Whilst pinpointing service-quality problems. Caluda. 2004. with which to develop some future strategies for the promotion of a quality health care service. long waiting lists. then. Furthermore. complained about the inadequate number of personnel in the hospitals’ cleaning. The majority (626 beds. Second. Arasli and Ahmadeva (2004) empirically measured. 2004. The current Minister of Health and Social Affairs.. Gulle. 1993). highlighted additional problems such as institutions’ financial incapability. Arabacioglu. In a recent study.

Originally. (4) assurance – the knowledge and courtesy of employees and their ability to inspire trust and confidence. for example. which a company provides and/or offers its customers in terms of its individualized and personalized attention (Parasuraman et al. (1988) replaced the former version of the service quality measurement. there are five common characteristics. competence. Jabnoun and Chaker (2003). 1991. which enjoy greater government patronage and funding. Boulding et al. 1996. Lim and Tang (2000) attempted to determine the expectations Service quality in public and private hospitals 11 . Uzun. developed an instrument and validated it across various service environments. credibility. At a later stage. they recommended that private hospitals need to carefully design inpatient-oriented strategies focusing on reliability improvement in order to compete effectively with the public hospitals. Carman. which could be applicable to service organizations: (1) tangibility – facilities. 2004. 2003. credit card services and car maintenance (Arasli et al. 1997. which included twenty-three items representing six dimensions (empathy. Babakus and Boller. equipment and the presence of personnel. inpatient satisfaction and recommendations and some background information about Northern Cyprus public and private hospitals. Coyle and Dale. 2005. Gabbie and Neill. 1993. 1990). access. 1993. Kilbourne et al. 2001. communication and a willingness to understand the customer. 2000. Lam et al. such as tangibles. reliability.service quality. 1996. Asubonteng et al. level of administrative response and support skills).. (1988). dentistry.. (3) responsiveness – willingness to provide help and a prompt service to customers. insurance. security. responsiveness. The scale’s founders contended that whilst each service-producing industry is unique. Mehta et al. many researchers and practitioners replicated. 1992). The main aim at that time was to develop general criteria for measuring service quality in various service organizations in different sectors. Fick and Ritchie.. 1995. They found that the public hospital inpatients were more satisfied with service quality than their private hospital counterparts. compared service quality practices between the private and public hospitals in the United Arab Emirates. 1999. 1994. such as higher education. reliability.. health care. Parasuraman et al. Half were aimed at measuring service user expectations and the remaining half measured perceptions. Thus there are a limited number of studies. They originally identified ten service quality factors generic to the service industry. communications. courtesy. tourism. Babakus and Mangold. which used the SERVQUAL scale specifically in the public and private health care industry. the SERVQUAL scale contained 22 pairs of items. Parasuraman et al.. Sohail. and (5) empathy – caring and understanding. tangibles. Literature review Parasuraman et al. The seven-point Likert scale is used by some researchers while others use the five-point format. Lam and Zhang. 1999. 2005... (2) reliability – ability to perform the promised service responsibly and accurately. 1988). (1985) initially developed the SERVQUAL scale. developed and integrated these reformed scales into the various service industry sectors (Pakdil and Harwood.. After Parasuraman et al. 1992. banks. Nelson and Nelson. Through the use of a modified SERVQUAL scale. Moreover. Sultan and Simpson.

1 12 and perceptions of inpatients in Singaporean hospitals through the use of a modified SERVQUAL scale that included twenty-five components representing the tangibles. H2b. communication. assuming that errors of judgment in the selection will tend to counterbalance one another”. We also aim to compare both types of hospitals’ service quality. responsiveness. Results also indicated that both groups have room for improvement. 2005).8 percent – a percentage we deemed acceptable. a total of 650 questionnaires were printed and distributed to respondents. with 25 items representing five aspects of service quality (responsiveness. H1b. Both public and private hospitals meet inpatients’ expectations. as well as their effectiveness in meeting the expectation of their inpatients. assurance.IJHCQA 21. Private hospitals are more successful than public hospitals in providing health care services for inpatients. H3a. Based on the above discussion and arguments. empathy. Both public and private hospitals do not meet inpatients’ expectations. In order to collect quantitative data for the study. Method We primarily develop and test a modified SERVQUAL scale for public and private hospitals in Northern Cyprus. Judd et al. Finally. In total. . Private Hospitals are no more successful than public hospitals in providing health care services for inpatients. Sample There is one public and 12 private hospitals that include large-scale clinics in which surgery is carried out. The total bed capacity in these hospitals is 294 of which 180 are public and 114 are private (Kobat. Analysis covering 252 inpatients revealed that there was an overall service quality gap between in-patients’ expectations and their perceptions. There is a difference between public and private hospitals concerning their service quality. we hypothesize that: H1a. There is no difference between public and private hospitals concerning their service quality. (1991. A modified SERVQUAL scale. discipline and baksheesh (devotion or dedication)). Family members who had benefited from the services of both public and private hospitals within a two-year period were asked to complete a self-administered questionnaire. assurance. 136) defined judgmental sampling or purposive sampling as “picking cases that are judged to be typical of the population in which we are interested. Our study sample consisted of Turkish Cypriot families (inpatients) in the Famagusta district of Northern Cyprus between December 2003 and January 2004 using judgmental sampling. An analysis covering 216 inpatients revealed that private hospitals provide better services than public hospitals in respect of service quality. 454 four usable responses were obtained for a response rate of 69. Andaleeb (2000) compared the quality of services provided by private and public hospitals in urban Bangladesh. accessibility and affordability dimensions. reliability. H2a. Improvements were required across all six dimensions. p. H3b.

(3) giving priority to inpatient’s needs (eight items).5 (Nunnally. Arasli and Ahmadeva. in the future studies. Responses to all items were elicited on a seven-point Likert scale ranging from 1 ¼ strongly disagree to 7 ¼ strongly agree. The majority (57.19 to 6. (5) food (six items).0 for Windows was used to analyze our data. if required. Lim and Tang (2000) and Andaleeb (2000). other dimensions may be added and adopted. A pilot study revealed that respondents had no difficulty understanding the questionnaire items indicating that the face validity of the instrument scale measurement was confirmed. Approximately 71 percent had either high school or vocational school education.914 was achieved indicating a good internal consistency for the forty-eight item scale. the popular ones were: agriculture/animal related (27. which I had asked for was given to me” (mean 3.2 to 5.32 for the public hospitals and from 4. However. that these dimensions may not represent all service quality aspects. housewives (15.1 percent). 2004. A survey instrument of 48 components was used in order to measure Famagusta hospital service quality. Analysis The SPSS 12. The quantitative survey was produced based on a synthesis of the literature we studied.6 percent) and professionals (14.1 percent). Moreover.Measures A questionnaire was developed based on the studies of Parasuraman et al. (2) relationships (nine items). The reliability of the scale was tested using Cronbach’s alpha.2). A high alpha value of 0. Expectation scores The mean expectation scores were high when compared to the perception scores – ranging from 3. Results Table I demonstrates respondents’ demographic breakdown. There were six dimensions in the present study: (1) empathy (ten items). This was individually distributed to 15 families in the Famagusta district.2 percent) were married and although occupations were widely dispersed. Jabnoun and Chaker (2003). and finally. which showed that dimensions like food and the physical environment were often studied. 1978). The lowest public hospital expectation score was obtained from question 44: “the food. (6) physical environment (nine items). This low expectation level may be the result of previous experience or negative word of mouth Service quality in public and private hospitals 13 . (1998). the results of explanatory factor analysis showed that all factor loadings were above the recommended cut-off value of 0. It is important to note. however. (4) professionalism of staff (five items).46 for the private hospitals. More than 64 percent of the respondents were between the ages of 38-57 who were almost equally distributed in terms of their gender. The mean scores for the forty-eight expectation and perception statements are presented in Table II for both public and private hospitals together with the mean service quality gaps calculated using Service quality ðQÞ ¼ Expectation (E) – Perception (P).

32).4 13.IJHCQA 21.4 10. perhaps.7 28.2 454 260 179 15 454 64 27 45 23 25 5 123 61 71 10 454 % 10.1 27.4 3. Although question 5 has the lowest expectation score. However. This high .3 34.9 37.1 13.4 49.0 50.1 5.2 39.19).0 57. this is not significantly lower than other items in the questionnaire.6 2.0 14 Table I. The highest public hospital expectation score was statement 12: “doctors were capable of performing tests and procedures on me” (5.5 1. Sample demographics communication from family members or friends who.2 100.0 9.1 6.4 9.0 13.4 100.5.6 100. had disappointing experiences with the quality of food or the limited choice of food.9 5. thus it can be evaluated as a high expectation score.0 14. The lowest expectation score in private hospitals was question 5: “the use of each procedure and test was explained to me before they were done” (4.7 33.7 100. it is slightly above 3.5 3.0 2.8 100. Inpatients’ families sometimes cook or they purchase food from restaurants for their relatives.1 Factor Age 18-27 28-37 38-47 48-57 58-67 68 and above Total Gender Female Male Total Education Primary school Secondary High school Vocational school Undergraduate Graduate Total Marital status Married Single Other Total Occupation Professional Administration Clerical works Sales works Services Agriculture/animal Manufacturer Student Housewife Others Total F 47 62 129 156 43 17 454 229 225 454 9 63 171 152 49 102.4 15.

Doctors spent enough time examining me 28.59 0.64 0.89 3.77 3.790 4.32 4.43 -0.821 4.69 4.20 0.27 0.748 0.763 0. In hospital.24 0.780 3.790 0. perception and gap scores in public and private hospitals .21 5.89 3.824 3.13 0.57 0.17 0.704 0.11 0.792 5. Doctors did their best to make me emotionally comfortable 14.15 5. I had complete trust in my doctor 30.15 5.95 3.776 0.73 3.769 0.40 5. Doctors were courteous while speaking with me and my family 26.48 0. I was presented with choices when doctors were deciding about my medical treatment 33.44 0.27 0.12 3. Nurses talked to me in order to get to know me better in their “spare” time 32.747 0.12 0.28 0. I had enough confidence in my doctor to discuss my very personal matters 0.41 5.786 0.737 Variance exp: ¼ 12:0%/a ¼ 0:89 0.752 5.68 6.89 5.Statements Variance exp: ¼ 22:0%/a ¼ 0:92 0.727 5.09 (continued) 15 Service quality in public and private hospitals Table II.17 0.05 3.779 0.70 5. Doctors were capable of performing tests and procedures on me 24.783 4.16 4.14 0.762 5.92 5.89 5.07 Variance exp: ¼ 21:9%/a ¼ 0:87 0. Doctors made me feel comfortable even when they were not really successful in treating me 3. Gap FL Gap Private hospital Exp.55 0.75 3.79 0.23 -0. Doctors discussed after discharge medical issues with me Giving priority to inpatient’s needs 21.74 0.70 5.81 5. Empathy 15.34 5.74 0.82 0.773 4.708 0.26 0.04 0.17 0.05 FL Public hospital Exp.19 0. the nurses did not pay attention (R) 16.04 0.22 0.16 3.00 3.727 0. Whenever I asked for help.80 0. Doctors worked hard to prevent me from worrying 29.08 0.32 4.02 0.768 5. expectations.787 3. Nurses were polite while speaking with me and my family 27.700 4.36 0.771 5.81 5.10 0.23 4.33 0.15 0. I was treated with respect 19.21 4.80 0.95 3.780 0.97 5.08 0.09 0.819 4.08 0. My personal concerns were of utmost importance for the hospital 23.92 0. I was involved in the planning of medical treatment 25.24 0.91 4.82 3.17 0.93 4. Per.07 0.67 4.77 3.56 0.04 5.34 0.741 0.87 5. I was taken care of as an individual not like a customer 12.74 5.76 3.723 5.77 Variance exp: ¼ 40:7%/a ¼ 0:89 0. Per.27 5.41 0.11 0.08 0.34 5.12 -0.782 5. Doctors took care of me as soon as I arrived on the ward 4.11 4.74 0.19 0.56 5.06 0.21 0.15 0.86 4.748 4.17 0.70 3.779 0.21 4.32 5.809 5.48 5.23 5.802 3.841 4.91 3. Doctors spent extra time with me to discuss my fears and concerns 18.795 4. Factor loadings. In hospital.12 5.774 0.21 3.

82 0.20 0.97 5.45 4.824 4.94 4. The nurses spent time with me to discuss my concerns about my condition 5.10 6. Doctors asked my permission before performing any test on me 31.06 3.60 3. I was treated with dignity and had adequate privacy during my treatment 1.25 5.65 0. a ¼ 0:91 0.15 0.775 0.87 5.818 0.58 5. Gap FL Private hospital Exp.14 5.90 5.831 0.803 5.90 4. I had a clear understanding of my condition during my stay in hospital 2.785 0.23 0.783 0.09 3.13 0.19 5. Per.841 6.98 5.721 3. Doctors gave me medical advise in a simple way that I can understand 11.745 0. Doctors spent extra effort to make sure that I understaood my condition and its treatment Table II.97 0.1 . The use of each procedure and test was explained to me before they were done 17.03 4.06 0.25 0.731 0.16 0.13 0. My doctor was interested in not only my illness but also me as a person 7.04 4.07 Variance exp: ¼ 8:2%/a ¼ 0:93 0.83 3.01 3.09 6.03 0.820 0. gentle and sympathetic at all times 6.815 0.34 -0.71 4. Doctors talked to me frankly and politely 8.819 0.16 -0.90 0.38 0.94 4.11 0.776 0.79 4.19 0.89 5.09 0.774 0.12 0. FL Public hospital Exp.819 4.58 3.810 Relationships 13.11 0.714 0.13 0.12 4. The nurses were kind. Doctors carried out my tests completely and carefully 10.99 3. Per.02 5.17 4.02 4.07 0.03 0.86 3.71 3.821 4. Doctors explained frankly to me the reasons for tests and procedures Variance exp: ¼ 20:7%/a ¼ 0:87 0.14 5.12 0.87 4.29 0.784 0.73 3.28 Professionalism of staff 9. The ward rules and regulations were explained to me 22.39 0.21 4.776 0.79 4.24 4.69 4.46 5. The nurses asked my permission before performing any test on me 20. Gap Variance exp: ¼ 15:3%/a ¼ 0:84 5.12 0.20 0.745 0.98 5.02 5.01 3.769 0.48 0.21 5.12 5.34 5.750 0.17 (continued) IJHCQA 21.22 3.19 0.16 Statements Variance exp: ¼ 9:3%.767 5.29 0.745 0.90 5.763 0.66 0.

807 4.64 3.861 4.05 0.768 5.18 0. 44.41 0.52 0.37 0.91 4.21 0. Gap FL Private hospital Exp.44 0.84 0.03 0.18 0.87 5.72 6. The bathrooms and toilets were always clean and pleasant to use 38.843 3. The screens were drawn around my bed.817 0.09 3.67 0.17 0.98 0.14 0.22 4. The beds.39 4.87 4. Outside noises were kept to a minimum 42. Per. .824 4.49 Variance exp: ¼ 18:8%/a ¼ 0:94 0. noises were kept at minimum level during night times 36.09 3.29 0. There was adequate number of bathrooms and toilets in the ward 41.69 0.14 FL Public hospital Exp.23 0. 47.22 5. 46.20 3.03 0.10 0.02 5.19 3.12 4.01 3.46 0.25 0.869 4.15 0. pillows and mattresses were comfortable enough 35.76 0.772 6.20 0.04 5. Inside the ward.850 3.47 3.19 0.21 3.91 6.77 0.82 4.34 5.08 Physical environment 40. all factor loadings (FL) and co-efficient alpha scores (a) are above the cut-off value recommended by Nunnally (1978) and Tabachnick and Fidell (1996) 17 Service quality in public and private hospitals Table II.784 6.64 3.68 0.61 5. 48.34 0.788 4.46 6. while medical procedures and examinations were carried out Notes: Each item is measured on a seven point Likert scale.724 0.849 4.37 0.21 0. Gap Food 45.35 0.44 0.50 0.796 6.749 6.23 0.98 0.738 5.45 0.712 4.58 3.64 0.815 5.16 3.37 0.76 4.33 0.861 4.761 5.719 5.856 3.15 0.717 5.818 0. The meals were well presented I was asked about the size of portion that I would like The food which I had asked for was given to me There was a choice of food on the menu After each meal the plates were cleared straight away The meals were still hot when they were served Variance exp: ¼ 33:1%/a ¼ 0:92 0.13 Variance exp: ¼ 29:4%/a ¼ 0:93 0.43 6.45 0.09 0.25 3.805 3.865 4. The ward was clean at all times 37.14 0.12 3.32 0.782 4.754 4. 43.14 0.24 0.66 0.89 0.28 0.52 3. The ward was well ventilated 34.732 0.88 5.17 5. The ward was well furnished and decorated 39.84 0.Statements Variance exp: ¼ 15:9%/a ¼ 0:90 0.16 3.51 0.94 0.831 4. Per.

inpatients put their priorities differently in public hospitals as: food (33. It seems that respondents are not satisfied with the public hospital food menu since both their expectation and perception mean scores were low.37 for the private hospitals. 27) explain: “Apart from the visits. especially those in the public hospitals. pillows and mattresses were comfortable enough”.12 for the public hospitals and from 4. there are differences between the two types of hospital services. Perception scores The mean perception scores were lower compared to the expectation scores.66) and bathrooms/toilets (0. The largest gap (0.24). It was followed by gaps in ward cleanliness (0. which I had asked for was given to me”. The largest quality gaps. physical environment (29.9 percent). while H3a is accepted. Table II also shows that although the overall expectation levels were comparatively higher than public hospitals.12 to 6. ranging from 3. Hence food becomes an important factor. Gap scores Table II shows that although overall expectation levels were low. showing that public hospitals are suffering from a lack of cleanliness and comfort.7 percent variance in the private. This confirms that private hospitals do not meet expectations about food.7 percent).1 percent).68) was observed in statement 38: “the beds. . which is a tangible quality factor.46). It was followed by the gaps related to food service (0. giving priority to patient needs (12 percent). This item’s expectation score was again highest in public hospitals. Of course.28) and portion size (0. interestingly. When we compared public and private hospital inpatients (Table II). Interestingly. Giving priority to patience needs (21.03 to 5. Therefore. food (15. and relationship (15. therefore. The hypotheses H1a and H2a. and relationships (9 percent) important in the public hospitals.12). private investment encourages high expectations even on a simple. in which the lowest and the highest expectations are reported.” Like public hospitals all these gaps come under the physical environment construct. both the lowest and the highest perceptions occurred in the same question. The largest gap (0.03) and the lowest expectation score in private hospitals was obtained from the statement 5: “the use of each procedure and test was explained to me before they were done” (4. The highest private hospital expectation score was related to: “the bathrooms and toilets were always clean and pleasant to users” (6. All these gaps came under the physical environment construct. the inpatients consider professionalism (20. none was met in public hospitals. but vital issue like the number of ward bathrooms and toilets.3 percent).64). which are the tangible quality factors. occurred in the food construct statements. therefore.8 percent). The lowest perception score in public hospitals was obtained from statement 44: “the food which I had asked for was given to me” (3.9 percent).12). are rejected.IJHCQA 21.4 percent). The highest perception score in public hospitals was obtained from the statement 12 “doctors were capable of performing tests and procedures on me” (5. Tomes and Ng (1995.37). about the only thing the inpatient can look forward to are meals to break the monotony. However. The highest expectation score in private hospitals was obtained from statement 41 “the bathrooms and toilets were always clean and pleasant to use” (6. p. The empathy dimension had the highest priority in both types of hospitals with 22 percent variance in public hospitals and 40.1 18 expectation level may be the result of a lack of trust in the doctors. still most expectations were not met in private hospitals. it seems that people are dissatisfied with public hospital doctors’ competency level. physical environment (18.34) was observed in statement 44: “the food. Significantly.

professionalism. patients’ expectations were not met in the private hospitals regarding the physical environment and the food quality served to them. it is interesting that there were variances in inpatients priorities. mentioned by the previous researchers such as Hariharan et al. Specifically.Discussion and conclusions Our empirical findings reveal that the study instrument provided sound psychometric properties. 2000). suggest that health care is a complex area that is unique in all its characteristics and it has too many dimensions to be fitted into a simple singular unit. doctors took care of me as soon as I arrived in the ward (Q. the instrument has been found to have face and convergent validity as well as acceptable reliability coefficients. food and the physical environment. Therefore. Lim and Tang. North Cypriot inpatients perceived public hospitals to be inferior in the quality of their service provision. the physical quality of equipment and facilities (toilets. who found that public hospital inpatients were more satisfied with service quality than their counterparts in United Emirate private hospitals. which is aligned with the majority of recent study findings (Pakdil and Harwood. our results contradict Jabnoun and Chaker (2003)... Northern Cyprus hospitals suffer from a number of quality problems. 15). showers. At the micro level. (2004). who examined SERVQUAL in both public and private hospitals. managers. inpatients seem to have preconditioned themselves to expect different health care service in both types of hospitals. relationships between staff and patients. which brings us to the important assumption that privatization would offer higher performance in Northern Cyprus’ health services sector. wards etc. private hospitals were found to provide a better service than their public counterparts. 1996). giving priority to the inpatients’ needs. and doctors did their best to make me emotionally comfortable (Q. Jabnoun and Chaker. (1998). This result is consistent with the previous empirical investigations (Withanachchi et al. Our findings also revealed that there are significant quality differences in employee related hospital activities. Our study has identified six service quality factors as perceived in both Northern Cyprus public and private hospitals: empathy. government officials. 2005. However.) were perceived to be better in private hospitals. Moreover. Healthcare services were found to be better in the private hospitals with the exception of choice of food on the menu (Q. etc. hospital managers should first be committed to delivering superior service quality and the achievement of inpatient satisfaction (Arasli and Ahmadeva. 2004.. and facility-related activities.. Regarding the other dimensions. such as building infrastructure and new equipment. Hoel and Saether (2003) and Angelopoulou et al. Our findings have important implications for private hospital owners. Results show that expectations in both hospital types were not met. Please note that the expectation for an empathetic response of both hospitals’ inpatients got the highest priority in rank. since job satisfaction leads to customer satisfaction and loyalty (Rust et al. Kibris Newspaper. except for the empathy dimension. The lack of management commitment to service quality in both hospital settings leads doctors and nurses to expend less effort increasing or improving inpatient satisfaction. etc. Kara et al. Interestingly. 43). 2003. 2005. Broadly. 2005). it may be difficult for inpatients to accurately evaluate quality. However. The biggest service quality gap occurred in the “physical environment” dimension. 25). academics and other related parties in the Northern Cyprus health services. While comparing public and private hospitals. 2004). such as the quality of the service provided by doctors and nurses. hospital administrations need to gather systematic feedback from their inpatients and to establish visible and transparent Service quality in public and private hospitals 19 . Additionally. Results derived from this study should be carefully considered by healthcare managers in both the Northern Cyprus public and private hospitals. Possible reasons for this gap. Hospital managers should also satisfy their employees.

P. Most customers are reluctant (Ekiz. E. S. Arasli. the expectation and perception sections should be separated. P. 62-81. “No more tears! A local TQM formula for health promotion”. pp. discharge management and co-ordination (Labarere et al. 2001) provided further insights into understanding inpatients’ perceptions and intentions. Third. for the researchers’ convenience. it was conducted in a limited geographic region (Famagusta. Replication studies using large samples elsewhere would be useful in order to corroborate our study findings. 2004) to make their needs and expectations explicit. Health Policy. although this may create difficulties contacting respondents just before their treatment and just before they are discharged from hospital. (1996). 15 No. hospitals’ processes (Lim et al. Vol. References Andaleeb. professionalism.. the study questionnaire included both expectation and perception questions. Asubonteng. 11 No. 10 March. Future studies should also investigate the effects of service quality dimensions on the patient’s satisfaction. “SERVQUAL revisited: a critical review of service quality”. 10 No.. Vol. and Katircioglu. “Service quality in public and private hospitals in urban Bangladesh: a comparative study”. (Andaleeb. 29). The Journal of Services Marketing. “Measuring service quality at a university health clinic”.. Including other dimensions such as baksheesh (extra payments in many Bangladesh services). Limitations and further research implications There are several limitations to our study. “Private and public medicine: a comparison of quality perceptions”. return intention and word-of-mouth communications about the institution. 1.T. 2. 14-20. 6. S. 3. and Ahmadeva. H. 135-45. Angelopoulou.. (2005).J. 32-7. Managing Service Quality. K.IJHCQA 21. Mehtap-Smadi. H. 53. Arikan. Second. and Babis.. In future. Nicosia. G. Future studies can conduct these calculations to be confident about the sample’s representativeness. Thus. 17 No. giving priority to the needs of the inpatient. This is also supported by Arasli and Ahmadeva (2004) that hospital staff aiming to bring a total quality management philosophy to their organizations should provide evidence-based training programs. McCleary. The hospitals need to organize training sessions based on the critical importance of service quality and the crucial role of inpatient satisfaction in the health care industry.E. L. pp. pp. International Journal of Health Care Quality Assurance. Vol. P.S. Northern Cyprus). the present study findings and our recommendation are inconclusive and tentative. positive relationships. International Journal of Health Care Quality Assurance. Kangis. Ministry of Health. J. Vol.1 20 complaint procedures so that inpatients’ complaints can be addressed effectively and efficiently. First. future studies should include the remaining regions in order to increase the research findings’ generalizability. although the opportunity to do so is clearly provided in order to promote and create a healing environment. food and the physical environment as the determinants of service quality in hospitals. 2000. 25-37. International Journal of Health Care Quality Assurance. 1. p. S. pp. (2004). the present study lacks a sample power calculation to detect differences between the respondent groups. H. Arasli. this study used empathy. 2004) even patient satisfaction and return intentions (Hasin et al. pp. (1998). (2005). Until further studies are conducted. . (2000).. 8 No. Vol. (1995). and Swan.A. Finally. “Customer service quality in the Greek Cypriot banking industry”. pp. Vol. 1999). personal interview. including their complaints. 41-56. Anderson.

. (1992). Seeluangsawat. “Measuring service quality: a reexamination and extension”. E. 11 No.. 12 No. and Dale. pp. N.M. Managing Service Quality. A. “Comparing the quality of private and public hospitals”.. 253-68. Hoel. Cronin. C. V. H. B. M. Franck.. available at: www.W.M. Vol. Lexington Books. 26 No. Famagusta. “Public-private partnership organizations in health care: cooperative strategies and models”. “A new tool for measurement of process-based performance of multispecialty tertiary care hospitals”. 66 No. Lonial. Pendleton. 141-53. Hospital & Health Services Administration. 1. “Organizational responses to customer complaints in hotel industry: evidence from Northern Cyprus”. A. TX. Service Management and Marketing. P. 30. (2004).R. 5. Journal of Marketing Research. pp. Journal of Business Research. and Boller. Kibris Newspaper (2002). 306-11. Vol. M. L. “An empirical assessment of the SERVQUAL scale to hospital services: an empirical investigation”. (2005). 767-80. M. and Chaker. Moseley. Kara. J. International Journal of Health Care Quality Assurance. 4. 4. (1996). “Comparing public and private hospital care service quality”. (2003). pp.R.. pp. 14 No. and Kidder. “Public health care with waiting time: the role of supplementary private health care”. Pittam. Eastern Mediterranean University. Carman. Hariharan. pp. 5-20. (2001).H. (1993). and Neill. 3. Hasin. (1993). E.B. R. A. M. Fort Worth. Boulding. “Quality in the hospitality industry: a study”. (2004). Judd. 17 No. (1998). E. (1990). “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. and Taylor. Coyle. International Journal of Health Care Quality Assurance. MA. J. Vol.. Vol. M. (2004). W. 2. 599-616. Vol.. pp. (1991).G. Health Service Research. J. 7-27. pp. Tarim. “An empirical assessment of the SERVQUAL scale”. Journal of Marketing.Y. Jabnoun. (1992). 38 No. 6th ed. Vol. S. Vol. E. Vol. 24. (2003).kibrisnewspaper.J. “SERVQUAL and Northern Ireland hotel sector: a comparative analysis – Part 1”. Kumar. pp. Vol. C. and Mangold. Research Methods in Social Relations. S. B. 6-13. 56.. and Ritchie. 5. “Quality assurance for clinical research: challenges in implementing research governance in UK hospitals”. 290-9. 22. 13 No.M. Rinehart and Winston Inc. Vol. “A paradox of service quality in Turkey: the seemingly contradictory relative importance of tangible and intangible determinants of service quality”. 55-68. Vol. Gronroos. European Business Review. Ekiz.S. Smith. W. Vol. 127-33. G.L. “Statistical measures of customer satisfaction for health care quality assurance: a case study”.A. Vol. 6. and O’Callaghan.. and Saether. Journal of Health Economics. L... and Zaim. Jack.G.Babakus. International Journal of Health Care Quality Assurance. Vol. pp. 17 No. and Aynsley-Green.E. 302-12. M. and Zeithaml. 239-47. Staelin. Lexington. 1. D. pp. S. G. (1990). M. International Journal of Health Care Quality Assurance. R.A. Managing Service Quality.. and Phillips. unpublished Master of Business Administration thesis. A.. Jr. Service quality in public and private hospitals 21 . 30 No.A. Camilleri.A. pp. Gabbie. Preece. pp. (1993). M.P. J. Journal of Retailing. 33-55. and Gora. O. Faculty of Business and Economics. International Journal of Hospitality Management. “A dynamic process model of service quality: from expectations to behavioral intentions”.. M. 1.S.A. pp. E. Vol.K. H. (1991). 8 No.R.A. (1992). pp. Vol. 6. pp. 2-9. M. 387-400. S. and (accessed 14 March 2002). Babakus. 2. pp. “Measuring service quality in the travel and tourism industry”. Fick. 17 No. Kalra. Journal of Travel Research. R. Dey.

International Journal of Service Industry Management. Wong. 2. Duffy. 1. Managing Service Quality. Stewart. Nunnally. T. (2004). (1996). Spreng. 64 No. N. A.K. 72 No. 18 No. 13 No. Vol. “Zero defecting: quality comes to services”. 3. Vol. R. Parasuraman. Vol. pp.L. (1999). V. personal interview. 13 No. 201-14. pp. (2005).M.A. (1988). T. 2. S. Lam. Vol... Jr. 341-9. Fourny. Vol. “Inpatient satisfaction in a preoperative assessment clinic: an analysis using SERVQUAL dimensions”.. “The satisfaction and retention of frontline employees: a customer satisfaction approach”. Labarere. 99-114. (1999). NY. Harvard Business Review. “Service quality of travel agents: the case of travel agents in Hong Kong”.C. pp. “Service quality in hospitals: more favorable than you might think”.com (accessed 10 February 2005). pp.IJHCQA 21. and Zhang. A. F. International Journal of Health Care Quality Assurance. L. Vol. R. 105-11. P. 15 February. Journal of Marketing.R. J. (1978).L. J. 1. 197-206. Australian and New Zealand Journal of Psychiatry. L.. Marin-Pache. S. International Journal of Health Care Quality Assurance. Vol. (1990). 7. P. (1985). L.. New York. (1997).1 22 Kibris Newspaper (2005). V. (1999). 7 No. 62-80.Q. Lim. 1. Psychometric Theory. Vol. 1. M. .A.K. pp. Zeithaml.A.H. and Nelson.T. and Pielack. pp. pp. S. available at: www. and Sasser. R. G. N. 807-11. Journal of Hospitality Marketing. H. pp. Kilbourne. F. (2005). 49. Vol. Total Quality Management. 111-24.E. 17-25. 10 No. and Giarchi. Lysonski. S. and Berry. 12-40. Rust. “Testing the SERVQUAL scale in the business-to-business sector: the case of ocean freight shipping service”. 68. 4 No. 132-50. The Journal of Real Estate Research. Duffy. “The applicability of SERVQUAL in cross-national measurements of health-care quality”. 5. Vol. 7-14. and Durvasula. Jean-Phillippe. “Monitoring consumer satisfaction with inpatient service delivery: the inpatient evaluation of service questionnaire”. Journal of Retailing. Journal of Marketing.D. pp. T. T. P. 41-50. Zeithaml.N. 20 No. pp. Tang.. T. Pakdil. H. Vol..L. H. Vol.. Vol. Sohail. and Patrice. pp. 524-33. and Berry. Vol. and Yeung. Kobat. and Jackson.. Medical Doctor in Ministry of Health and Medical Center. pp. pp. M. “Reassessment of expectations as comparison standard in measuring service quality: implications for further research”.. Reichheld.L. Journal of Retailing. G. pp.C. 58. Tourism Management. Journal of Services Marketing. V. 423-33. and Stedman.L. 6. Managing Service Quality. pp. 17 No. S. (2000).kibrisnewspaper. pp.C. Parasuraman. S. and MacKoy. Bergen. The Journal of Services Marketing. Vol. W. (1996). (1994). and Tang.A. 16 No. “An empirical examination of a model of perceived service quality and satisfaction”. 36.. Vol. “A conceptual model of service quality and its implications for future research”. 3. 15-30. 7. V. W. Nelson. K. M. Mehta.. A. Vol. 290-9. A.A. “Measuring service quality in clubs: an application of the SERVQUAL instrument”.C. (2004). Miller. and Harwood. Meehan.S. Parasuraman. “An innovative framework for health care performance measurement”. (2003). “RESERV: an instrument for measuring real estate brokerage quality”. “SERVQUAL: a multiple-item scale for measuring consumer perception of service quality”.. pp. D. (2002). T. 13 No. Lam. “A study of inpatients’ expectations and satisfaction in Singapore hospitals”. Zeithaml. (1995). 9 No.H. McGraw-Hill Book Company.. J. “Refinement and validation of a French inpatient experience questionnaire”. F. 1. Famagusta.E. Lim. and Berry.

B. Or visit our web site for further details: www. 361-9.P.S. F. and Ng. 16 No. pp. 1. Corresponding author Huseyin Arasli can be contacted at: huseyin.).J. Valdivia. “Inpatient satisfaction with nursing care at a university hospital in Turkey”. 3 No. “International service variants: airline passenger expectations and perceptions of service quality”. Tabachnick. 3rd ed. 8 No. Harper Collins College Publishers.. A. Washington. (2000). 68-123. and Souliotis. Yi. Vol. pp. Using Multivariate Statistics. Vol. W. S.. pp. Review of Marketing. R. pp. and Crowe. Vandamme. Chicago. Karandagoda. 3. and Simpson. “The ‘unexpected’ growth of the private health sector in Greece”.C.. Vol. Y.T.A. P.Sultan. 167-80. IL. in Zeithaml. (2001). pp. 4 No. 4. N. 2. “A performance improvement programme at a public hospital in Sri Lanka: an introduction”.emeraldinsight. V. (1995). (1990). pp. 3. Uzun. 74-81. 188-216. M. (1996). T. Withanachchi. Tomes. 74 No. “Service quality in hospital care: the development of an in-inpatient questionnaire”. Y. 5.R. J. E. Qualitative Market Research: an International Journal. 10 No. Journal of Health Organization and Management. 25-33. and Leunis. Y. S.Y. (2005). L.G. Karnaki. “Measurement in a cross-cultural environment: survey translation issues”. “Development of a multiple-item scale for measuring hospital service quality”. NY. M. Vol. Pavi. Journal of Services Marketing. pp. Vol. (1997). 14 No. 2. Vol. and Fidell. K. . O. DC. (1993). America Marketing Association. “A critical review of consumer satisfaction”. International Journal of Services Industry Management. Health Policy. Further reading McGorry. International Journal of Health Care Quality Assurance. Tountas. (2000). World Development Indicators (2003). (Ed. World Bank Publications. pp. New York. 208-12. Journal of Nursing Care Quality. 24-33. 30-49. 18 No. 3. and Handa. Vol. (2004) Service quality in public and private hospitals 23 To purchase reprints of this article please e-mail: reprints@emeraldinsight. International Journal of Health Care Quality Assurance. “Achieving hospital operating objectives in the light of inpatient preferences”. World Development Indicators Indicators in CD Database. pp..

The Gap Model operationalized by SERVQUAL is widely used to measure service quality.The current issue and full text archive of this journal is available at www. Outpatients Paper type Research paper International Journal of Health Care Quality Assurance Vol. and Wynne W. 1990. Performance levels. Oliver. Bitner. Customer services quality. It draws on the disconfirmation paradigm from the psychology and consumer behavior literature and the Gap Model (Parasuraman et al. Chin University of Houston. 2000). Wicks Bryant University. The service quality Gap Model is operationalized by the SERVQUAL instrument (Parasuraman et al. Smithfield. is used to develop a framework to evaluate patient satisfaction in three service process segments: pre-process. that the process segment is the most important to the patient and that the antecedents have differing impacts on patient satisfaction depending where in the process the antecedent is evaluated. 2008 pp. and post-process service experiences. Rhode Island. 1988. see Carman. USA.emeraldinsight. 1988). 24-38 q Emerald Group Publishing Limited 0952-6862 DOI 10.1 24 Received 24 March 2006 Revised 21 February 2007 Accepted 20 March 2007 Measuring the three process segments of a customer’s service experience for an out-patient surgery center Angela M.. Originality/value – This study is the first to evaluate patient satisfaction with all three process segments. 1996) and has been adopted for health care operations as well (for example. 1990. Texas. 1996. Research limitations/implications – Only one out-patient surgery center was evaluated. 1991. Patient satisfaction criteria specific to hospital selection are not included in this study.1108/09526860810841138 Introduction The operations management and marketing literature focus on measuring service quality as the gap between expectations and perceptions. All three segments should be measured. Design/methodology/approach – A partial least squares (PLS) approach. Reidenbach and Sandifer-Smallwood. The lack of proper segmentation and methodological criticisms in the literature motivated this study. 1990)... Practical implications – Results indicate what is important to patients in each service process segment that focus where ambulatory surgery centers should allocate resources. Keywords Patients. Houston. Shewchuk et al. 1985. Shelton. a form of structural equation modeling. Although SERVQUAL is a good base for measuring service quality and . Findings – Results indicate that each process stage mediates subsequent stages. process. United States of America. However. the SERVQUAL instrument only measures expectations (resulting from the pre-process segment of the service experience) and perceptions (resulting from the post-process segment). 21 No. USA Abstract Purpose – The purpose of this research is to develop an alternative method of measuring out-patient satisfaction where satisfaction is the central construct. an approach widely used in service operations (Spreng and Page.htm IJHCQA 21.

1993. 1993. 1992. 1988). An out-patient surgery center was selected for this study. see Cronin and Taylor.the possible trade-offs between functional areas. higher than the gap scores (Parasuraman et al. poor discriminant validity. 1998. Additionally.. Teas... Peter et al. Babakus and Boller. 1992. or higher than expectations scores (Brown et al. Low reliability. Overall satisfaction model . Therefore. 1993). is the central construct in a series of partial least squares (PLS) models based on the tripartite evaluation model (Figure 1) from the psychology literature (Rosenberg and Hovland. several problems exist owing to the nature of the creation of the gap measurement (for example. not quality. and post-process (Babin and Griffin. 1990. spurious correlations and variance restriction problems make gap measure a poor choice as a measure of psychological constructs (Peter et al. Service process measurement should include all three consumption experience segments: pre-process. Vandamme and Leunis. customer satisfaction. Peter et al. 1993). The difference between in-patient and out-patient treatments is important because the transient nature of this type of service experience could produce different patient satisfaction antecedents than an in-patient experience (Reidenbach and Sandifer-Smallwood. 1993). our study develops an alternative method for measuring patient satisfaction in a larger retention framework where satisfaction.. 1990). 1993).. 1993). marketing. service operations. 1994. Few patient satisfaction studies have been performed on out-patient surgical experiences even though many traditional in-patient procedures have been converted to out-patient procedures (Peyrot et al. Rosen and Karwan. Singh.. SERVQUAL only measures the pre-process segment (expectations) and the post-process segment (perceptions). Measuring the three process segments 25 Figure 1. 1994). process. 1960). The R 2 values for the perception scores are often higher than the overall gap scores (Cronin and Taylor. 1992. psychology and health care operations literature and by a series of focus group discussion. Our framework was developed from operations management.

However.e. two insurance questions and one open-ended question. The questionnaire was included with the patient’s discharge papers. The sample size requirement in PLS is typically determined by locating the dependent construct in the model with the largest number of predictors (i. Pilot survey data were drawn from 112 usable responses.1 26 Method Our pilot survey consists of 100 questions related to the survey constructs. Retention model . A total of 631 usable surveys were completed and returned (17 percent response rate). tangibles are not applicable for the post-process segment. 2004b) for a complete discussion of the Figure 2. 1988). The same patient satisfaction antecedents were used for each segment except for tangibles. In our study the constraining construct involved twelve predictors. independent variables) and applying procedures used in multiple regression (Chin and Newsted. which patients were expected to return to the doctor at a post-operative appointment. The dotted lines leading into and out of overall satisfaction indicate how satisfaction fits within the larger retention framework (Figure 2). the patient satisfaction definition antecedents are listed in Table II (see Wicks et al. The patient satisfaction definitions for each segment and for overall satisfaction are listed in Table I. Therefore. There were few missing data in the survey results. the post-process transactions primarily relate to errors in insurance submission. The degree of loyalty depends on the patient’s overall satisfaction. The relevant constructs were determined for each service process segment from the literature and focus groups. six demographic questions. Some doctors did not forward the surveys to the hospital resulting in a lower than expected response rate. 1999). See Witten and Frank (2001) for a detailed discussion of the algorithm’s use. The Overall Satisfaction Model is presented in Figure 1. The dotted lines indicate where the exogenous variable for cognitive and behavioral antecedents relates to overall satisfaction. Therefore. That is. therefore. (2004a.IJHCQA 21. These types of processes are primarily phone transactions. the sample size is sufficient for our regression-based PLS analyses. Overall Satisfaction in the model leads directly to loyalty and loyalty leads directly to retention. The expectations minimization algorithm was used to substitute missing data in both the pilot and final surveys. The revised survey was administered to all the hospital’s out-patient surgery patients over 18 years and was conducted for a period of eight weeks. a sample size of 631 far exceeds the minimum required to provide sufficient analytical power (Cohen.

for example. is defined as the mental process by which knowledge is acquired about the out-patient surgery center.e. Patient satisfaction antecedents’ definitions framework’s development. Loyalty is defined as the attitude toward reuse of the center. and personnel appear neat and clean Table II. The validity of several other constructs outside the satisfaction portion of the PLS model is logically connected to this study in Figure 2. Patient satisfaction definitions Antecedent Assurance Empathy Communication Competence Confidentiality Convenience Courtesy Reliability Responsiveness Security Tangibles Definition The degree to which the health care provider has the ability to convey trust and confidence to the patient The degree to which the health care provider attempts to understand the patient’s feelings and concerns The degree to which patients are informed about the outpatient surgery in language they can understand The degree to which the health care provider displays the ability required to perform the health care service The degree to which the patient’s records. the satisfaction definitions and the patient satisfaction definition antecedents used in this study). rigorously correct) The degree to which the health care provider promptly responds to the needs of the patient The degree to which the risk in the health care environment is reduced for the patient The degree to which the health care facilities. .Latent variable Overall satisfaction Pre-process satisfaction Process satisfaction Post-process satisfaction Definition The degree of positive affective orientation toward the patient’s outpatient surgery experience The degree of positive affective orientation toward the patient’s pre-admission experiences The degree of positive affective orientation toward the patient’s outpatient stay experiences The degree of positive affective orientation toward the patient’s post-discharge experiences Measuring the three process segments 27 Table I. equipment. Cognition. Behavior is defined as the mental process linked to specific directed action toward the out-patient surgery center. diagnosis and treatment are kept confidential The degree to which the health care service is convenient and easy to use The degree to which patients are treated with courtesy by the health care providers The degree to which the health care provider performs the service in a manner that can be relied on to be proper (i. Retention is defined as the actual reuse of the center by the patient.



Evaluation criteria Five models are evaluated using a PLS software package developed by Chin (2001). Partial Least Squares focuses on prediction using an econometric perspective and inference related to latent variables using a psychometric perspective (Chin, 1998). These two perspectives create a method that allows analytical modeling with latent variables and provides:
. . . the researcher with the flexibility to: (a) model relationship among multiple predictor and criterion variables; (b) construct unobservable Latent Variables; (c) model errors in measurement for observed variables; and (d) statistically test a priori substantive/theoretical and measurement assumptions against empirical data (i.e. confirmatory analysis) (Chin and Newsted, 1999, p. 308).

The PLS method is less stringent on the sample size and residual distribution restrictions found in other analysis models (Chin et al., 2003) and is better suited for explaining complex relationships with small data sets as it tends to avoid inadmissible solutions and factor indeterminacy (Chin et al., 2003). The PLS approach has also proved to be a robust method, providing results that are unattainable relative to other types of covariance methods. See Chin et al. (2003) for a more thorough discussion of PLS benefits and a comparison of PLS and other covariance methods. As in other Structural Equation Modeling (SEM) approaches, PLS modeling provides both measurement and theoretical/structural information in terms of the network of constructs, indicator loadings and path coefficient measures. Indicator loadings represent the measure’s strength and their underlying constructs. Estimated path coefficients indicate the strength and the sign of the theoretical relationships among model constructs (Thompson et al., 1985; Igbaria and Greenhaus, 1992; Hulland, 1999). The PLS analysis first stage typically assesses the measurement model that includes item reliability, construct validity and discriminant validity. The second stage involves assessing the structural model using the PLS bootstrap procedure – Q2 and R2 calculations. Wold (1982) found that PLS was appropriate for complex predictive models. Ryan et al.(1999) showed that PLS was a better loyalty predictor because of its ability to test all the relationships among the model indicators. Recommendations for model evaluation criteria from Chin (1998) were used. Table III indicates the measurement model tests while Table IV shows the structural model tests.
Item reliability Loading scores of the indicators Average Variance Extracted (AVE) Composite reliability (rho) Overall AVE Cross loadings Greater than 0.70 Greater than 0.50 Greater than 0.70 AVE values of the latent variable (LV) are greater than the square of the correlation among the LV’s The correlations of the indicators should load higher within their own blocks than to the correlations with other blocks

Convergent validity Discriminant validity Table III. Measurement model test criteria

Results Overall patient satisfaction model The overall patient satisfaction model is composed of four latent variables. Three measure the patient’s overall satisfaction with each of the three process stages and one latent variable measures the patient’s overall satisfaction with the entire service process. Stages correspond to the service process segments and are labeled “OA Stage 1”, “OA Stage 2”, and “OA Stage 3” in Figure 3. Assessing the measurement model The block of items weights and loadings (i.e. indicators) measuring overall satisfaction are given in Table V. Indicators OAA_1 and OAA_2 represent the overall affective evaluation towards the out-patient experience. The remaining indicators as presented in the table, tap into each more detailed aspects of satisfaction and are labeled as follows: . assurance (ASR); . communication (CMM); . competence (CMP); . confidentiality (CFD); . convenience (CNV); . courtesy (CRT);
Nomological validity R 2 Path coefficients Effect size Similar to regression analysis Similar to standardized beta weights in regression analysis Small effect: 0.02 Medium effect: 0.15 Large effect: 0.35 Greater than zero

Measuring the three process segments 29

Significance testing Predictive relevance

Bootstrapping: 500 samples Bootstrap t-tests Stone-Geisser Q2

Table IV. Structural model test criteria

Figure 3. Overall satisfaction model


Indicator OAA_1 OAA_2

Weights 0.078 0.079

Loadings 0.961 0.963 How satisfied/dissatisfied are you with your entire out-patient surgery experience? Overall, how satisfied or dissatisfied were you with all aspects of your out-patient surgery experience? Overall, during your entire out-patient surgery experience, how satisfied or dissatisfied were you with: The trust and confidence you had in the hospital personnel you dealt with How well everyone you dealt with clearly explained the procedures to you How competent the personnel were that you dealt with How well all aspects of your patient information were kept confidential How easy and convenient it was to reach and use the out-patient surgery facilities How courteous all the personnel were How understanding and concerned all the personnel were How reliable all aspects of the service were How responsive all personnel were How well all personnel provided an environment safe from criminal activity and accident How neat and clean all the facilities and personnel appeared Overall, I believe the Out-patient Surgery Center performed my surgery properly Overall, I believe the decision to use the Out-patient Surgery Center was a wise choice

ASR_OA1 CMM_OA1 CMP_OA1 CFD_OA1 CNV_OA1 CRT_OA1 EMP_OA1 RLB_OA1 RSP_OA1 SCR_OA1 TNG_OA1 Table V. Overall satisfaction construct – outer model weights and loadings COG_1 COG_1 0.069 0.073 0.069 0.066 0.067 0.073 0.073 0.076 0.073 0.070 0.071 0.073 0.072 0.919 0.925 0.923 0.867 0.884 0.937 0.932 0.943 0.934 0.902 0.920 0.930 0.917

. . . . .

empathy (EMP); reliability (RLB); responsiveness (RSP); security (SCR); and tangibles (TNG).

Additionally, indicators COG_1 and COG_2 were included to measure the cognitive evaluation towards the experience. Each indicator’s wording is also provided in Table V and in total is meant to converge towards a global measure of satisfaction with the entire out-patient experience. Examining the Table reveals that of 15 indicators, the loadings for all indicators except two, are equal to or greater than 0.90 representing a strong link between the indicator and overall satisfaction construct. The two remaining indicators, confidentiality with a loading of 0.867 and convenience with a loading of

954 0. 0.812 0. represent a strong relationship.832 0.841 0.900 0.902 0. Table VII presents the correlations among construct scores with the AVE results on the diagonal.892 0. and OA Stage 3).924 0.867 0.885 0.997 0.961 0.998 and 0.996 0. Using the same wording for items OAA_1 and OAA_2.787 0.998 0.921 0.988 Table VII.861 0.837 0.884 0.809 0.01.872 0.997.900 0.997 0.932 0. two indicators were used.887 0.865 0.837 OA Stage 2 0.760 0.826 0.950 0.794 0.980. For each of the three process stages (OA Stage 1.941 0.789 0.866 0.831 0.998 0.810 0.834 0.869 0. The cross-loadings provide similar results. The item loadings are provided in Table VI also resulting in high composite reliabilities for the three stage constructs of 0.746 0.773 0.0.998 0.932 0.859 OA Stage 1 0.969 0.895 0.923 0.965 0.796 0.895 0. The composite reliability.837 0.926 0.802 0.869 0.846 0.919 0.840 0.882 0.934 0.935 0.889 0.808 0.824 0. and “post-discharge experiences” for OAP_1 and OAP_2.809 0.898 0.889 0.856 0. Overall satisfaction – Survey: Correlation among construct scores (square root of the AVE extracted in diagonals) .887 0. Measuring the three process segments 31 Overall OAA_1 OAA_2 ASR_OA1 CMM_OA1 CMP_OA1 CFD_OA1 CNV_OA1 CRT_OA1 EMP_OA1 RLB_OA1 RSP_OA1 SCR_OA1 TNG_OA1 COG_1 COG_2 OAPR_1 OAPR_2 OAS_1 OAS_2 OAP_1 OAP_2 0.920 0.835 0.778 0.843 0. OA Stage 2. Overall satisfaction model – loadings/cross loadings of items Overall Overall Stage 1 Stage 2 Stage 3 0.884. The AVE value square roots.842 OA Stage 3 0. all item cross loadings are higher for the construct on which the item should load than on any other construct. are all larger than the correlations.988 respectively.902 0.944 0.835 0.836 0.954 0. indicates strong item convergence towards a highly reliable scale. we replaced “out-patient surgery” with “pre-admission experiences” for OAPR_1 and OAPR_2. The results of both analyses indicate that the model’s psychometric properties are sufficiently strong to enable structural model estimate interpretation.843 Stage 2 Stage 3 0.875 Stage 1 0.869 0.852 0.757 0. as required.955 0.988 0.863 0.815 0.846 0. 0.891 0.989 Table VI. All the loadings are significant at an alpha of 0.793 0. “surgery stay experiences” for OAS_1 and OAP_S.900 0.902 0.

are 0.18 and the post-process segment (Stage 3) has only a 0. The highest impact is the path coefficient value of 0. Specifically.6 percent of the variance in overall patient satisfaction with out-patient surgery experience. The pre-process segment (Stage 1) has a significantly lower impact of 0.0676 respectively. Moreover. as just noted. The f 2 for Stage 1 and Stage 3 are 0. Overall satisfaction model results indicate that the patient’s satisfaction with the actual surgical stay.36 from Stage 1 to Stage 3 and an even lower value of 0.IJHCQA 21. the global set of 15 items for overall satisfaction provides an operationally discriminant difference to those used for the three stages.973. The Q2 predictive relevance values.891 from Overall Stage 1 to Overall Stage 2. satisfaction towards the out-patient stay (i. indicating a small effect for both segments on overall patient satisfaction. Typical for path analytic/structural equation techniques. with a lower value of 0. Conclusions and recommendations Our study establishes and tests the relationships between three service process segments and overall patient satisfaction. 0.e.18 and the post-process stage has only a 0. Stage 2 has a large impact on overall patient satisfaction with an f 2 of 0. In particular. using the cross-validated redundancy option. we noted the construct discrimination among the stages as well. In terms of substantive effects and predictive relevance. In terms of satisfaction at the start of the process in Stage 1 impact. As found when assessing the measurement model.148 path coefficient.7511 for the Stage 3 and 0.790 for overall satisfaction.e. indicated in the model as Stage 2 in Figure 3 has the most significant impact on the patient’s overall satisfaction with the entire service process.0811 and 0.18 from Stage 1 to Overall Satisfaction.67.1 32 Structural model assessment Bootstrapping results indicate that all path coefficients are significant at an 0. The model is an excellent overall patient satisfaction predictor. it should not be surprising to find significance for all paths owing to the relatively large sample size independent of the effect size (i. Furthermore. The path coefficients for Overall Stage 1 indicate that the pre-process stage has the highest impact on the stage immediately following the registration process and decreases as the patient moves father away from the pre-process stage. The strength of the relationships between patient satisfaction and the three service experience process segments is also tested. These results indicate that models based on .01 alpha and estimates are presented in bold in Figure 3. Stage 2’s impact (path coefficient) on overall satisfaction is 0. whether paths minimally impact or larger). While this is high for predictive models. we see that the model explains 92. the relative strength of each stage’s impact on overall satisfaction as well as among each other is consistent.148 effect on overall satisfaction. This implies that the model constructs have high predictive ability. Stage 2) has the most impact on overall satisfaction with the pre and post stage satisfactions being much less influential and approximately equivalent. As such. it is consistent with logic that that the degree of patient satisfaction with the actual process stage service experience should have the most dramatic impact on the patient’s overall satisfaction with the entire service experience with a path coefficient of 0. what is also important is whether paths estimated are also substantive with high R-squares. the results are consistent with our intuition that it should have the most impact on Stage 2 and less direct effect on each subsequent stage. The pre-process stage has a significantly lower path coefficient of 0.788 for Stage 2.666.

The results of the Pre-Process Satisfaction model indicate that courtesy has the most impact on customer satisfaction for this segment. The remaining antecedents were ranked as competence. closely followed by courtesy. The remaining antecedents are ranked as confidentiality. empathy. reliability. Tangibles may be important in this case because of the correlation between cleanliness and a good surgical outcome (i. competence. patients pay attention to the facility’s neatness and cleanliness. and security. These results cannot be generalized to all segments since process satisfaction impacts overall satisfaction more than the post-process segment. If the health care provider can handle the pre-registration process well then it can probably handle the surgery to a good standard.891 from Overall Stage 1 to Overall Stage 2. communication. This indicates that pre-process segment impact. in fact. security and then convenience. confidentiality. no infection following surgery). the path coefficient for courtesy is almost twice that of the next highest path coefficients: reliability.180). assurance had the highest rankings across all process segments. The greatest impact on overall satisfaction is the actual surgical experience. courtesy is most important. The number one ranking for convenience in the process satisfaction segment was unexpected. The tangibles antecedent was not included for Post-Process Satisfaction. but this may be true since process satisfaction had such a large effect on overall satisfaction. reliability. equivalent to the Stage 1 service experience pre-process segment. For this service process segment. courtesy. ranked second in the process segment. The same 11 antecedents were evaluated for Pre-Process Satisfaction and for Process Satisfaction. Our analysis also found that. The remaining antecedents are ranked in order of impact on pre-process satisfaction as follows: reliability. When the Overall Satisfaction model was evaluated. Assurance at this stage can impact how comfortable the patient feels about the surgical process. each process stage mediates subsequent stages. for this model. One possible explanation could be that the process segment convenience aspects act to reduce stress over the actual surgical process. security. or expectations. empathy. responsiveness. however. each process stage influences the development of overall patient satisfaction and all three stages should be included in the model. empathy. Our research establishes and tests the relationships between patient satisfaction antecedents and overall satisfaction for each service process stage. Assurance. However. the highest impact is represented by the path coefficient of 0. The health care provider needs to convey to patients that the registration process will be done correctly and that everything the patient needs for the actual surgery will be processed and ready. Assurance has the greatest impact on the formation of Post-Process satisfaction. Measuring the three process segments 33 . however. tangibles. competence. communication. The results of the Process Satisfaction model indicate that convenience has the most impact on the formation of overall process satisfaction. communication. The path coefficients for Overall Stage 1 indicate that the pre-process stage has the highest impact on the stage immediately following the registration process and decreases as the patient moves farther away from the pre-process stage. confidentiality. responsiveness. have significantly less impact on overall satisfaction. and empathy. For example. Convenience is closely followed by assurance and courtesy. diminishes as the patient moves away from the pre-process segment.e. Overall Stage 1 has a dramatically lower effect on Stage 3 (0.expectations. assurance and tangibles. responsiveness.

but the organization should focus on these aspects during the registration process to alleviate anxiety about the impending surgery.IJHCQA 21. Designing the out-patient surgery process to be convenient for the patient on the day of surgery can have the greatest . assurance for the post-process segment and for overall satisfaction. communication. The organization should also allocate resources to make the out-patient surgery experience as easy to get through as possible by minimizing any additional stress on the day of surgery. The results of some rankings were unexpected. so paperwork should be in place when he or she arrives at the surgery center. The results of the different satisfaction models indicate the antecedents have differing impacts on satisfaction depending on where the antecedent is measured. which may have occurred since a communication aspect was included in the assurance definition. However. competence. assistance could be in the form of clear and adequate directions possibly from an information desk at the out-patient entry. so tangibles were not included in the rankings. Perhaps these policies have been in place so long and so much emphasis has been placed on them that patients do not question this aspect of the service unless a problem arises.1 34 followed closely by courtesy. specific entry and departure areas for the patients and perhaps valet parking. Directional assistance should be available so patients can easily arrive at the proper location within the facility. staff should design parking facilities and procedures to be as convenient as possible by providing adequate signage. The health care literature stresses the importance of communication in evaluating patient satisfaction (Shelton. Confidentiality ranked low in all aspects of the out-patient surgery experience. 2000). The patient may view the health care provider’s ability to convey trust and confidence is more crucial than the ability to explain the procedure or merely convey information. The organization should focus on making the center easy to find by providing good directions and appropriate signage for example. When the patient is discharged. The most important pre-process segment antecedent for the patient was courtesy. Results indicate that health care service staff should allocate resources to training service providers to be able to courteously convey trust and confidence to the patient in all three of the service process segments. communication was eighth in the overall rankings. Patients are pre-registered for out-patient surgery. and security. reliability. Confidentiality and convenience had the lowest impact. Empathy ranked ninth out of ten antecedents consistently evaluated in all three process-segment models and ranked last in the process segment. This result was also surprising since governmental regulatory agencies have emphasized patient confidentiality and motivated the development of the patient’s bill of rights (Shelton. empathy. convenience for the process segment. 2000). The empathy definition developed for this study limits the measurement to the degree to which the health care provider attempts to understand patients’ feelings and concerns. transportation to the facility exit should be ready and waiting so the patient can easily leave the facility. Patients may consider assurance more important in the out-patient surgical setting than how empathetic the health care providers appear to be. How well the patient feels that the surgery will be performed may be much more important. Tangibles were not evaluated in the Post-Process Satisfaction model. responsiveness. The low ranking for empathy may have occurred because approachability and sense of security were omitted from the newly-developed definition. The remaining surgical procedures should be designed to be as stress-free as possible.

Further studies should be conducted to clarify the importance of these factors in the determination of patient satisfaction when the patient has some input into selecting the health care provider and the type of health care coverage. Value has been determined to be important in health care (Donabedian. Barsky.. 2001). the major determination would need to be about selecting satisfaction antecedents for industry-specific applications in the service sector. 1978. 1993) and the satisfaction model might prove valuable in this area as well. 1993. The generalized model could also be applied to public service and not-for-profit service areas. Naumann and Giel (1995) and Rust et al. Service models have been applied to service segments within manufacturing organizations (O’Hara and Frodey. The model should be modified for public services by determining satisfaction antecedents and the importance of each antecedent in not-for-profit organizations. 2001). Archer and Wesolowsky (1994). Waldbridge and Delene. 1995) included value in their studies. The literature reviews and focus groups determined general patient satisfaction antecedents. Satisfaction antecedents developed for this study should be modified and applied to on-line services. image and value should be included in the generalized model. 1993. 1995. He or she needs to feel that any billing or insurance problems are going to be taken care of appropriately. more work is needed to determine if satisfaction antecedents vary in impact among service industries. value and image should be included as well. 2000. Barsky (1995). Kristensen et al. Shi and Singh. The model also appears generalizable. Training programs for administrative personnel in billing and insurance to properly address these issues can also have a great impact on post-process satisfaction. 2000) for a review of access). this study does not include access. Good results were obtained from these models in an out-patient surgical setting. however. while access. Assurance needs to be the focus in any post-process interactions with the patient. Access. 2000. Bolton and Lemon (1999). and focuses on an insurance-based healthcare system. Many other types of health care services exist and should be studied to see if the antecedents’ weights from this study differ when evaluating other health care service operations. Shi and Singh. 1988. A more generalized model should be developed to evaluate satisfaction in other types of services. The Measuring the three process segments 35 . Access has been included in numerous health care studies as a construct for determining health care quality and/or patient satisfaction (Ware et al. (2001). Technology has had an enormous impact on how organizations do business (Harvey et al. Shelton. Patients also need to feel that any financial information will be kept strictly confidential. the distributor and other entities along the supply chain is extremely important (Preis. (1994. These factors have been included in quality studies in non-health-care services (see Anton.impact on evaluating overall satisfaction. 2003). Our study only evaluated patient satisfaction antecedents for an out-patient surgery center located in a large USA city. Therefore. 2001). Shi and Singh. The assumption was made that the health care provider and the extent of health care coverage had already been determined. image and value as satisfaction antecedents. Waldbridge and Delene (1993) determined that image was an important health care quality determinant. Naumann and Giel (1995) and John (1992) found image an important quality determinant. Sale. Supply chain management is a particularly rich area where retailer satisfaction. The generalized model could be easily modified for supply chain applications.

pp. (Ed. 24 No. M. pp. pp. 171-87. NJ. pp. pp. 253-68. (1993). pp. Chin. Journal of Business Research. R. pp. J. “A partial least squares latent variable modeling approach for measuring interaction effects: results from a Monte Carlo simulation study and an electronic-mail emotion/adoption study”. Bolton. Lefebvre.. “The nature of satisfaction: an updated examination and analysis”. 14 No. 11 No. Statistical Power Analysis for the Behavioral Sciences.W.). J. 155 No. and Lemon. J. Technovation.R. 56. 78 No. and Griffin. J. Donabedian. Vol. B. L.0”. Journal of Retailing. P. “The partial least squares approach for structural equation modeling”. Mahwah. (1999). (2001). Journal of Marketing. 18. 69-82. 2. 5. Information Systems Research. 127-39. 36 . J. “Technology and the creation of value in services: a conceptual model”. (Ed. and Newsted.O. however. Vol. Carman. version 3. K. 55-68. 25 No. 189-217. Vol. G. P. Vol. N. Marcolin.. “Structural equation modeling analysis with small samples using partial least squares”. “Research note: improving the measurement of service quality”. Vol.IJHCQA 21. A. Vol. J. Cohen. pp. “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. Chin. R. 1782-9. Inquiry. present. and Taylor. (1995). pp. (1998). Hillsdale. 307-41. 295-336. Lawrence Erlbaum Associates. (1994). (1992). P. Thousand Oaks..W. and future of customer access centers”. W. 13 No. Journal of Marketing Research. pp. (1992). Harvey. 36 No. Cronin. S. (1990). B. 2nd ed. 66 No. (1988). W. 3. G. Vol.. W. Lawrence Erlbaum Associates. E.W. (1990). 33-55. 2. in Marcoulides.P. G. Again. T. “An empirical assessment of the SERVQUAL scale”. Statistical Strategies for Small Sample Research. and Wesolowsky. Journal of Business Research. International Journal of Service Industry Management. 4. (1988). 2. Archer. (2000). CA. W. (2003). 16. Modern Methods for Business Research. unpublished manuscript. NJ. Archives of Internal Medicine. “A dynamic model of customers’ usage of services: Usage as an antecedent and consequence of satisfaction”. G.1 model should also be applicable to manufacturing organizations that include significant service segments.A. pp. 2. Babin. pp. (1999). 481-96. Bitner. M. in Hoyle. diversity of means”. Jr. “Evaluating service encounters: the effects of physical surroundings and employee responses”. 120-30. “The clinical course of palpitations in medical out-patients”. pp. Churchill. Babakus. 355-66. E. the model provides a foundation upon which to build industry-specific models. (1993). 127-36. Barsky. Vol. and Peter. Vol.). Chin. 173-92. Journal of Retailing. Vol. pp. European Journal of Operational Research. Vol. 54 No. Brown. and Lefebvre. pp. 41. 1. “PLS-Graph user’s guide. and Newsted. References Anton. (1998). Vol. Chin. 1. and Boller. “A dynamic service quality cost model with word-of-mouth advertising”. Vol. determining applicable satisfaction antecedents is vitally important. Sage Publications. 69 No. “The past. Journal of Marketing.W. “Measuring service quality: a reexamination and extension”. “Quality assessment and assurance: unity of purpose.

L. C. Milwaukee. 58-70. (1996). 47-55. G. pp. J. “The career advancement prospects of managers and professionals: are MIS employees unique?”. Vol. (1993). and Zeithaml. Chicago. and Giel. Reidenbach. Customer Satisfaction Measurement and Management. Macmillan Press. pp. Gaithersberg. and Keiningham. Rosenberg. 49 No. R.. 13 No. and Greenhaus. 41-50. A. pp. 19 No.. (1960). Vol. 2. Vol. New Haven. P. (1993). Vol. 890-7. Parasuraman. B. V. (1995). and behavioral components of attitudes”. 46-51. P. Preis. (2000). pp. C. E. “Consumer satisfaction and perceived quality of out-patient health services”. Basingstoke. and Rosenberg. Rosen. and Morrison.. (1999). Journal of Marketing. Journal of Supply Chain Management. 24-34. Management Decision. J. T. Naumann. “Return on quality (ROQ): making service quality financially accountable”. John.T. Vol. 39-52. Quality Press. R. Peter. 2. Vol. Vol. 8. “A service quality model for manufacturing”. “A conceptual model of service quality and its implications for future research”. 2. M. Ryan. (1990). (1995). (Eds). “SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality”. 3. Vol. pp. A. and Karwan.J. and Berry. “Prioritizing the dimensions of service quality: an empirical investigation and strategic assessment”. pp. and Hovland. R. V..I. (1999). 12. pp. 20. (1994). A. (1988). Vol. “Caution in the use of differenced scores in consumer research”. 64 No. O’Hara. and Brown. Measuring and Improving Patient Satisfaction. M. 4. Quality Assurance: A Pathway to Excellence. “Use of partial least squares (PLS) in strategic management research: a review of four recent studies”. Journal of Health Care Marketing. K. (1992). Parasuraman. 4. C. Sale. “Cognitive. Vol. (2003). MD. in Hovland. A. Decision Sciences. Rayner. Marketing Research.. R. 4. pp. pp. Vol. D. 1. 10 No. “Customer satisfaction: some results for European retailing”. Return on Quality: Measuring the Financial Impact of Your Company’s Quest for Quality. and Sandifer-Smallwood. M. CT. International Journal of Service Industry Management. Aspen Publishers. “Diagnosing customer loyalty drivers”. pp. Cooper. “The impact of interpersonal satisfaction in repurchase decisions”. (1994). 12 Nos 7-8.Hulland. Kristensen. pp. M. 478-500. affective. 655-62. Journal of Health Care Marketing. 12-40. pp. R. and Ostergaard. (2001). 11 No. Rust. T. Berry. P. Oliver. and Schnapf. 51-61. 3. Irwin/McGraw-Hill. H. 5 No. WI. 23 No. (1993). pp. Rust. 2. Yale University Press. 59 No. MA. M. 30-8. J. Journal of Retailing. 195-204. Zahorik. A. pp. L. (2000). (1992). K. Journal of Consumer Research. 18-27. Journal of Health Care Marketing. L.. M. Journal of Marketing. Shelton. Boston. Total Quality Management. T. Vol. 31 No. J. D. (1985). J. 11 No. 39 No. Churchill. and Frodey. Juhl. K. “Improving quality through patient-provider communication”. “Exploring perceptions of hospital operations by a modified SERVQUAL approach”. Satisfaction: A Behavioral Perspective on the Consumer. and Keiningham. IL.. Zeithaml. Peyrot.. Zahorik. Measuring the three process segments 37 . Probus Publishing Company. Vol. Attitude Organization and Change: An Analysis of Consistency Among Attitude Components. Igbaria. Vol. Strategic Management Journal.

RI. G. Bryant University. Fletcher. 11. 2-15. “A reexamination of the determinants of consumer satisfaction”. (1993).. 1. and Gale. V. and Page. 420-51. Vol. (1991). Systems under Indirect Observations: Causality. 13 No. Vol. R. J. A. “In search of service quality measures: some questions regarding psychometric properties”. and Chin. pp. 18-34. O’Connor. and White. “Expectations as a comparison standard in measuring service quality: an assessment of a reassessment”. 6. Vol. “The development and evaluation of a patient satisfaction model for health service organizations”. W. Smithfield. R. CA.. DeSouza. performance. H. “The measurement of meaning of patient satisfaction”. Journal of Marketing. pp. Teas. pp. L. pp. I. Vol. International Journal of Service Industry Management. Singh. 18 No. and Chin. 1-54. Vol. W. E. pp. A. pp. Further reading Parasuraman. and Frank. (1996). working paper. pp. (2001). 20-6. Ware.. Wicks. H.. Vol. Journal of Health Care Marketing. (1991). Data Mining – Practical Machine Learning Tools and Techniques with Java Implementations. R. Bryant University. 65-75. Vandamme. RI. R. and Leunis. A. L. Corresponding author Angela M. and Berry. Journal of Marketing. Or visit our web site for further details: www. 1. “Expectations. 19 No. Quality Progress. 6-16. L. A. 4 No. “Refinement and reassessment of the SERVQUAL scale”. Health Services Management Research. pp. 8-21. Academic Press. (1978). “Soft modeling: the basic design and some extensions”. Vol. 3. 4.. 18 No. “Measuring physician attitudes of service quality”. Smithfield. . MD. in Joreskog. (Eds). “Development of a multiple-item scale for measuring hospital service quality”. 132-9. 10. Wold. Delivering Health Care in America: A Systems Approach. Health and Medical Care Services Review. (1990). 58 No. Zeithaml. “The strategic management of service quality”. 1187-205. Wicks can be contacted at: awicks@bryant. pp. Teas. (1994). Wicks. working paper. Psychology and Marketing. and consumers’ perceptions of quality”. 1. Shi. Journal of Health Care Marketing. Prediction. Journal of Retailing. S. evaluation. (1982). 67 No. J. J.IJHCQA 21. “A multifacet typology of patient satisfaction with hospital stay”. and Singh. Aspen Publishers Inc. San Diego.. and Stewart. Spreng. (1985). (1993).emeraldinsight. R. 30-49. Fletcher. Gaithersburg. pp. (2004a). 4 No. 1. J. Vol. 18 No. A. A. D.1 38 Shewchuk. 1 No. Vol. and Wold.G. (2001). Walbridge. Part 2. K. S. 12. S. P. Witten. Vol. To purchase reprints of this article please e-mail: reprints@emeraldinsight. pp. and Delene. Davies-Avery. (1993).. (2004b). Structure. “Definitions of the antecedents of patient satisfaction for an ambulatory surgery center”.

no matter how comprehensive. Richard Locke III Division of General Internal Medicine. Minnesota.259 had previously completed a Minnesota Multiphasic Personality Inventory (MMPI). Satisfaction determinants range from structurally-based ones such as the type of health care delivery system. Patient satisfaction has been widely studied. including interactional style and the physician’s age (Kirsner and Federman. Mayo Clinic. were most likely to rate the overall visit as excellent. and Robert C. Keywords Patients.000 patients who had filled out a nine-item questionnaire after an out-patient visit. Minnesota. Of these. Findings – Among patients who scored high on the pessimism scale. USA Abstract Purpose – The purpose of this research is to determine whether a pessimistic or hostile personality style adversely affects satisfaction with out-patient medical visits. 1. to physician characteristics. Minnesota. The association of pessimism and hostility scores with patient satisfaction ratings was assessed.1108/09526860810841147 . 2008 pp. Health services Paper type Research paper Introduction Practicing clinicians know that certain patients are difficult to satisfy.htm Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients Brian A. USA. inconsolable and personally challenging. Patients seen in a solo or single-specialty practice. Rochester. 1.. Design/methodology/approach – An eight-item patient satisfaction survey was completed by 11. 39-49 q Emerald Group Publishing Limited 0952-6862 DOI 10. Personality. Colligan Department of Psychiatry and Psychology.636 randomly selected medical out-patients two to three months after their episode of care. International Journal of Health Care Quality Assurance Vol.emeraldinsight. nor how polished the physician’s interpersonal skills. Dierkhising and Kenneth P. Among the hostile patients. Originality/value – Pessimistic or hostile patients were significantly less likely to rate their overall care as excellent than optimistic or non-hostile patients. Rochester. McLeod and G. efficient and expert their care. 1993). Mayo Clinic. 21 No. The MOS included more than 17. while 66 percent of the least hostile patients rated it as excellent (p ¼ 0:002). USA Pessimism and hostility scores 39 Received 6 May 2006 Revised 13 September 2006 Accepted 23 September 2006 Ross A.The current issue and full text archive of this journal is available at www. but little has been written about the association between patients’ personality characteristics and their satisfaction ratings. 57 percent rated their overall care by physicians as excellent. 1997). Many patient and health care provider demographic characteristics have been related to patient satisfaction with a health care encounter. Thomas G. Costello. United States of 59 percent rated overall care by their physicians as excellent. while 72 percent with scores in the optimistic range rated it as excellent (p ¼ 0:003). Offord Division of Biostatistics. Mayo Clinic. Rochester. The Medical Outcomes Study (MOS) evaluated patient satisfaction based on practice type and payment method (Rubin et al. rather than in multi-specialty groups or health maintenance organizations.

1 40 Physician age and gender have also been correlated with patient satisfaction. 1997). lower satisfaction is reported by patients after seeing younger. including the patients’ personality characteristics. 1994). Furthermore. female physicians (Hall et al. Methods Two archival data sets were abstracted... such as performing a physical examination. patients with depression or anxiety disorders are more likely to express dissatisfaction from unmet expectations (Kroenke et al.259 medical out-patients had completed both the patient satisfaction survey and. 1993).. We then assessed the degree of association between: . and physician-specific factors related to patient satisfaction. G. Conversely. Patient satisfaction is associated with compliance and willingness to continue receiving care from a particular physician (Rubin et al. For example.636 medical out-patients who completed a patient satisfaction survey for the Department of Internal Medicine from March 1998 through March 1999. 1997). Although much has been written about organizational.. Of the MMPI and the patient satisfaction responses. surprisingly little has been written about patient characteristics and their relationship to medical care satisfaction ratings. personality traits of pessimism and hostility. 1997).. interactions with physicians and allied health staff. before that survey was completed. We hypothesized that pessimistic or hostile patients would report less satisfaction with their care. lower satisfaction ratings were reported by patients who were young. and all study subjects gave research authorization. and . 1984. structural. 1. understanding factors associated with patient satisfaction.IJHCQA 21. The study was approved by our institutional review board. and who lived locally (Locke. The topic of the eighth item was the completion of all scheduled tests and consultations (yes/no). The survey response rate was 60 percent. an MMPI. Robbins et al. A five-point scale was used to rate seven items pertaining to satisfaction with access. Pessimism and hostility were chosen for study because these . 1980.000 Minnesota Multiphasic Personality Inventories (MMPIs) archived at our institution since 1959. specifically. have been studied and. An eight-item questionnaire was mailed to randomly selected medical out-patients two to three months after their care episode. The second data set comprised scores from approximately 335. The first data set consisted of information from 11. as assessed by the MMPI. 1993). have been associated with higher patient satisfaction ratings (DiMatteo et al.259 out-patients formed the basis for our study. Effective communication skills and particular physician behaviors. general satisfaction with the visit and willingness to recommend our center to others. particularly patient waiting time.. longer waiting times result in lower patient satisfaction (Probst et al. This study investigated the personality characteristics of pessimism and hostility as they relate to patient satisfaction ratings.. September 2002). in a study of patient characteristics among out-patients at our center. as expected. Organizational factors. When the two data sets were merged we found that 1..R. personal communication. patients’ reports of satisfaction with care. Therefore. Bartlett et al. not satisfaction. is important. patients who believe their health status is good are more satisfied with their care (Probst et al. All MMPIs had been obtained before the satisfaction survey. who were employees of the center.

poorer physical health. It was initially developed when McKinley and Hathaway (1943) noted that: Competent internists have estimated variously that from 30 to 70 percent of the ambulatory patients who appear for medical attention come primarily because of one or more complaints that turn out to be psychoneurotic in nature. immoral. The PSM scale for the MMPI is based on Seligman’s explanatory style theory (Colligan et al. which are standardized to a mean of 50 and an SD of 10. unsocial. Finally. High scores on the pessimism (PSM) scale reflect a pessimistic explanatory style. in our experience. These included patient’s residence distance from our medical center. Furthermore. . . relationships that might not otherwise be uncovered in smaller or more highly selected samples. are considered relatively stable (Maruta et al. 5-32). Two interaction variables were included in the models as well: 1 – distance of residence from our center by employee/dependent status and 2 – age by employee/dependent status.Hostility amounts to chronic hate and anger. scoring high on the Ho scale) as: . Our large sample size allowed us to detect small. The scale’s developers describe a “hostile person” (i. For the question about recommending the medical center to others. optimistic. . physical symptoms. Statistical methods Logistic regression models were used to assess the association between patient satisfaction ratings and the PSM and Ho scores. Research shows that a pessimistic explanatory style is predictive of an increased likelihood of depression. ugly and mean. Pessimism and hostility scores 41 The MMPI scales are reported as T-scores.. The dependent variables were seven patient satisfaction responses from the eight-item survey. 1993. 2000). as assessed by the MMPI. . we adjusted for the patient’s rating of whether all the tests and consultations ordered had been completed during the patient’s episode of care (yes/no). The MMPI consists of 550 unique true/false items about thoughts. For six questions. from experience with previous internal analyses. . which suggests that people who believe that the cause of an adverse event is internal and personal (rather than external). 1995). responses were coded “1” for “definitely would recommend” or “0” for any other response. . 1954).. lower levels of achievement and increased use of medical and mental health services (Seligman. low scores. we also adjusted for previously identified predictive covariates. emotional symptoms. 1990). 0 ¼ no) and receiving primary care. attitudes. 1 ¼ yes. Additionally.. responses were coded “1” for “excellent” or “0” for all other response categories to that item. We considered this variable because many of our patients travel long distances to our center for intensive out-patient . 1994). these qualities come closest to defining the intangible characteristics that physicians sense in patients who are difficult to satisfy. being a medical center employee or a dependent of an employee (“employee/dependent”. 1989. and previous life experiences (Swenson et al..personality traits. feelings. age. pp. [and] sees people as dishonest. stable (rather than transient) and global (rather than specific) possess a pessimistic personality trait. These are known and important explanatory variables when modeling patient satisfaction at our center. Maruta et al. This procedure for collapsing and dichotomizing the five-point scale is in keeping with the convention from marketing literature (Jones and Sasser.e. Hostility was measured by the MMPI hostility (Ho) scale (Cook and Medley. but significant. lone who has little confidence in his fellowman.

386 (31 percent) lived 21 to 120 miles away. more than 10 years after the MMPI. and .e. 219 (17 percent). we assessed whether the time between completing the MMPI and the patient satisfaction survey affected the associations we intended to study. 1 had missing time data. Three sets of explanatory variables were used in the modeling. either PSM or Ho). . either PSM or Ho) and the interaction between time and the MMPI scale of interest as explanatory variables. 617 (49 percent) were 41 to 65 years old.039 patients (83 percent) had their tests and consultations completed (85 [7 percent] had missing data).1 to 5 years after the MMPI. we believed that scheduling a timely. the adjusting variables described above and the interaction between time and the MMPI scale as explanatory variables. 222 (18 percent) 1. The other model consisted of the MMPI scale of interest. .259 out-patient participants: . 27 (10 percent) were 18 to 40 years old. .e.1 to 10 years after the MMPI. 1. 515 (41 percent) were 66 years or older. 719 (57 percent) were female. Among these patients: . Therefore. we modeled the interaction of time and the MMPI scale score within the context of two models. The survey was completed as follows: . Results Patient characteristics At the time the satisfaction survey was completed by the 1. 277 (22 percent) were seeking primary care.IJHCQA 21. including only the MMPI scale of interest (i. 5. . 632 (50 percent). and . . Travel distance varied considerably: . . One included the MMPI scale of interest (i. efficient. and . 388 patients (31 percent) lived within 20 miles. 199 (16 percent) lived 121 to 250 miles away. 201 (16 percent) were medical center employees or dependents. The first model was done univariately.1 42 evaluations during a single episode of care. The second model included only one of the MMPI scales of interest and the adjusting variables described above. and complete appointment itinerary could affect ratings of patient satisfaction. The third included both MMPI scales of interest and the adjusting variables already mentioned. 185 (15 percent) within 1 year after taking the MMPI. and . Therefore. During the visit studied. Since the MMPI and the patient satisfaction survey were not completed concurrently. . . Wald x2 statistic p values were calculated from these logistic regression models. 286 (23 percent) lived more than 250 miles away.

even after adjusting for completion of tests/consultations and for all the previously identified predictors of satisfaction. p . willingness of physicians to listen to patient and family (54 percent v. 70 percent. 65 percent. 66 percent.e. 63 percent. while 59 percent of the pessimistic patients rated the overall care provided by their physicians as excellent. 89 percent of optimists. This pattern was fairly consistent for all survey questions. the odds of a patient giving the center an “excellent” rating were significantly lower. Pessimism and hostility scores 43 . . 63 percent. physicians responding to questions about the patient’s medical condition and treatment (53 percent v. and .Findings Table I shows the percentage of “excellent” ratings by PSM T-score categories and the p values from the logistic regression models with three sets of explanatory variables. Pessimistic patients (PSM T-score $ 60) were significantly less likely to give “excellent” ratings for various aspects of their care than those classified as optimistic (T-score # 39). physicians responding to questions about the patient’s medical condition and treatment (57 percent v. p ¼ 0:047). with higher PSM T-scores. 72 percent of the optimistic patients rated it excellent (p ¼ 0:003). Specifically. respect shown by physicians (57 percent v. A smaller proportion of patients who scored high on hostility (Ho scale T-score $ 60) gave excellent ratings on various aspects of their care than did patients who scored low on the Ho scale (T-score # 39). This can be explained by the relatively large positive correlation between the PSM and Ho T-scores (r ¼ 0:61. the PSM scale scores were not associated with willingness to recommend the center (86 percent of pessimists v. Furthermore. p ¼ 0:282). p ¼ 0:008). p . p ¼ 0:002). p ¼ 0:008). Table II displays the percentage of “excellent” ratings by Ho T-score groupings and the p values from the logistic regression models. overall care provided by their physicians (57 percent v. . 67 percent. 67 percent. 0. 66 percent. This is evident in their responses on individual items: .001). The exception is the question pertaining to the patient’s willingness to recommend the center. the association weakened when adjusting for the Ho T-score.001). a significantly smaller proportion of pessimists than optimists rated other aspects of their care as excellent: . 71 percent. overall care received (55 percent v. higher Ho T-scores) as for the PSM scale.001). reflecting an increasing pessimistic explanatory style. and . p ¼ 0:001). . p ¼ 0:002). The results from the models were also similar. . The same patterns were present among the “excellent” ratings in relation to patient hostility (i. p ¼ 0:003). However. respect shown by physicians (64 percent v. . 0. . . p . overall care received (52 percent v. In general. With higher PSM T-scores. helpfulness of allied health staff (53 percent v. the percentage of patients giving “excellent” ratings was significantly lower. helpfulness of allied health staff (47 percent v. for which the ratings were not associated with these MMPI scale scores. p ¼ 0:002). willingness of physicians to listen to the patient and family (60 percent v. However. p ¼ 0:001). 64 percent. 75 percent. 0.

0 ¼ no].003 0. patients with high scores ($60). 0 ¼ no].002 0. d Entries are the percentages of patients who “definitely would recommend” the center Table I.219 0. and variables previously identified from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].229 0.008 0.30 30-39 40-49 50-59 60-69 $ 70 Optimistic Pessimistic (n ¼ 6) (n ¼ 92-95) (n ¼ 307-311) (n ¼ 393-401) (n ¼ 323-329) (n ¼ 102-106) (#39) ($60) 59 64 60 57 53 55 86 p1 a p2 b p3 c 0.002 0. 0 ¼ not excellent) and the independent variable being the PSM T-score. c p3 is the p value from the test of the coefficient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent. PSM T-score.002 0.221 0. b p2 is the p value from the test of the coefficient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent. patient age [in years].075 0.843 0.841 .047 0.282 0. 0 ¼ not excellent) and the independent variables as for p2 but with both the PSM and hostility scale T-scores included in the model.774 0.002 0.133 0. a p1 is the p value from the test of the coefficient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent. pessimistic. and patient age by center employee/dependent status interaction).056 0. * Entries are the percentages of patients rating that aspect of care as excellent. Relationship between patient satisfaction rating of “Excellent” and the PSM T-score PSM T-score groups * Subtotals . distance from the center by center employee/dependent status interaction.005 0. sample sizes are ranges because the number of respondents varied among questions. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes. 0 ¼ no). Within PSM groupings. center employee/dependent [1 ¼ yes.003 0. seen in primary care area [1 ¼ yes.002 0.44 IJHCQA 21. Patients with low scores (#39) were classified as optimistic.011 0.1 Questionnaire item 83 83 83 83 100 83 100 88 89 86 86 62 62 62 64 61 59 57 56 43 51 88 70 64 61 59 52 71 65 63 89 71 75 66 65 68 64 64 67 62 61 65 60 55 61 59 72 75 67 Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend centerd Notes: PSM ¼ pessimism scale of the Minnesota Multiphasic Personality Inventory.

048 0.011 0. Relationship between patient satisfaction rating of “Excellent” and the Ho T-score .046 .006 0. 0 ¼ no].026 0.001 0.008 0. d Entries are the percentages of patients who “definitely would recommend” the center Pessimism and hostility scores 45 Table II. b p2 is the p value from the test of the coefficient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.328 0. hostile. center employee/dependent [1 ¼ yes.001 0. Patients with low scores (#39) were classified as nonhostile. c p3 is the p value from the test of the coefficient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.001 0.001 0. patient age [in years]. * Entries are the percentages of patients rating that aspect of care as excellent. and patient age by center employee/dependent status interaction). Ho T-score. Within Ho groupings.403 0. 0 ¼ not excellent) and the independent variable being the Ho T-score.434 0. 0 ¼ no).001 0. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes. patients with high scores ($ 60).947 0.Questionnaire item 47 65 65 53 59 53 71 89 87 89 84 82 88 65 64 57 59 58 56 50 54 35 43 64 63 68 61 58 56 39 67 53 47 52 83 67 70 66 63 66 60 61 69 63 59 60 57 48 48 39 66 70 66 57 57 54 Ho T-score groups * Subtotals . sample sizes are ranges because the number of respondents varied among questions. distance from the center by center employee/dependent status interaction.0. 30 30-39 40-49 50-59 60-69 $70 Nonhostile Hostile (n ¼ 6) (n ¼ 92-95) (n ¼ 307-311) (n ¼ 393-401) (n ¼ 323-329) (n ¼ 102-106) (# 39) ($60) p1 a p1 b p1 c 0. 0 ¼ not excellent) and the independent variables as for p2 but with both the optimism-pessimism scale and Ho T-scale scores included in the model.068 .002 0.001 0. seen in primary care area [1 ¼ yes. 0 ¼ no].0.941 Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend centerd Notes: Ho ¼ hostility scale of the Minnesota Multiphasic Personality Inventory. and variables previously identified from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].097 0. a p1 is the p value from the test of the coefficient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.002 0.

Additionally. these patients would still recommend the center because of other factors such as the center’s reputation. Adverse encounters were believed to result from the physician’s characteristics and behaviors or from organizational and structural factors surrounding the care episode. our approach to studying the contributions of patient personality has not been previously taken. In general.e. 88 percent) who reported “definitely would recommend the center” (p ¼ 0:434). Among patients who would definitely recommend the center.g. 83 percent) and non-hostile patients (Ho T score # 39.02 to 0. depression) at the time of the survey or episode of care. unknown to the physician. regardless of their opinion about some aspects of their experience during a particular care episode. the exception to this trend was the question pertaining to a patient’s willingness to recommend the medical center to others. Previously. However. there was an approximately 15 percent to 20 percent decrease in the odds of giving an excellent rating for every 10-point increase in the PSM or Ho T-scores. These may include emotional states (e. the estimated odds ratios that corresponded to a 10-unit (1 SD) increase in the MMPI T-scores increased with the interval. However. Our results are a first step towards understanding that certain aspects of the patient’s personality affect ratings of their satisfaction with care. When significant associations existed. except for the question about willingness to recommend the center. Table III displays the odds ratios for “excellent” ratings corresponding to 10-unit (1 SD) increases in MMPI scale scores for PSM and Ho.1 46 Again. before the encounter. The time interval between completing the MMPI and the patient satisfaction survey did not affect the association between the MMPI T-scores and the satisfaction ratings. patient satisfaction ratings for particular physicians and health care organizations are tacitly assumed to be a reflection of physicians or health care system. The odds ratios were estimated for each of the three models. This may result from feelings that. Our analysis shows that pessimistic patients (i. There was no significant difference in the percentages of hostile patients (Ho T score $ 60.e. Discussion Patient satisfaction has been studied from various vantage points. having a pessimistic explanatory style as theorized by Seligman) or hostile patients (i. We included all patients who had completed both a patient . Now it is evident that some aspects of the patient’s personality affect ratings of satisfaction with care.03 for every 5-year interval increase. these odds ratios increased by about 0. These occur independently of other factors already known to contribute to variations in ratings of patient satisfaction. Clearly there are likely to be other patient-related characteristics that affect patient satisfaction ratings.. our findings indicate that important data about the factors contributing to patient satisfaction ratings are missing if patient personality characteristics are not considered.IJHCQA 21. high scores on the Ho scale) are significantly less likely to rate satisfaction with their care as excellent. these aspects of patient personality were experienced subjectively and understood solely through physician’s intuition and judgment. or certain patient expectations. Patients who had a long interval between completing the MMPI and the patient satisfaction survey were more likely to “definitely recommend” the center to others than were those with a shorter interval. It is notable that willingness to recommend our center to family and friends was not associated with hostility or pessimism.

01) (0.00) (0. d For example. Odds ratios (95 percent CI) for percentage of “Excellent” ratings for a 10-unit (1 SD) increase in the MMPI T-scores * .76-0.01 Ho scale Model 2b Model 3c (0.98 0.97) (0.85-1.83-1.00) (0.91) (0.74-0.84 0.06) (0.80-1.92 0.95) (0.82 0.76-0.86 0. 0 ¼ not excellent) and the independent variable being the PSM or Ho T-score.94) (0. In addition.75-0.10) (0.95) (0.90 0. 0 ¼ no].76-0.80-1.92) (0.77-0. center employee/dependent [1 ¼ yes.92 0.93) (0.77-0. PSM or Ho T-score.79-1.84 0. and patient age by center employee/dependent status interaction).21) 0.80-1. seen in primary care area [1 ¼ yes. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.76-0.81-1.07) 0.87 0.86 0.79-1.81 0.93 0.90 0.85 0.76-0.02) (0.73-0. 0 ¼ no].95) (0.94) (0. c Model 3 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.74-0.96) (0.80-1.86 0.84-1. if the 95 percent CI for the OR contained 1.77-0.70-0.71-0.91) (0.85 0.03) (0.98 (0.75-0.74-1.98 (0.94) (0.79 0.98) (0.85 0.11) 0.92 0.05) (0.78-1.00) (0.83 0.77-0.79-1.28) Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend center * * Notes: CI ¼ confidence interval.87 0.88 1.81 0.96) (0.00) (0. a Model 1 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent. MMPI ¼ Minnesota Multiphasic Personality Inventory.76-0.99 (0.75-1.85d 0.01) (0. 0 ¼ no).74-1.80-1.94 (0.93) (0. for the PSM scale and the overall care by the physician.83 0. * * ORs are for the percentage of patients who “definitely would recommend” the center.90 0. distance from center by center employee/dependent status interaction.97) (0.73-1.86 0.Questionnaire item 0.89) (0.84 0.76-0. b Model 2 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent. Ho ¼ MMPI hostility scale.87 0.94) (0. * See Tables I and II for the p values of the ORs that were significantly different from 1 (associated coefficient was different from 0).80-1. the OR was not significantly different from 1 at the a ¼ 0:05 level.95) (0.85 0. PSM ¼ MMPI pessimism scale. 0 ¼ not excellent) and the independent variables as in model 2 but including both PSM and Ho T-scores.83 0.06) (0.94 0.92 (0.08) (0.94) (0.83 0.91) (0. patient age [in years].86 0.72-0.74-0. there is a 15 percent decrease in the odds of giving an “excellent” rating for every 10-unit (1 SD) increase in the PSM T-score Pessimism and hostility scores 47 Table III.73-0.13) (0.94) (0.19) Model 1a PSM scale Model 2b Model 3c Model 1a 0. OR ¼ odds ratio.72-0.81-1.85 0.75-1.16) 0.81 0. and variables previously identified from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].

T. including status as employee/dependent.P. References Bartlett. L. M. pp. Levine. Roter. institutional policy makers need to be aware of the potentially significant contribution of patient personality factors in adversely affecting the patient satisfaction ratings of individual physicians. 71-95. the possibility exists that physician care or manner may be modified by patient personality factors. “The effects of physician communications skills on patient satisfaction. Vol.C. as defined in this article. Conclusions and recommendations This research clearly demonstrates that patient personality characteristics play an important role in the results derived from patient satisfaction surveys. and Miller.. M. since astute physicians are attuned to the personal qualities of their patients.. Offord. R. (1980). 37 Nos 9-10. 376-87. Grayson. “Satisfaction. significant differences were noted in satisfaction on the basis of levels of hostility or pessimism. . Friedman. who had also been asked to complete an MMPI. while contributing little to the practical management of hostile or pessimistic patients. pp. 50 No. D. (1984).1 48 satisfaction survey and an MMPI and did not exclude cases in which there was a long interval between the survey and the MMPI. L. S. 1216-31. pp. Vol.. A.H.A. Such patients are diagnostically and personally challenging for physicians. pp. C. Golden. Ehrlich. had a combination of medical and psychological issues requiring multidisciplinary investigation. H. Patient mix may temper an individual doctor’s satisfaction ratings. Schulman.. M. R.M. Medical Care. 1. and Prince. K. This influence is independent of physician or practice characteristics. Malinchoc. 32 No. and type of care received. A. DiMatteo.. Journal of Chronic Diseases.M. (1994). Journal of Clinical Psychology. 755-64. J.. (1994).M.L. P.W. Barker. Medical Care.. This research also suggests that it may be informative to identify personality characteristics of those who were sent satisfaction questionnaires and did not return them. and Seligman. Physicians are much less likely to obtain excellent ratings from pessimistic or hostile patients. 4. recall.. Colligan. D. gender.. Taranta. We included these independent variables in the models as adjusting variables. and adherence”.. Vol.M. “CAVEing the MMPI for an optimism-pessimism scale: Seligman’s attributional model and the assessment of explanatory style”. Therefore.S. Cook. and communication in medical visits”. Furthermore. and Libber. 12. Irish. 38. Although these findings are intriguing.. 414-8. Patient satisfaction ratings may be decreased if these patients are also characterized by traits of pessimism or hostility. age of patient. J. Patient satisfaction at our center is associated with several variables. one might speculate that patients coming to a tertiary care medical center for evaluation. E. pp. “Predicting patient satisfaction from physicians’ nonverbal communication skills”. Journal of Applied Psychology.E. Nonetheless. distance traveled for care. M.R. Hall. 18 No. Finally. this research is a first step towards understanding how patient personality affects reported levels of satisfaction with medical care and why some patients are difficult to satisfy regardless of other factors related to their care. Time limits were not imposed because we were studying two personality traits that are relatively stable. Vol. W. D.IJHCQA 21. (1954).E.. Vol. and Medley. “Proposed hostility and pharisaic-virtue scales for the MMPPI”.

Jennings. Rubin. M. 75 No. (1989). pp. (1993).. McKinley. Journal of the American Medical Association. “Keeping hostility in perspective: coronary heart disease and the Hostility Scale on the Minnesota Multiphasic Personality Inventory”. J. 1427-31. Vol. Greenhouse. C. Robbins. pp. Offord. Osborne. Swenson. S. (1990).. 7. and Malinchoc. R. Brunner/Mazel. and Chamberlin.. and health”. C. Vol. 109-14.E. K. K. Frye. R. and Selassie. D.P. “Patients’ ratings of out-patient visits in different practice settings: results from the Medical Outcomes Study”.E.H. (1995).C. M. T. R. Maruta. Maruta.A.C. achievement.. Pessimism and hostility scores 49 To purchase reprints of this article please e-mail: reprints@emeraldinsight. (1997). pp. (1993). 17-20. 339-47. A. (2000). Kroenke. Mayo Foundation. 140-3 (“Erratum”. Brief Therapy Approaches to Treating Anxiety and Depression. K. Jackson. Helms. and Colligan. Seligman.. M. M.L. Azari. pp.emeraldinsight. Vol. “Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome”. and Creten.brian@mayo. 11. Harvard Business Review.E. in Mayo Clinic Proceedings. and Sasser. 103 No. 88-99.P. “Explanatory style: predicting depression.J.L. Kosinski.W. 75 No.A. “The identification and measurement of the psychoneuroses in medical practice”.S. pp. Costello can be contacted at: costello. J...D. 133 No.M. 3. M. 1. 3rd ed.C.P.. . K. and Federman. “Why satisfied customers defect”. Corresponding author Brian A.. Journal of Family Practice. Mayo Clinic Proceedings.. Vol. Or visit our web site for further details: www. “Patient and physician satisfaction with an out-patient care visit”. Vol. “The influence of physician practice behaviors on patient satisfaction”.R. A User’s Guide to the Mayo Clinic Computerized Scoring and Interpretative System for the Minnesota Multiphasic Personality Inventory (MMPI). D.. Gandek. American Journal of Medicine. 5. B. and Hathaway. Vol. 45 No. R. and Offord. p. D. W. 2. (1997).. Vol. NY. Callahan.G.R.L. (1993). 736. J. 318). Bertakis. Kirsner. H.C. 161-7. (2000). Probst. T. 25 No. 418-25. R. (1943). pp. T. Journal of the American Medical Association. 270 No.A. and Ware. Vol. J. J. Jr.C. 122. 2. “Optimists vs pessimists: survival rate among medical patients over a 30-year period”. Hamburgen. pp. pp. Jr. “Patient satisfaction: quality of care from the patients’ perspective”. McHorney. Vol. Colligan. Family Medicine.. (1997). E.. 835-40. Archives of Dermatology.. Colligan. 5. 68 No. L... W.E. R. pp. New York. Rogers.O.Jones. W. J.. Mayo Clinic Proceedings.A. D.

The article’s first section discusses expectations theory outlined in customer satisfaction and service quality literature with particular reference to the Santos and Boote (2003) disconfirmation model. Understanding the role of expectations in aged care is important because it can increase customer satisfaction. Section three continues to build the argument by further differentiating between customer expectations in intangible services and then health care services. Australia. This section finishes the argument by illustrating why aged care service This article arose from the author’s Master of Conflict Resolution at Latrobe University. 21 No. Design/method/approach – The author first explores expectation theory and how it links to customer behaviour and then discusses confirmation/disconfirmation Customer satisfaction Paper type Case study 50 Received 21 June 2006 Revised 10 July 2006 Accepted 15 July 2006 International Journal of Health Care Quality Assurance Vol. Additionally. 1.1108/09526860810841156 Introduction This article discusses the role expectations play in complaints handling and argues that aged care face more complexities in understanding expectations than most other services. It begins by differentiating between customer expectations in tangible products and intangible services. Additionally. understanding customer expectations at the outset of providing services can reduce the incidence of complaints that may occur after the services have been rendered. Section four outlines how the role of expectations in aged care differs from those in health care.htm IJHCQA 21. developing and implementing effective complaints handling systems to assist the industry as it grows in demand. Section two builds the argument that aged care services involve a unique and complex form of customer expectations. with the onset of the baby-boomer generation entering into aged care. Patients. School of Law. is critical. both owing to the ageing population and to the social nature of baby boomers to complain when their expectations are not met.The current issue and full text archive of this journal is available at www. Caulfield North. Keywords Elder care. Australia Abstract Purpose – The purpose of this paper is to argue that understanding and exceeding customer expectations in the aged care services is more complex than other health services and general services because of the multiple stakeholders and additional intimacies that exist. . Findings – The author builds an argument that aged care service providers must understand consumer needs and expectations so that customer satisfaction is generated. 2008 pp.1 The role of understanding customer expectations in aged care Leib Leventhal Conflict Management Systems Designer. Originality/value – Exploring patient and relative expectation and satisfaction in different theoretical contexts.emeraldinsight. 50-59 q Emerald Group Publishing Limited 0952-6862 DOI 10.

Additionally. an industry standard or objective norm relating to the marketplace.staff must adopt unique approaches to understanding customer expectations. but will only be missed if not provided for. Those emerging from dissatisfaction are complaints. Predictive or “will expectations” are those that the consumer thinks will happen in the next service encounter. (1992. These post-purchase affective states range from delight. implicit or explicit. word of mouth or customer needs. Expectations have also been described as standards: . places responsibility on the provider of goods or services to continually improve . services and the like. Over time. a relationship standard based on the overall experience a customer has had in the past with a particular product or service. people. A review of customer expectation theory Customer expectations are related to complaints through post-purchase affective states that cause affective behaviour such as complaining. 2001). Affective behaviours stemming from satisfaction and delight are compliments. Prior experiences with organisations also form the basis of consumer expectations. increasing in intensity as more dissatisfaction is felt (Santos and Boote. along with organisational and structural attributes. satisfaction and dissatisfaction – all relative to the original customer expectation. events. unrealistic or realistic (Ojasalo. 47) put it: Expectations provide the yardstick people use to evaluate the attractiveness and desirability of outcomes. an ideal standard or subjective norm. Understanding customer expectations 51 How expectations form What forms the basis of expectations has been discussed extensively in the literature. and . customer pre-attitudes or even the traditional marketing mix can influence what the consumer will expect from a product or service. and (3) exciting requirements – those unexpected needs that produce great satisfaction. (2) expected needs – those which customers are able to articulate when asked about what they want. p. image. products. Expectations can be based on market communication. while “should expectations” are those that the consumer thinks should happen in the next encounter. strategies for understanding customer expectations and implications for the aged care sector in the wake of its baby-boomer growth stage are discussed. The penultimate section examines a case study that illustrates how customer expectations in aged care involves multiple stakeholders and that understanding customer expectations is critical as the first step in managing complaints. which therefore. In the final section. 2003). They have also been identified as being fuzzy or focused. customers “expected needs” can become “must be needs”. . Expectations have also been described as customer needs divided into three main categories: (1) must be needs – those which the customer would not think about expressing. As Gilbert et al.



products and services (Lim et al., 1999). In line with what has been termed adaptation theory, which states that customers of particular groups of products or services do not change their suppliers or providers because their expectations have adapted to an environment where there has been no additional stimuli to cause them to change. However, over time, when new information becomes available regarding other suppliers or providers, and the consumers’ expectations change, consumers will weigh up the cost of staying with the adapted current provider against moving to a new one (Gilbert et al., 1992). Disconfirmation theory Adaptation theory was the basis of what has now become known as Disconfirmation of Expectations Theory rooted in the works of Helson (1964). At a basic level, confirmation or disconfirmation theory has been explained as meaning whether the product or service delivery met the consumer’s expectations. If expectations were met then they are said to have been confirmed. If consumer expectations were not met, they are said to have been disconfirmed. Ultimately, confirmation of expectations is what determines consumer retention (Bendall and Powers, 1995). At this level, confirmation happens when expectations are met. Others argue that confirmation occurs when performance exceeds expectations and disconfirmation occurs when performance falls short of expectations. When performance meets expectations, indifference is said to occur (Gilbert et al., 1992). Notwithstanding the wide acceptance of confirmation/disconfirmation theory, authors maintain that it is lacking (Olshavsky and Kumar, 2001). Spreng et al. (1996) in Olshavsky and Kumar (2001) found that expectations as well as desires influence overall satisfaction. Swan and Trawick (1979) also cited by Olshavsky and Kumar (2001) distinguish predictive expectations and desired expectations:
Predictive expectation is the pre-usage estimate of the performance level that the product was anticipated to achieve. . .Desired Expectation was the consumer pre-usage specification of the level of performance that the consumer wanted (Olshavsky and Kumar, 2001 p. 60).

Under the confirmation/disconfirmation model, predictive expectations are used as the measure. In their study, Swan and Trawick (1979), cited by Olshavsky and Kumar (2001), found that when performance was equal to (met) predicted expectations, the result was (as noted earlier) consumer indifference. In contrast, however, when performance was equal to (met) desired expectations, satisfaction was exceedingly higher. This theory is known as the desires as standards model. Thus, the disconfirmation of expectations model has been seen as only providing part understanding of customer satisfaction causes. To address this lack of acknowledgment of desired expectations as a source of customer satisfaction, Santos and Boote (2003) formulated a model based on disconfirmation of expectations theory that included delight (as an affective state) in addition to satisfaction. They maintain that expectations range, starting at the peak (see Figure 1). The predicted expectation, located at the centre of the vertical spectrum, generates an indifferent response when it is fulfilled (confirmation, as stated above). Moving upward from the centre, satisfaction occurs in between the fulfilment of predicted and desired expectations. Positive disconfirmation exists when satisfaction occurs. Of course this applies when the higher “should be” and “ideal” expectations are met. At this level delight occurs. Delight and satisfaction lead to complimentary behaviour

(Santos and Boote, 2003). Moving below the centre of the vertical spectrum, negative disconfirmation exists when expectations fall between “predicted” and “worst imaginable”. In between “predicted” and “minimum tolerable”, negative disconfirmation will generate acceptance by the consumer and dissatisfaction occurs when expectations fall below “minimum tolerable” until “worst imaginable”. Dissatisfaction leads to complaints behaviour (Santos and Boote, 2003). This conceptual model incorporates desires into the disconfirmation of expectations theory. In doing so, we see that when predicted expectations are met (confirmation), indifference occurs. On the other hand, when desired expectations are met (positive disconfirmation), satisfaction occurs. These two affective states become complimentary and inclusive. Up until this article, only the predictive expectation was used when looking at the disconfirmation of expectations model, which calls the predictive expectation the “core” expectation; that is, at the centre of the vertical spectrum and the other expectations such as desired, “peripheral” expectations (Santos and Boote, 2003). In summary, expectations have been identified as the foundation of affective states such as being satisfied or dissatisfied with products or services, which leads consumers to either compliment or complain about the product, supplier, service or service provider. Expectations were defined and an extensive list of types of expectations was identified. Expectations were also identified as customer needs and three types of needs were found. Adaptation and disconfirmation theory was found to be the dominant model for understanding expectations and supported how negative disconfirmation of expectations can lead to complaining behaviour by the consumer. This review supports the argument that effective complaints handling begins with effective management of consumer expectations. The article goes on to illustrate how expectations become more complex in services than in products, leading to the additional complexities of the health industry and then aged care. Customer expectation in products and services Product quality is commonly ascertained by tangible cues such as style, hardness, colour, label, feel, package, fit and functionality, and has been epitomised by the Japanese “Zero Defects” philosophy – doing it right the first time (Parasuraman et al., 1985). Product quality has been measured by counting the incidence of internal and external failures (Garvin, 1983 as cited by Parasuraman et al., 1985). Service quality, on the other hand, is largely undefined and harder to understand because of its intangible nature. Additionally, there is heterogeneity amongst providers of the same services as well as between each time a service is delivered by individual providers themselves.

Understanding customer expectations 53

Figure 1. Disconfirmation of expectations



Finally, different products, production and consumption take place at the same time in service delivery (Parasuraman et al., 1985). Within services, customers, comparing their expectations to actual performance, judge quality. Customers seek consistent performance delivery and service satisfaction is determined by whether there was positive or negative disconfirmation of expectations as discussed above (Parasuraman et al., 1985). Additionally, service outcomes and delivery processes are critical to providing services. Sasser et al. (1978), as cited by Parasuraman et al. (1985), argued that service quality is determined by three factors: (1) materials; (2) facilities; and (3) personnel. Gronroos (1982) as cited by Parasuraman et al. (1985) talked about two types of quality: technical (outcomes) and functional (delivery). Additionally, Lehtinen and Lehtinen (1982) as cited by Parasuraman et al. (1985) discussed three service quality dimensions: corporate quality (image), physical quality and interactive quality. Other service quality expectations have been identified in the literature; including reliability, responsiveness, competence, access and approachability, courtesy, communication, credibility, security, understanding customers and finally the tangible aspects of service delivery (Parasuraman et al., 1985). Services intangibility and delivery process inclusion make identifying quality and understanding expectations in service delivery more elusive and multi-dimensional than that of products (Lim et al., 1999). Health care customer service expectations Health services have undergone major change owing to environmental forces including increased competition from alternative providers (Gilbert et al., 1992). It is thus critical for health care service providers to understand customer expectations; enabling them to compete effectively and retain customers (Gilbert et al., 1992). Customer expectations of health care and other industry services are different. The health care industry is complex, multifaceted and undergoing rapid changes. The most noted difference that contrasts health services to other professional services is the intimate relationship that exists between the customer and the health care provider. Within health care, intimate relationships form the foundation of customer satisfaction. This intimate relationship is epitomised by “caring” – the central unifying health service domain (Perucca, 2001). Caring has been identified as the most important factor that impacts on health care customer satisfaction, which includes staff interpersonal attributes and how they respond to patient needs (Perucca, 2001). Specific skills that customers expect in health care are: . competence, such as skillful and timely medication administration; and . knowledge, honesty, listening skills, availability and professional attitude (Perucca, 2001). Similarly, Lim et al.(1999) stated that caring is divided into technical aspects (competence of the provider, thoroughness, clinical and operating skills of doctors) and interpersonal aspects (humane, socio-psychological relationships between patient and health care provider, explanations of illness and treatment, availability of information

Finally. which make it harder to understand customer expectations in general services. 2005). aged care service customers are frail and elderly who. being able to tune out the world and tune in the patient. 424). Loyalty comes from satisfaction. 2001). p. body language and facial expressions (Perucca. aged care services have additional layers of customer expectations that make providing these services far more complex than general health care. attitude. quality of care: . five common interpersonal expectations in health care – important to patients’ wellbeing – are staff attitudes (sincerity and trust). In addition. in a majority of cases. In short. . a plethora of other stakeholders often become involved with service delivery. and . p. health care services have the additional complexity of expected interpersonal skills and caring attitudes that staff must have in addition to their technical based competencies. customer dissatisfaction will occur and the possibility of complaints opens (Bendall and Powers. aged care residential services are permanent residential arrangements and with that comes more extreme intimate issues such as . privacy (advocating for patient privacy) and appearance (all tangible aspects of care) (Perucca. which is expected to maximise an inclusive measure of patient welfare. 1980. In summary. . each with his or her own set of interests and concerns (ACAA. 50). 1995). . 1999. . 1992 as cited by Lim et al. non-verbal gestures. An important health industry feature is that meeting customer expectations is not enough to guarantee customer loyalty and retention. in addition to intangible and process elements of service quality. if patients’ quality of care expectations have been exceeded. [is] fully meeting the needs of those who need the service most. unlike health care services.. becomes that kind of care. cited by Lim et al.and courtesy and warmth received).. responsiveness (recognising needs and responding). Of course. 2005). eye contact. 2001). at the lowest cost to the organisation within limits and directives set by higher authority and purchasers (Ovretveit. 424). Interpersonal elements that influence health care customer impressions include: . 1999. . defined as: A process by which health care providers influence loyalty and maintain existing patients. . 1995. if expectations are negatively disconfirmed. . p. are unable to articulate their concerns because of a lack of self confidence and fear of retribution (ACAA. Customer expectations in aged care services In addition to the interpersonal skills and caring attitudes needed to meet customer expectations in health care. and ability to break preoccupations. they will be satisfied and the health care service provider will retain customers (Bendall and Powers. Aside from involving care recipients’ physical wellbeing. Consequently. which turns into customers’ intention to return to the service provider. Like other products and services. sensitivity (open ended questioning). after one has taken into account the balance of gains and losses that attend the process of care in all its parts (Donabedian. Understanding customer expectations 55 Quality of care impacts on the patient’s intention to return to the health care provider.

the daughter’s heartbreak and guilt feeling for breaking her vow to her mother could at least be minimised by making sure her mother received the same treatment in the aged care facility. 2006). the Aged Care Act 1997. when. The daughter cared for her mother from 1994. these rules and principles may not be made clear to residents’ relatives. Quality of Care Principles 1997 and User Rights Principles 1997 define what aged care service customers should expect from their service and service provider.IJHCQA 21. when her mother began to suffer dementia. other stakeholders. Different family fragments give an additional complexity as multiple sets of expectations are involved. likes and dislikes. when she could no longer bear the burden of being a full-time carer. at the age of 92. she became an expert at knowing every aspect of her mother’s needs. It also involves deeply personal issues such as customer residency and security and family guilt. with the onset of baby-boomer generation retirement and the aging population. the purpose of which is to analyse the model of disconfirmation of expectations theory in a real case scenario. In no means is the following case meant to be treated as a judgement of the circumstances that surrounded the complaint. The daughter and mother had lived together all their lives. The information in this case study has been gathered from written documents and interviews with the daughter of a care recipient (her mother) who resided in an aged-care facility. including immediate family members. Finally. walking. Upon admission to the home. A good example of this scenario is illustrated in the following case study. Additionally. During the course of their lifelong companionship. During the nine and a half years of care that the daughter experienced. The daughter felt that she was at the point of breakdown and let herself be persuaded by family and friends that after nine and a half years of caring. The case solely represents the views of the complainant. wants. In summary. often feel guilty for having to place their elderly relative in a home and expect the best of care (however so undefined) to be given to their loved one (Thomas. owing to the intangibility of the nature of service and lack of communication that exists within aged care facilities. the mother was independently able to go to . concerns. until 2003. The daughter agreed to this oath and was faithfully fulfilling her carer’s role until 2003. customer expectations in aged care will broaden to include updated information technology processes. aged care services have the additional complexities of understanding and meeting the expectations of other stakeholders aside from the direct customer. To assist in meeting the aged care residents’ and their families’ expectations. However. all of which the daughter expected to be done in the same manner in the aged-care facility. Moreover. feeding. Case study This case study is the basis of a complaint lodged against a nursing home. fears. security and emotional support (Thomas. in addition to the intangible nature of services. the mother asked her daughter to swear to her that she would never put her into a hospital or nursing home. The daughter wrote a full list of expectations and instructions (care plan) for the home staff to follow. 2006). This way. she was expert at administering medication. it would be the best thing to place her mother in the hands of professional carers. The mother’s dementia worsened to the point of not knowing her daughter by face most of the time. was placed in the care of a nursing home. the importance of process delivery and the necessity of having a quality caring environment.1 56 home. dressing and bathing. hearing and anxiety.

as defined above. As a mismatch of customer expectations and experiences are the beginning of the complaints process (Thomas. One-to-one interviewing could be used as an additional method for strengthening customer satisfaction and managing customer expectations (Halliday and Hogarth-Scott. These included. issuing medication without authority and with misleading information. the daughter communicated these expectations and expected and them to be fulfilled. Unfortunately. Hence. Now.the toilet at night time. converse. 2001) or “minimum tolerable” (Santos and Boote. she lives with her psychological trauma (and ongoing treatment) of knowing that she did not fulfil the vow that she had taken with her mother. 2003) expectations. according to the daughter. are those that the customer can articulate when asked about what he or she wants. anxiety instructions not being listed to. The second expectations’ group not met in this case were those relating to the alleged poor quality of care. which led to the affective state of dissatisfaction. medicated to the point of being unconscious. This case illustrates that both levels of expectations were not met. 2006). they were the expectations that were listed on the care plan that the care recipient’s daughter handed to the nursing home. providers need to create cultures for better practices in complaints handling (Thomas. having kidney failure and pneumonia. 2006). these expectations refer to quality of care standards and principles set out in the Aged Care Act 1997. This model goes through phases: Understanding customer expectations 57 . not walked. those that must be delivered no matter what. according to the daughter. 2003) expectations. At this stage. feed herself with minimal assistance and walk with a walking frame. 2000). Lim et al. this service was at the level of the “worst imaginable”. over the next few weeks. not fed according to her visual impairment needs. The daughter naturally then lodged a complaint via the external complaints resolution scheme and is still pursuing a satisfactory settlement. In this case. As stated above. Strategies for positively disconfirming customer expectations in aged care The onset of the baby boomer generation entering aged care is increasing demand for services. the mother not being warmly dressed. 2001) or “desired” (Santos and Boote. She felt that her mother’s life was taken away from her owing to what she witnessed and described as horrific care conditions. The first group of expectations that were not met were those defined above as “expected” (Ojasalo. These expectations. One basic strategy already in place in many aged care facilities is to understand customer expectations through resident and family meetings or discussions. In aged care. (1999) discussed a method of increasing customer satisfaction called quality deployment function. it is alleged that medications led to the mother’s death as she was not able to communicate any discomfort after suffering a heart attack. In line with the Santos and Boote (2003) model of positive/negative disconfirmation. not taken to the toilet at night. hearing aid not being attended to. it became evident that the daughter’s expectations were being negatively disconfirmed to the point of causing extreme dissatisfaction because the service was the “worst imaginable”. wash herself after toileting. These expectations are defined as “must be needs” (Ojasalo. allegedly owing to illnesses that were not detected because her mother was. Her mother died ten weeks after entering the home. understanding the future customers’ needs and expectations will minimise the amount of time and money spent on complaints handling. This case can be divided into two components for analysis of expectations. according to the daughter.

3. Harper & Row. “Handling complaints in Australia’s residential aged care facilities – a report”. pp. 1. government. Bendall. it is vital to understand all stakeholders’ quality aged care expectations. New York. 2005). (2000).M. Vol. Gordon. concerns and expectations to be met.W. Different types of expectations were identified. Journal of Health Care Management. 6. resulting in the daughter taking action through the external complaint resolution scheme. (2) understanding their expectations through interviews.IJHCQA 21. and Hogarth-Scott.P. Journal of Health Care Marketing.V. Finally. (3) ranking customers expectations. Conclusion This article discussed expectation theory and how meeting customer expectations can lead to either confirmation or positive/negative disconfirmation. Helson. D. S. 9 No. 200-12. As a result of not going through this process. R. pp. care recipient.. Vol. there are multiple parties that includes families. 12 No. Services were highlighted as being distinct from products owing to their intangibility and delivery process requirements. Had the nursing home in our case study paid attention to the written expectations and nursing instructions for the care recipient document they could have either brought the daughter’s expectations in line with the service provider. Sydney.C. etc. Aged care services have been seen to be even more complex as the customers include multiple stakeholders such as immediate family that have their own interests. A case study of negative disconfirmation in aged care illustrated how it is the expectations of other stakeholders that are critical in understanding.).K. References ACAA (Aged Care Association of Australia) (2005). 4. F. Ojasalo. Vol. Adaptation Level Theory. J. “Cultivating loyal patients”. 9 No. 46-55. (1999). Lim. Lumpkin. and Powers. “New customers to be managed: pregnant women’s views as consumers of healthcare”. Halliday. Listening Post. Health care services were seen to add an additional layer of complexity in meeting customer expectations as there is the added element of quality of care that includes technical and interpersonal relationship dynamics between customers and service providers.1 58 (1) understanding who the customer is (in aged care. and Dant. 15 No. 11 No.R. 423-34.L. pp. Journal of Applied Management Studies. (1964). J. H. T.H. or given the daughter the choice of seeking a different provider that would have better suited her needs. in aged care. P. (2001).. . (1992). the events described above occurred. 50-2. Gilbert. (1995). Vol. P. N. pp. “An innovative framework for health care performance measurement”. 3. and (4) identifying quality management systems that address meeting those expectations. Managing Services Quality. S. “Adaptation and customer expectations of health care options”. Managing Service Quality. NY. pp. 55-69. “Managing customer expectations in professional services”. and that to avoid complaints to the external complaint resolution scheme. Tang. Vol. providers should do pre-admission assessments to determine whether a potential resident is suited to that facility (Phillips. and Jackson.

A. 20-4. S. and Kumar. Journal of Marketing. 14. (2001). 49 No. (2003). Zeithaml. (2006). 4. Melbourne. Does your facility fit your residents?”. Russell Kennedy. pp. . R. Parasuraman. “A conceptual model of service quality and its implications for future research”. and Berry. 9. Vol. V. April-May. “One size does not fit all. Phillips. 2. “Customers with options”. Summer. 142-56. L. 60-73. Vol. National Health Care Journal. 41-50. A. post-purchase affective states and affective behaviour”. pp. Dissatisfaction and Complaining Behavior. and Boote. Nursing Management. 32 No.L.W. Thomas. Journal of Consumer Satisfaction. 3 Understanding customer expectations 59 To purchase reprints of this article please e-mail: reprints@emeraldinsight.. pp. Corresponding author Leib Leventhal can be contacted at: LeibLeventhal@bigpond. Vol. Vol. “Revealing the actual role of expectations in consumer satisfaction with experience and credence goods”. pp. (2005).emeraldinsight. L. pp. J. Perucca. Health and Aged Care Brief. Santos.A. Or visit our web site for further details: www. (1985). (2001). “A theoretical exploration and model of consumer expectations. J.Olshavsky. Journal of Consumer Behaviour. “Complaints: the right culture hears the message”.

2004a). when diagnosis-specific analysis requires data pooling over several years in order to reach adequate case numbers. (2) Medical Responsibility Board. Stockholm. and (3) Patients’ Advisory Committees respectively. MMC. empirical evidence about the causes of and conditions influencing adverse events varies according to the investigation method.The current issue and full text archive of this journal is available at www. how they can be used. It is likely that a variety of data sources will be needed including patient claims 2003). e.htm IJHCQA 21. Empirical evidence about the number of adverse events for patients varies according to data collection methods. It then presents three types of data on patient claims and complaints in Sweden: data generated by the Patient Insurance Fund.emeraldinsight. We describe three main types of Swedish patient claims and complaints’ data: (1) data generated by Patient Insurance Fund activities. which makes it difficult to know how much the data correspond to general injury rates and health care patterns. the Medical Responsibility Board and the Patients’ Advisory Committees and considers methodological issues in using the data.. may add to difficulties using the data in comparative analyses of safety performance Research limitations/implications – The databases’ safety analysis and quality improvement value depends on understanding their function.. data collection method and their limitations as a source of data about the true incidence and prevalence of injuries and safety problems. This means knowing more about the different systems’ advantages and disadvantages for reporting adverse events and for gathering safety data (Zhan and Miller. 2004). Thomas and Petersen. Safety. Measurement.. both from research studies and from routine monitoring for timely action (Handler et al. Complaints Paper type Research paper 60 Received 14 August 2006 Revised 29 December 2006 Accepted 6 February 2007 International Journal of Health Care Quality Assurance Vol. Better patient safety depends on better data about incidence and causes. Adjustment for confounders not present in the databases. 2003. Sweden Abstract Purpose – The purpose of this paper is to describe patient complaints and claims data from Swedish databases and assess their value for scientific research and practical health care improvement. Patients.g. 2008 pp.1 Patient claims and complaints data for improving patient safety Pia Maria Jonsson and John Øvretveit Medical Management Centre. Originality/value – This is the first thorough review of the possibilities and limitations associated with the use of claims and complaints data in health care research and improvement. data on hospital case-mix. 60-74 q Emerald Group Publishing Limited 0952-6862 DOI 10. Design/methodology/approach – The article first describes previous research into patient claims and similar schemes. 2000. 21 No. Keywords Quality improvement. their strengths and weaknesses. but little is known about the data. Findings – The databases’ value is problems related to spontaneous reporting. Similarly. e.g. . 2000. Sweden. 1. The National Board of Health and Welfare.1108/09526860810841165 Introduction Research shows significant safety problems in health care in Sweden and abroad (Kohn et al. Phillips et al. Karolinska Institutet. Another issue is the balance between the size of study materials and the timeliness.

which may have resulted from a healthcare episode without having to ¨ ¨ prove negligence (Patienforsakringen. n.7 per cent of hospitalisations and that 28 percent of these events were due to negligence (Brennan et al. 1991).. 1991).d. In Sweden. discuss the value of patient complaints and claims data for research and practical improvement work.. Research into patient claims The frequency of adverse events that occur when patients receive medical care has been reported in a number of studies. 2004). The committees also host databases with complaints’ information. Patients can apply for injury compensation. the hospital admissions with adverse events prevalence was estimated at 9 per cent of admissions and 40. In Denmark.d. 2004b).).. The county councils’ Patients Advisory Committees handle all types of patient complaints concerning health services ¨ (Patientnamnden. The National Board of Health and Welfare (2004 a) estimated that adverse events contribute to Patient claims and complaints data 61 . The Medical Responsibility Board investigates complaints against health services staff to examine whether there is a reason to impose disciplinary sanctions owing to negligence or malpractice (HSAN. which we describe later. and holds extensive claims’ data.9 per cent and death in 20. outline the databases’ development and the information available. n.5 per cent (Baker et al. events judged to be preventable occurred in 36. all healthcare providers are obliged to have a medical malpractice insurance policy to cover indemnity for patient injuries.8 per cent. Can these data be used to monitor care safety and to highlight safety issues? What can we learn about patient safety from the experience of the Patient Insurance. The Harvard Medical Practice Study estimated that adverse events occurred in 3.. The Canadian Adverse Event Study estimated that the incidence of adverse events among hospital patients was 7. 1995).. This organisation is financed from tax revenue raised by the local government counties. The Quality in Australia Health Care Study reported that 16. The high proportion of patient management errors. Based on various databases and studies.000 women in the general population were hospitalised owing to care complications in 2002 (The National Board of Health and Welfare. Complaints’ data are registered in The National Board of Health and Welfare’s RiskDataBase. the Medical Responsibility Board and the Patients’ Advisory Committees? Our purpose. and . 2001). 1996). Among these cases. yet the precise prevalence and magnitude of medical error remains unknown (Weingart et al. Drug complications were the most common type of adverse event amounting to 19 per cent of all cases (Leape et al. was regarded to suggest that many of the events would be preventable. 2000). Data about these claims are available in an extensive database hosted by the Patient Insurance Fund.000 men and 243 per 100. statistics compiled by the National Board of Health and Welfare show that approximately 203 per 100. therefore. is to: . . Patients using private providers in the county can also apply for compensation to this publicly funded patient insurance fund.In Sweden.).. present previous and current data analyses. 58 per cent of all adverse events.6 per cent of hospital admissions were associated with an adverse event and 50 per cent were judged to have a high preventability score (Wilson et al.4 per cent of the adverse events were judged to be preventable (Schioler et al.

USA. where patients do not have to prove negligence in a court of law (although they can use this route). 1998). One of the few empirical studies that contrasted the two systems considered preventable in-hospital medical injury under the no fault system in New Zealand (Davis et al.g. New Zealand and the Nordic countries). which traditionally produce the most claims – accident and emergency. Research also considered whether physician performance and type of speciality is related to malpractice claims. but can have their claim assessed and compensation awarded through another system. 2000). Weycker and Jensen. the study claims that volume and type of medical injuries were significantly different to those reported in other studies in countries with a tort law. However. 2003). 2004). Studies have examined the number of malpractice claims against physicians’ in the context of their credentials and found these to be strongly associated (Branney et al... usually administered by a government agency and tax funded (e. Insurance against claims is also high and medicine is practiced more defensively (Bovbjerg and Sloan. This study identified 906 claims from patients with diabetes where the total indemnity paid was almost $27 million.. which is thought to be important for effective safety reporting systems. When compared to all claimants. seeking compensation may be easier and less expensive. which allows patients to seek redress from a doctor for perceived negligence (e. How has data from both types of malpractice claims systems been used for research.800 deaths per year. 1986). 1989). There are thought to be advantages and disadvantages to each.. Data suggested problem areas for attention that included supervision and foetal heart monitoring.IJHCQA 21. and the total costs to society less. diabetes patients were older and predominantly male... Legal redress may act as a deterrent against lower practice standards (Hiatt et al. 1990). The Physician Insurers Association of America (PIAA) database has been used as a surveillance tool for diabetes-related malpractice claims (Meredith et al.g. although there is no clear evidence. UK). and (2) a no-fault system. Under a no-fault system. This was one of the first studies showing how these data help to predict and understand adverse events.. obstetrics and trauma and orthopaedics (Davy et al. It also may be more likely that health care personnel report “errors” or “near misses”. systematic research into the epidemiology and aetiology of adverse events in the Swedish healthcare system has only just begun. insurance costs are lower.. Can these data be used for patient safety research or routine monitoring and improvement? Patient claims data are collected under two different systems: (1) a legal claim under tort law. 2000. 1994). 1998). Under a tort system. which found rates associated with both physician performance and specialty (Taragin et al. An unpublished UK study found standardised incidence ratio of error highest in the specialties.. The proportion of diabetes claims was highest in . A later study reviewed 64 serious obstetric accidents referred over five years to the UK Medical Protection Society – one of the three main UK litigation databases (Ennis and Vincent.1 62 around 1. Patient claims and complaints systems provide different types of data about health care adverse events. Although comparisons are difficult. compensation awards can be high. and have data been used to study and improve care quality? One early review of empirical studies described the value of research into malpractice claims and called for better data (Zuckerman et al.

Claims databases have also been used to assess economic costs (Fenn et al. More studies are examining which type of patients file claims and why (Hickson et al. was associated with the highest level of injury severity.860 3. Number of complaints to the Patient Insurance Fund. Levinson et al. 1993.572 m. 1997-2004 .552 8. Little research has considered the role of nursing or paramedic professions in patient claims. Since the databases were developed at different times and for different purposes. 1989).. Table I displays the number of complaints and claims made to each body (1997-2004). Other studies found communication with patients and families to be a likely factor in precipitating claims and have proposed improving communications as an intervention to reduce claims (Vincent et al.546 19. Medical Responsibility Board and the county councils’ Patients’ Advisory Committees represent instances to which patients (and sometimes their relatives) apply when they think they have been treated incorrectly. 1996. Annual reports from the Medical Responsibility Board and The National Board of Health and Welfare Table I.995 22... 2000.119 3. In 1989. Tsai et al. internal medicine. Prevention programs designed to reduce liability among high-risk specialties could also lead to improved care quality for patients with diabetes. m. Goebel and Goebel (1999). general and family practice.395 8. or that health care has not met their expectations. 1998.717 8. 2004). 22.003 9. Patient claims and complaints data 63 Year 1997 1998 1999 2000 2001 2002 2003 2004 Patient insurance 8.064 3. found evidence that malpractice lawsuits could be prevented by quality interventions such as clinical guidelines.377 3. Medical Responsibility Board and Patients’ Advisory Committees. The study concluded that the PIAA database can be a useful resource to monitor trends in diabetes-related malpractice. Moles et al.227 3. one study reported a dramatic rise in the incidence of nurses as defendants in malpractice claims (McDonough and Rioux. Adamson et al.129 8.239 18.. (2004) reported that medical experts considered that 83 per cent of 371 malpractice cases reviewed could be “improved by quality management”.070 3. Nurse negligence has been reported to be associated with 27 per cent of all USA claims and with 26 per cent in one Taiwan study (Beckman. Malpractice claims research has been used for financial risk management and quality improvement.. 2005).. Tsai et al. 2001. as compared to all claims. Persson and Svensson.938 Medical Responsibility Board 2. 1994.. 1989). 1997).174 8. 16. A greater proportion of diabetes claims.871 9. The Swedish databases In Sweden the Patient Insurance Scheme.ophthalmology.250 3. Lester and Smith. they differ in the numbers of complaints as well as in the amount and character of information they contain.664 Patients’ Advisory Committees m. for example.500 Sources: Statistics from the Patient Insurance Fund.

irrespective of fault or negligence. Indemnity for patient injury could be paid on objective grounds. both public and private care providers are obliged to have a medical malpractice injury policy that covers patient indemnity. Figure 1 shows the annual numbers of both applications for claims and compensated cases from the Patient Insurance Fund (1975-2003).1 64 Patient insurance scheme The county councils’ voluntary patient insurance scheme came into force in January 1975 and medical malpractice insurance was subsequently introduced for almost all Swedish public and private care. if it was caused by faulty medical or dental equipment or by incorrect diagnosis. and . 3. if infection has been transmitted in the course of treatment. In January 1997 the voluntary insurance scheme was replaced by The Patient Injury Act (1996). when a treatment injury as described in the insurance conditions occurred. 1975-2004 . The conditions in the Act on Injury to Patients largely correspond to the conditions of the previous voluntary scheme.IJHCQA 21.400 claims in 2003.000 in 1983. 5. 9. Number of claims to the Swedish Patient Insurance Fund.000 in 1993. in the event of accidents in connection with medical or dental care and in connection with incorrect prescribing. Cases reported by the patients to the Patient Insurance Fund are scrutinised from a strictly medical point of view to establish whether the injury is of such a nature that compensation should be paid. 7. . There is no indemnity in cases where the treatment simply has not led to the desired result or where (predictable) complications arise. Claims applications have increased to: . Under the act. Figure 1. if the injury concerned could have been avoided. .300 in the first year of operation in 1975. Indemnity for personal injury can be paid.

The numbers of complaints to the Medical Responsibility Board and the numbers of disciplinary Patient claims and complaints data 65 . When taken. 1998. Certain cases are examined by the chairman alone.). Regarding such injuries. there is a higher risk of women injured by radiological examinations. but a generally higher risk of lethal patient injury among men. Anyone who is or has been a patient can file a complaint to the Medical Responsibility Board. e. 1999).Overall 40-45 per cent led to a compensation payment. data about possible surgical interventions. Previous studies addressed a range of clinical topics – e. surgery. Medical responsibility board The Medical Responsibility Board is an independent national authority. medical specialty. care giver type. care level. Apart from complaints about errors in medical treatment. injury cause... . Diagnosis and operation codes are used to analyse injuries to patient groups (diabetes. breast implant etc. data can be analysed by: . operation for short-sightedness. cataract etc. basic diagnosis. injuries related to certain clinical fields. 1997. county council. 2003b). the complaint may be submitted by a close relative. and . cardiovascular disease. data include: . this action is usually an admonition or a warning. injury effects. . injury year. to specific types of medical error or to the use of selected medical technologies ¨ ¨ ¨ (Cronstrom et al. Ohrn et al. 1997). After 1994. after which the Board examines the case and decides. 1996).. which investigates complaints against all registered health care professionals to examine whether there is cause for disciplinary action (Instruction to The Medical Responsibility Board. there were previously also complaints about poor service or care quality. injury cause and effect. . 2006).. since 1998. If the patient him/herself is incapable. . cases solely concerning services a patient has received are referred to the Patients’ Advisory Committees. although a small proportion of cases involve withdrawing registration following notification from the National Board of Health and Welfare.) or patients undergoing a particular treatment (hip joint replacement.g. gynaecology and ¨ ˚ obstetrics (Jonsson and Wahlberg.g. 1996. . Consequently. . The complaints are reviewed by medical experts. Gender-specific analyses have indicated differences between women’s and men’s injury patterns ¨ (Jonsson and Raf. and . Johansson and Raf. . Specialties with many cases registered in the database include orthopaedics. Over the years about 60 per cent of cases have concerned female patients (Pukk et al. patient consequences. Raf and Claes.

2004). have few direct sanctions and do not have disciplinary powers.IJHCQA 21.227 3. Number of complaints received and disciplinary actions taken by the Medical Responsibility Board. The study identified second-hand information as an aggravating circumstance when assessing the urgency of care needs.659 2. The Stockholm region also showed the highest number of disciplinary actions per inhabitant. but was most prominent in dental care and general medicine. 1995-2004 Source: Annual reports from The Medical Responsibility Board .064 3. e. Kalmar and Kronoberg counties. Data from the Medical Responsibility Board have been used in regional comparisons (The National Board of Health and Welfare.860 3. Analysis showed large differences in Sweden between counties in number of claims per inhabitant in 1999/2000. Recently. but there have been few scientific analyses of the material.1 66 actions in 1995-2004 are presented in Table II. an exploratory study analysed factors and circumstances related to complaints in emergency medical dispatching. in which committees’ tasks were specified more closely and the working field was expanded to include all government-funded health care and certain social welfare problems experienced by older people (Law of the Patients’ Advisory Committee. which shows that a steady increase in the number of cases appears to be levelling off. 2002). Hence.g. partly based on complaints to the Medical Responsibility Board (Wahlberg et al. Nearly all disciplinary actions against physicians concerned misdiagnoses (subarachnoid haemorrhage in particular).664 Disciplinary actions n 330 410 391 401 378 335 277 293 300 357 % 13 15 14 13 12 11 9 9 9 10 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Table II.377 3. 1998). They give advice to patients and provide a quasi-independent body for investigating dissatisfaction and mediating disputes Complaints n 2. In January 1999. The high claims rate in the Stockholm region applied to all types of activity. The most common reason for a nurse receiving a warning or an admonition was negligent handling of drugs. Uppsala.. in contrast to sparsely populated area rates.250 3. the survey identified two areas that educational programs could improve patient safety. 2003).119 3.070 3.521 2. a new law came into force. The Patients’ Advisory Committees do not make medical judgements. Cases from the Medical Responsibility Board have been presented in the Swedish Medical Association Journal. Patients’ advisory committees The first Swedish law about the Patients’ Advisory Committees was created in 1980. Another study analysed all available complaints about stroke management made to the Medical Responsibility Board over a five-year period (Johansson et al. Goteborg and Bohus counties. Claims rates were ¨ appreciably higher in Stockholm..

it is problems patients do not want to raise directly with personnel. It is also their task to refer patients to other agencies. Complaints are often questions or criticisms that patients or relatives have tried to take up with healthcare personnel. 2003).255 298 2. the reverse was true. Results showed that. The rates per specialty. 2005 Source: Stockholm County Patients’ Advisory Board. whereas complaints about care and treatment were more likely to be registered in the complaints to the Patients’ Advisory Committee. feed-back sessions at local hospitals have been a popular way of sharing experience. but feel they have not been heard or respected. but the effectiveness of using data in the prevention of patient injuries has not been studied systematically. to file a malpractice claim.. information Organisation. were compared with corresponding rates for the Medical Responsibility Board and the Patient Insurance Scheme. 53 per cent concerned inpatient care.000 discharges. calculated per 100. communication. In 2001. because. According to Committee representatives. resources Other complaints All n 555 204 787 197 1. One of the Patients’ Advisory Committees’ duties is to prevent the same problems from occurring again by reporting the case statistics to the National Board of Health and Welfare. 24 per cent primary health care and 8 per cent mental health services. The Committee’s aim is to solve problems quickly and in a non-bureaucratic way. public health care districts and other involved authorities. an analysis was made linking data about complaints to the Stockholm County Patients’ Advisory Committee with data from National Patient Register (Arnetz and Arnetz. This analysis and the studies noted earlier show how each database provides a different picture.between patients and health services or personnel. Table III shows the complaints’ distribution by one county’s Patients’ Advisory Committee about different issues (Stockholm County Patients’ Advisory Committee. the importance of knowing the strengths and weaknesses of each and often the need to use multiple data sources. they feel they may suffer in the future as a result.000 complaints were filed in 2002 (The National Board of Health and Welfare. 2002). The previously mentioned study on emergency medical patching (Wahlberg et al.743 % 32 12 45 11 100 n 967 431 1. Analysis also considered data from patient questionnaires in the same hospitals. for example. Distribution of complaints to the Stockholm County Patients’ Advisory Committee. by gender.951 Women % 33 15 43 10 100 Table III. The conclusion was that dissatisfaction about lack of information and patient participation was more likely to be detected by surveys. hospitals. Of these. Reports to the National Board of Health and Welfare show that more than 22. Sometimes. Little research has used data from the Patients’ Advisory Committees. 2006). Annual Report 2005 . Patient claims and complaints data 67 Men Type of complaint Medical treatment Interaction. while applications and claims in specialities such as obstetrics and gynaecology were higher. for example in the fields of neurology and geriatrics. for example. 2003) drew some data from one of the committees.

1 68 Methodological concerns As the complaints and claims’ databases are so voluminous and the information in them relatively detailed. The ICD 10 classification Y-codes. This may interest researchers when societal resources are allocated to prevent accidents. but there were variations regarding complaints per 1. is important. The upward trends in patient complaints and claims have been interpreted by many observers as a consequence of better informed patients and more support from healthcare system in filing claims. It was noted that neither reporting nor compensation rates were constant. there are great difficulties in calculating rates in outpatient care owing to the lack of outpatient services national registrations. While this is possible for hospital inpatient care through links to the National Patient Register. Hence. However. Cases are registered in order to assess liability and damages or to solve patients’ problems. Regarding Patient Insurance. encouraging and assisting the complaints process. Increased healthcare utilisation is likely to increase the magnitude of harm. The problem of spontaneous reporting One special methodological problem analysing and interpreting data from the databases is that they are based on spontaneous reporting. The data might not be collected consistently over time. 1992).000 inhabitants. e. researchers and quality improvement practitioners should use these data with caution and awareness of their limitations. Similar differences may exist between various clinical specialities. and only give a partial picture. let alone make a claim (Øvretveit. and by healthcare providers’ attitudes and approach to informing.IJHCQA 21. county councils were compared regarding claims’ numbers and ´ compensated cases from the Patient Insurance Scheme (Rosen and Jonsson. Some may make false claims. Analysing patient injury rates in the general population also permits comparisons of the safety problem magnitude across different society sectors. 1993). One way of dealing with problems related to spontaneous reporting is to follow long-term . A critical question is how far matters reported to different instances correspond to general dissatisfaction or injury patterns. the Patient Insurance etc. it may be advisable to relate the numbers of claims to the healthcare utilization rates. insurance practice over the years also affects material composition. in comparative studies. number of complaints per 1. If we challenge the self-evident healthcare utilisation rates rather than focusing on how much harm the healthcare system does in the general population then rates calculated per inhabitant rather than per patient/discharge may need to be studied. The tendency to lodge a complaint may be affected by patients’ knowledge regarding the possibilities of applying to the various instances for support or compensation.g. they seem to have a potential to help both quantitative and qualitative quality and safety of care analyses. 2004b).000 hospital discharges and number of injuries for which compensation was paid in relation to number of complaints. used in Sweden since 1998. have been the basis for the production of this kind of statistic from the National Patient Register (The National Board of Health and Welfare. not for the purpose of assessing quality and its determinants. The tendency in various patient groups to report shortcomings in service and treatment to The Medical Responsibility Board. In 1992. different age groups and between women and men. Most patients experiencing problems do not complain. traffic safety.. but there may be cut-off points where the benefit-harm ratio gets too low and the level of healthcare utilisation should be questioned.

we cannot exclude that results may be somewhat biased by lack of adjustment for confounders when comparing the claims rates from different departments. Unfortunately. Hence. owing to few previous studies on risks and safety. the practice of medicine and safety of care may be different today compared to the early 1990s. it is not the number of observations but rather the quality of the short case stories registered beyond the numerical data that might set limits to the materials’ utility. it is difficult to know how much of a change is happening in different fields over time.g. While adjustment for confounders such as age.. different specialties or patient groups. however. however. Here. In a recent study involving data from the Patient Insurance Scheme. 2003). Adjustment for confounders Special difficulties arise when the purpose of the analysis is to compare complaints or claims rates between hospitals or healthcare units.g.. This. Size becomes even more critical if analysis is to deal with several confounders. Responsiveness inherently means that service is adjusted to patients’ needs and expectations. However. No correlation was found between managers’ adverse events’ perceptions and the actual claims frequency from patients’ associated with the department. High patient satisfaction should be one care target at all healthcare units. e. selection by diagnosis and type of medical or surgical intervention easily reduces the volume of study materials. the same logic does not necessarily apply to complaints about. Adjustment for confounders has been an important topic when comparing the quality of hospital care based on data from the National Quality Registers in Sweden (Appelros et al. e. the variations between hospital case-mix that occur. could also be used in qualitative analysis of problems that patients experience in health care. orthopaedics and general surgery were compared with hospital managers perceptions care quality in their departments (Pukk et al. Owing to medical and technological development. claims rates from departments of general medicine. sex and severity of illness is important when comparing clinical outcomes. A solution may be to pool data over several years to attain enough observations. The Patients’ Advisory Committees data. 2003a).trends that reveal themselves in the proportions of total materials represented by. Patient claims and complaints data 69 .g. there seems to be a weak case for comparing hypothetical standard populations instead of real-life patient ones. needs to be balanced against the rapidity of change in medical practice. Although the study gives an indication of an important phenomenon that should be analysed further. e. gynaecology/obstetrics. this procedure does not deal with the differences in reporting tendency that may exist between men and women and different age groups. In the claims data. Size of materials and timeliness of study Although three databases contain large numbers of complaints regarding different medical specialties. regardless of patient population composition. owing to organisational factors. may be additionally aggravated by differences in reporting tendency. The size of the study material is mainly a problem in quantitative research. lack of information and patient participation. If we assume that better informed patients and more sovereign healthcare consumers is a “mega trend” permeating the healthcare system during the last few decades then analysing trends in proportions rather than in absolute numbers may be a good idea.

approximately 9. McLoughlin et al. 1. This and other studies show the value of data on claims and complaints for providing information for researchers and practitioners. Conclusions The risk of adverse medical events and medical errors can never be entirely eliminated. be noted that claims data include all levels of care. Hence.IJHCQA 21. Australia and UK (Danzon. including ICD 10 codes for medical and surgical treatment complications (The National Board of Health and Welfare. 2006.500 cases in 2002).000. e. Analysis of existing data at a local and national level can provide valuable insights for quality interventions as well as for research. In comparison. Tentatively. when a number of patients died owing to malpractice). 2006. the risk of serious patient injury has not changed over time. We could not locate publications that systematically compared claims systems of different countries although trends comparisons have been made in medical malpractice in the USA. 1990). Canada. while the Patient Register only covers hospital inpatient care. and what consequences repeated events can have for the patients affected. e. under certain circumstances. To what extent this is due to patients underreporting problems. the healthcare professionals’ reporting tendency has not been subjected to study. However. at what type of institution and in what medical service an injury or an incident occurred. the material can show. the annual numbers of Lex Maria cases have not changed much since the mid 1990s. Correspondingly. therefore. patient safety indicators constructed from administrative data and developed in. which contains information on cases since January 1992.g. 2006). which is related to quality and is driven by patient and user perceptions. is not possible to judge today. The number of registered complications in 2002 was approximately 22. Changes are also possible to these databases and collection systems to make them even more valuable for quality improvement. Serious injuries. Such analyses could also shed light on the extent patients’ claims and complaints reflect safety problems grasped by purely medical-technical safety indicators.g.200 claims in 2002 – can be compared to the numbers of injuries coded as mishaps (approximately 3. Following analysis. diseases and risks in health care must.1 70 Relationship to other sources of safety information As illustrated earlier the National Patient Register includes information about all hospital discharges in Sweden. or that not all complications lead to injury entitled to compensation. the USA and Canada and by the OECD Patient Safety Panel could be applied in overall safety analyses in Sweden (Agency for Health Care Research and Quality. but knowledge of risks gives care providers more opportunities for improving quality and helps care consumers choose care and treatment. in practice. In 2002. It should. There is a case.. 2004b). Statistics regarding “Lex Maria cases” are collected in the Board’s RiskDataBase. Canadian Institute for Health Information.400 cases. however. As opposed to patient claims and complaints. be reported to the National Board of Health and Welfare – according to a special law. . often the senior physician or the nurse with medical responsibility. the numbers of claims to the Medical Responsibility Board – 3. “Lex Maria” (named after an incident at Maria Hospital in Stockholm in the 1930s. Patient Insurance Fund claims.000 cases were reported according to Lex Maria. The obligation to report rests upon the person nominated by the health care principal. The Swedish Patient Register is in many ways comparable to hospital data sources in other countries. are relatively few.

Briant. (2000). (1989). Canada. and Fenn. cihi. Baker. P. 3.. Medicine and Health Care. Vol.J. R.A. J. Ghali. Brown. 4. 67. pp. (2003). R. L. A. A.. The epidemiology of error: an analysis of databases of clinical negligence litigation”. Localio.. and Arnetz. pp. and Terent. R. 330-8.C. pp. J..M. Sage Publications... Cox. E. International Dental Journal. Etchells. and Thomasson. 12 No. 2. 48-58. New England Journal of Medicine. Blais. Pons. F. A. 18-55. (1990). Lawthers. 150 No. P. N. 11. 2.R. V. V. C. D. Lay-Yee. (1998).. pp. Vol.. S. The Western Journal of Medicine. “Nursing negligence”. Bovbjerg.. (2002).A. Patient Safety Indicators Overview. Branney. 145-9. 187-95. available at: http://secure. Agency for Health Care Research and Quality. Hebert. Quality and Safety in Health Care. pp. AHRQ (2006).R.G. and Rene. (1990).A... and Scott. Davis. “Case ascertainment in stroke studies: the risk of selection bias”. for using data from a number of sources to provide different perspectives on the rate and causes of safety and quality problems. T.R. 356-60. (2003).htm ¨ ˚ Appelros.H. Stockholm. pp. British Medical Journal. Tschann... A. M.R. Owall. pp. Brennan. P.therefore.. unpublished report to the UK National Patient Safety Authority and Department of Health. pp. Patient Safety. Sweden’s Health Care Report 2001. Reid. P. “Patients’ views of the health services – what do complaints to the patients’ advisory committee tell us?”. 324 No. P.. B. and Vincent. and Tamblyn.qualityindicators. CA. Norton. Palacios-Derflingher. Vol. A. 170 No.. 251-6. “Patient safety: lessons from litigation. 3.P. Law. and Oppenberg. Esmail.S.. 99-105. Danzon. J. 48 No. “Preventable in-hospital medical injury under the no fault system in New Zealand”. Canadian Institute for Health Information. R. and Sloan. Analysing Malpractice in the Hospital Setting. (1996). “Incidence of adverse events and negligence in hospitalized patients. Beckman. 1678-86. Acta Neurologica Scandinavica. P. 6. (1991). Leape. Canadian Medical Association Journal. The Journal of Emergency Medicine. R.L. and Hiatt.E. pp. B. Gullion. Weiler. “No-fault for medical injury: theory and evidence”.G. G.. Vol.M. M. pp. W. J. University of Cincinnati Law Review. Ennis. available at: www. 19 No. Laird. Each system has its biases. L. N. but using a combination can provide a more objective picture. Manchester Health Services Centre. 370-6. “Physician communication skills and malpractice claims. N. G. H. 1365-7. Vol. 53-123. R.. Arnetz.. R.. Newhouse. S. O’Beirne. Vol. the United Kingdom and Australia”. Vol. 107 No... P. 18 Nos 1-2. References Adamson. Results of the Harvard Medical Practice Study I”. Vol.A. “Malpractice occurrence in emergency medicine: does residency training make a difference?”. Vol. The National Board of Health and Welfare. J. L. Flintoft. “Obstetric accidents: a review of 64 cases”. pp. Manchester.M.O. (1998). “Treatment injuries in dentistry – cases from one year in the Swedish Patient Insurance Scheme”. Sheps.. pp. A. “The ‘crisis’ in medical malpractice: trends in the United States. CIHI (2006).. Hogeras. Hebert. P. A. (2004). Davy. S. “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada”. A complex relationship”. Thousand Oaks..jsp?cw_page ¼ patient_safety_e ¨ ¨ Cronstrom. (2004). C. Patient claims and complaints data 71 .. 300. Majumdar.ahrq. Vol.

6. C.S. pp.. Barnes. 11. L. A. W. W. S. L.M. 277 No. Donaldson. and Wahlberg. J. (1996). Vol.. Miller.. Vol. K.M. 1583-7.L. 1567-71. Vol. A. and Raf. Sanders. available at: www.. and Hiatt. Hickson. 7. . (1989). “Defining. DC. The relationship with malpractice claims among primary care physicians and surgeons”. T. Vol. H. 4-12..M.R. Forum. C.H. McDonough. British Medical Journal. “A compilation of ‘diagnostic errors’ in Swedish health care. Newhouse. Weiler. R. Cerebrovascular Diseases.B.T.H. pp.. R. 43. A... Building a Safer Health System. and Klasco.. ˚ Jonsson. 94 No. pp. Osteotomy & Continence Nursing. Laird. G. 865-68 (in Swedish). Instruction to The Medical Responsibility Board. M. N. Academic Emergency Medicine. (1993).. Lawthers. pp.H. Newhouse. 7 No.G. pp. New England Journal of Medicine.A.. and Asplund. Lagerstedt.och Sjukvardens Ansvarsnamnd” (“Who can you turn to if you are dissatisfied with the care you receive?”). 272 No. K. Lester. ¨ ˚ ¨ HSAN (1996). “Listening and talking to patients.A.A. L. To Err Is Human.. B. P. Law of the Patients’ Advisory Committees (1998:1656). J. Journal of the American Medical Association. pp. V..G. Vol.S.. “Clinical practice guidelines for pressure ulcer prevention can prevent malpractice lawsuits in older patients”. M. 3848-50. Peterson. Brennan.E. (1997). Journal of Wound. Laird.P. Leape.B. 320. Brennan. Vol. The Swedish National Committee on Gender Disparities in Patient Care. P. English summary available). L. Journal of the American Medical Association. B. and Thorpe. 26 No.. Law of the Patients’ Advisory Committees (1998). ¨ Johansson. 3. 20. pp. D. “Obstetricians’ prior malpractice experience and patients’ satisfaction with care”. Barnes. E. (1999). (2000).se ˚ Johansson.. 321 No.C. L.1 72 Fenn..L. M. Stockholm (SOU 1996:133). J. 4. Washington. Lakartidningen. and Sloan.A. R.IJHCQA 21. 18 No. Mullooly. A remedy for malpractice suits”. 377-84. Levinson. Hebert. 94 No. Localio. Gillam. P.M.. pp. R.S. Lawthers. T... Diacon. J. “Current cost of medical negligence in NHS hospitals: analysis of claims database”. ¨ Missed diagnosis is most often a fracture” (in Swedish). 175-84. identifying.R. “Increasing number of nurses named as sole defendants in malpractice suits”. A. and Smith. M. Clayton. (1994). pp. Hodges. and Rickman. P. Entman.. 16-21.M. and Frankel. K. “Halso.B. F. L.B.. Hiatt. ¨ Jonsson.P.. 158 No. K. P. and measuring error in emergency medicine”. A.A. Vol.. and Goebel. Gray. “Is quality of health care for women worse than for men? Two ¨ out of three insurance claims concern women”. pp. 7. Vol. “The nature of adverse events in hospitalized patients.T. Leape. (1991). Handler.. The Western Journal of Medicine. Results of the Harvard Medical Practice Study II”. pp.. New England Journal of Medicine.P. (Eds) (2000). 1. S. “Mishaps in the management of stroke: a review of 214 complaints to a medical responsibility board”. Githens. pp. and Corrigan. N. and Rioux. “Physician-patient communication. (2004). Localio. Dull. 480-4. H. Lakartidningen. (1989). 553-9. 1. L. J. Kohn. A.L. (1997a). Gender Equality in Health Care. H. Goebel.A.W. 268-72.. A. “A study of medical injury and medical malpractice: an overview”. Vol.hsan. 10 No. Roter. (1997b). Vol. Whetten-Goldstein. Norstedts.. G.. and Raf. pp. 247-70 (in Swedish. National Academy Press. 10.. Vol. 1996: 571. 1183-8. N. 324 No. Vol. “Reported shortcomings and problems in health care from a gender perspective”.. S. (2000).

and Jonsson.McLoughlin. 4. J.J. 21 No.. “Complications are frequent after surgery for excessive hand ¨ sweating. pp.). Stockholm (in Swedish).. (2004). 8.. Lundberg. (Statistics – Health and Diseases 2004:2). R. Tropp. 121-6. Lundberg. Patients’ Advisory Committees’ reports to the National Board of Health and Welfare. R. The National Board of Health and Welfare. pp. Vol. The National Board of Health and Welfare. I. R. and Claes. ¨ Raf. Quality Management in Health Care. (1993). International Journal for Quality in Health Care. T. available at: www.. Franca. adverse events in primary care in the United States”. pp. “Orthopaedic surgery the most common cause of patient injury”. and Gaffney. D. Patient Insurance. J.patientforsakring. P. Øvretveit.. Jonsson. Lakartidningen..d. H. J. Fryer. K. B. 18. and Green. and Svensson. Horn.M. S. pp. 8. D. A. 930-32 (in Swedish).L.. 42. pp. L. Pukk. Moles. H. 18. Somekh. (The) National Board of Health and Welfare (2003). ¨ Lakartidningen. 534-9 (in Swedish). (The) Patient Injury Act (1996). Project Report. 103 No. F. B. and Penman. British Dental Journal. (The) National Board of Health and Welfare (2004a). pp. 96 No. J. Patient Safety and Safety Improvement – An Overview. (1999).A. Vol. C. D. J. P. Vol. Aylesbury. 102 No. shows data from the Patient Insurance. A. Meredith. V. (2003a). 232-9.. K.D..V. R. M.cs Persson. Technical Communications Publications Ltd. Vol. L. and Elfstrom. Sweden’s Health Care Report 2001. 225-31. G. 69-90. Jr. (1992). ´ Rosen.. Gaffney. Injuries reported to the Patient Insurance Scheme as a Basis for Injury Prevention. se/w_ptn/19010. Simper.. Vol. pp. 13 No. (2005). Patient claims and complaints data 73 . but the total number of ¨ injuries is relatively low”. G. 12 No. 184 No. Vol. Quality Management in Health Care.E.. U.R.. and Olsson. Vol. available at: www. Supp. (The) National Board of Health and Welfare (2004b). Cook.A. Brommels. Stockholm (in Swedish).M.. “Learning from malpractice claims about negligent. pp. Scheer.M. pp. 14-20. “Selecting indicators for patient safety at the health system level in OECD countries”. J.. M. L.. “Do women simply complain more? National patient injury claims data show gender and age differences”. M. (2006) Vol.. 130-3. Phillips. ¨ ¨ Patientforsakringen (n. and Bates.A.sll. Hospitalisation due to injuries and poisoning in Sweden 1998-2002..B. 3.. V. Miyoshi. (1998). Measuring Service ¨ Patientnamnden – The Patients’ Advisory Committee (n. A. S. pp. ¨ ¨ Ohrn. Monitoring and Evaluation of the Health Services. 7. Millar. 12 No.. “Do health care managers know the comparative quality of their care?”.d. Stockholm (in Swedish). Lakartidningen. (2006). Mattke. Rutberg. The Swedish Institute for Health Services Development.. Vol. “Use of the Physician Insurers Association of America database as a surveillance tool for diabetes-related malpractice claims in the US”. (1998). Peneloza-Pesantes. Quality and Safety in Health Care. The Patients’ Advisory Committee. Vol. Penaloza-Pesantes. The single injury is expensive. Diabetes Care. “Dental negligence: a study of cases assessed at one specialised advisory practice”. Bartholomew.). “Prolonged national economic effects following patient injuries in Swedish health care. 2. Dovey. and Bedi. 1096-100. Patients should be informed about the risks”. Vol. 2001. 3020-5 (in Swedish). Pukk. Spri. Stockholm (in Swedish). R. (2003b). The Patient Injury Act (1996:799). (The) National Board of Health and Welfare (2002). J. 4.

N. pp.jonsson@ki. Vol. pp. J.. (1994). To purchase reprints of this article please e-mail: reprints@emeraldinsight. European Journal of Emergency Medicine.. Vol. Vincent. and Frolich. pp. “Adverse events in British hospitals: preliminary retrospective record review”. Annual Report 2005.B. C.A. T.E. Or visit our web site for further details: www.. Trout. (1986).maria. British Medical Journal. Svenning. International Journal of Health Care Quality Assurance. 7. A.. “Incidence of adverse events in hospitals. and Carson.. Bech. R. Thomas..emeraldinsight. F. B. Vol. A. 4. K. Harrison. pp. (2001). 2.R. British Medical Journal..J. 517-9. J. W. M. and Jensen. M. 322. 39. 269-77. R. R. 3 No. M. pp. Weingart. 4. Vol. 163 No. 5370-78 (in Danish). Koller.I. 49 No.B.. Weycker. and Harrison. pp. Vol. W. Sonnenberg. Neale. pp. Kung. pp. and Hamilton. Medical Journal of Australia. “The quality in Australian health care study”.M. E.. Tsai. 9. and Woloshynowych. Karns.T. 320. Wilson.L.C. Cedersund. L.R. “Does physician performance explain interspecialty differences in malpractice claim rates?”. P. 32 No.J.A. “Administrative data based patient safety research: a critical review”. 61-7. S. and Bovbjerg. C. 458-71. Pedersen. Stockholm County Patients’ Advisory Committee.A... Law & Contemporary Problems. Vol. (2001). Newby. A. Stockmarr. “Information on malpractice: a review of empirical research on major policy issues”. 85-111. .W.. Ugeskrift for Laeger. 17 No. H. Supp.. A retrospective study of medical records”. G. Vol. Vol. “Medical malpractice among physicians: who will be sued and who will pay?”. (1995). Wilson.R.T. Stockholm (in Swedish). Vol. (2004). (2003). T. and Miller. G.M.C. L. Stockholm County Patients’ Advisory Committee (2006). S. E. Zuckerman. S. Shapiro.1 74 Schioler. (2000). Vol. Quality and Safety in Health Care. R. 661-7. Wahlberg. 12. “Measuring errors and adverse effects in health care”.. and Petersen.. pp. 163 No. Journal of General Internal Medicine. B. D. R. M.. 10 No.D. Corresponding author Pia Maria Jonsson can be contacted at: pia. Vol.. (2000). W. Gibberd. and Chiang.IJHCQA 21. Runciman. “Epidemiology of medical error”. pp. “Factors and circumstances related to complaints in emergency medical dispatching in Sweden: an exploratory study”. Mogensen. R. Y. Gibberd. (2003). Lipczak. and Wredling. Health Care Management Science. 7394-400. A. 7. B. Medical Care.L. 272-8.S. 1. (2003). II. ii58-ii63.. Zhan. 18 No..R. “Relationship between malpractice claims and medical care quality”. C.

both specialists and general practitioners in private practice are responsible for most patient referrals to institutional providers and represent vital stakeholders for hospitals (Mackesy and Mulligan. Clinicians tended to rate their services and offerings higher than referring physicians (p ¼ 0:019). 1998.The current issue and full text archive of this journal is available at www. Geographic range was correlated with the frequency of patient commendation (p ¼ 0:005) and the perception of friendliness (p ¼ 0:039). 21 No. In the German health care system. Originality/value – Survey results should be useful for continuous quality improvement by regular measuring and reporting to executive mutually beneficial International Journal of Health Care Quality Assurance Vol. Rosemann et al. Doctors. This study aims to evaluate the perception of hospital services by referring physicians and clinicians for quality improvement. 1. 75-86 q Emerald Group Publishing Limited 0952-6862 DOI 10. well established in industrial markets. Findings – Referring physicians’ (n ¼ 53) and clinicians’ (n ¼ 22) survey results concordantly revealed that timely and significant information about hospital stay as well as accessibility to hospital staff are major points for improvement. Dieter Metze and Thomas Luger Dermatology Department..emeraldinsight. Hospitals. Since referring physicians play a strategic role ensuring the survival of institutions providing health care services. The number of referred patients was correlated with medical reports’ informational value (p ¼ 0:042). 2006).htm Evaluating hospital service quality from a physician viewpoint Peter Hensen. is of growing importance in the rapid changing health care market. A comparative questionnaire survey was established to identify improvement areas and factors that drive referral rates using descriptive and inferential statistics.1108/09526860810841174 . 1990). Although Germany has a health care system that allows patients direct access to specialized care (Coulter. They influence the patient’s choice of where to be admitted and organize most of the pre. Meinhard Schiller. Design/method/approach – Referring physicians in private practice and hospital clinicians at a large dermatology academic department providing inpatient and outpatient services at secondary and tertiary care levels were surveyed to determine their perceptions of service quality. Munster University. Germany Abstract Purpose – The purpose of this research is to show that referring physicians play a strategic role in health care management.and after-care treatments (Braun and Nissen. particularly medical reports. Customer services quality. 2008 pp. Munster. Hospitals should pay careful attention to their communication tools. Keywords Questionnaires. referring physicians act as de facto gatekeepers to hospitalization. Germany Paper type Research paper Evaluating hospital service quality 75 Received 5 October 2006 Revised 15 December 2006 Accepted 1 January 2007 Introduction Evaluating customers’ and stakeholders’ perceptions needs and expectations. Research limitations/implications – Although the study has a limited sample size it appears that surveying physicians’ perspectives is an essential tool for gathering information about how provided health care services are perceived. 2005). Significant differences between both samples were found with respect to inpatient services and patient commendation.

2002). 1999). Overall. such as socioeconomic status (Carr-Hill et al. physician-specific influences on the referral process were investigated equally. Variability in physician referral decisions is observable. patient questionnaires and customer complaint systems are widely applied for user orientation in health care systems and hospitals respectively (Castle et al.1 76 partnerships between medical professionals in hospital and external physicians are essential and should be sought. 2 ¼ “good”. Moreover. were shown to predetermine referrals from primary care physicians to specialists. Nevertheless. 2003). a quality improvement process was initiated that focused on relationships between clinicians and referring physicians. Each item was carefully worded in a clear and precise manner. A six-point ordinal scale was used: 1 ¼ “very good”. A questionnaire study using measurement and feedback was conducted to identify improvement areas from referring physicians’ perspectives.. controversial results. . Understanding factors that drive referral rates can help identify improvement areas and to anticipate future demands for hospital services. 2003) or individual insurance coverage (Shea et al. but with a lack of consensus and with. to some extent.. The questionnaire items enabled respondents to rate their perceptions in respect to each specified quality aspect. 2005). Our main approach was to compare our results with a corresponding survey regarding the same items from the clinicians’ point of view. Method We used a quantitative survey research design. 3 ¼ “satisfactory”. 2005). hospital clinicians should know exactly how the services they provide are perceived by referring physicians. suggesting that referral patterns are related more strongly to the type of community than the supply of specialists (Chan and Austin.. 1999. To accomplish our objectives. Presently. To increase feasibility and respond-rates. 1992) and validated in internal audits among attending physicians. and community-specific characteristics. The term “clinician” used in this study encompasses physicians at the clinical department including residents and attendings (i.e.IJHCQA 21. 4 ¼ “sufficient”. Several patient-specific characteristics. surveying referral physician perspectives is not yet extensively established in the hospital care sector. 1996) or urban location (Chan and Austin. In contrast. Data collection ¨ We conducted our study at the University of Munster dermatology department. 5 ¼ “faulty”. a questionnaire was developed containing 14 items suggested by previous research on physician referrals (Beltramini and Sirsi. senior and junior doctors). Starfield et al. In a large German dermatologic centre providing outpatient and inpatient care at a secondary and tertiary care level. and 6 ¼ “insufficient”. 2003). such as disease severity (Chan and Austin. the questionnaire size was limited to a one-page-only design and the number of items was restricted to a reasonable quantity... satisfaction with services provided by health care institutions like hospitals is subject to referring physicians’ expectations and is a key factor for referrals (Piterman and Koritsas. but most remains unexplained (Franks et al. and to reveal associations between quality-related variables and physician-specific aspects.

who frequently referred patients to the dermatology department. . outpatient consultation availability. Using these data. . . cooperation with physicians in private practice. . time interval in which medical reports are supplied. . No incentives for completion were offered. Equally. 2 ¼ regional area. To get an image from hospital medical professionals. and 3 ¼ . regular newsletter. Bivariate correlation analysis was performed to study the association between descriptive variables. and 3 ¼ supra – regional area. supplied medical reports’ significance and informational value. To avoid personal cost. CA). and the rated questionnaire items (Spearman correlation). names and addresses of miscellaneous specialists and general practitioners. Factor analysis was used to examine the relationships among the items to identify components that summarize evaluation questions. hospital staff friendliness. 20 km. The geographic range between private practice and the hospital were coded using: 1 ¼ city area.0 (SPSS Inc. Over the years. 20 patients. . . . questionnaires were sent by mail to a total number of 304 external physicians in private practice including general practitioners and specialists. release 13. inpatient services. the annual number of referred patients was scaled (Table I) as follows: 1 ¼ 0 2 5 patients. . such as geographic range or annual number of referred patients. clinical departments’ perceived reputation. 20-50 km. was difficult. were continuously stored in a database. Referring physicians were asked for their medical specialty. clinicians’ medical expertise. San Diego. 50 km.. therefore. . and the practice’s postal zip code. an unmodified questionnaire was sent to all dermatology department residents and attending physicians. respondents were free to use an accompanying stamped and pre-addressed envelope. hospital services and staff accessibility in urgent cases. outpatient services. Pearson’s Evaluating hospital service quality 77 . . . The Mann-Whitney U test was used to examine whether there were significant differences in the average values between the referral physician and clinician subgroups. . available hospital bed quantity and capacity. Reminding non-respondents. commendations from recurring patients. A chi-square test (Fisher’s exact test) was used to analyse significance differences between deficiency frequencies. the number of referred patients per year.Our evaluation questions covered the following quality aspects: . Our survey was performed anonymously – respondent’s personal data were recorded on the questionnaire. and . Data analysis Statistical analysis was conducted using SPSS. education and training for external doctors. . 2 ¼ 6 2 20 patients.

these values were combined to a conjoint deficiency variable that represents poorer quality needing action.IJHCQA 21. Moreover. external physicians’ estimations of patient commendations were low. see Table I) but two respondents did not answer this question.3 60. were returned from the subsequent internal survey. Value 1 “very good” and 2 “good” frequencies were summed to a conjoint variable indicating an acceptable quality level without need for action. The overall Cronbach’s alpha for the questionnaire was 0.05 statistical significance level. Physician medical expertise was highly ranked by referring specialists.20 patients Not specified Geographic range between clinic and respondents City area (.3 78 Number of referred patients per year 0-5 patients 6-20 patients . Data overview and characteristics of referring physicians who responded correlation tested association among questionnaire items. Regarding the referring dermatologist subgroup. The calculated deficiency frequencies and a ranking of priority are shown in Table III.845.4 11. A total of 22 useable questionnaires.8 17. Identifying improvement areas Means and standard deviations were calculated to obtain an average rating for items 1-14. In short. 50 km) Not specified Table I. In contrast.4 per cent). Response rates and the average ratings divided into referring physicians and clinicians along with the comparative statistical results (Table II). 20 km) Regional area (20-50 km) Supra-regional area (. representing nearly the complete physician staff in the clinical department.7 17 11.2 3. The absolute deficiency frequencies in our study were used to show areas of improvement.0 60. a 21 per cent response rate was obtained. 5. Under the assumption that a potential quality problem is indicated by lower ratings from 3 to 6. 17. a frequency of 60 per cent to 79 per cent is suitable for detecting areas of improvement with lower priority.1 Characteristic Specialist status of respondents Dermatologist Not specified n 51 2 9 9 32 3 9 6 32 6 % 96. Nearly all respondents declared to be dermatologists (n ¼ 51. 0. The alternative hypothesis would be accepted at a p . the proportions of referring physicians’ ratings of each questionnaire item were displayed (Figure 1). Results A total of 53 usable questionnaires were returned by referring physicians (response rate.0 17. a deficiency frequency of 80 per cent and higher can be considered to indicate urgent improvement areas. The length of . Absolute frequencies also containing missing values are more predictive for the given population in small samples than relative ones.

2. * Mann-Whitney U test.43 ^ 0.86 2.95 ^ 1.26 ^ 0.00 ^ 0. mean values.84 2.03 1.03 3.1 96. 12.4 3.53 ^ 0.10 2.95 ^ 0. 9.8 88.77 ^ 0. 50 51 52 51 94.63 3. 10.84 ^ 1.73 1.69 1.5 84.78 3.80 ^ 1.22 22 22 21 20 100 100 95.05 ^ 0.2 98.2 2.77 ^ 1. and comparative statistics .014 0.0 90.002 .73 ^ 0.28 ^ 0. 14.5 92.98 ^ 0.3 96.6 96. 3. 4.87 2.27 ^ 0.80 . 0. 11.2 92.81 2.65 2. 7.81 2.56 2.90 2.2 77.4 100.60 2.76 ^ 0.41 ^ 1.65 1.46 ^ 0. 0.96 ^ 1. item response rates.42 ^ 0.10 Clinicians n ¼ 22 % Mean (^ SD) p-value * 1.49 ^ 0.86 19 22 22 22 22 22 22 86.001 6.84 2.No.92 2. 48 51 41 90.9 86. 8.81 19 22 20 51 49 49 45 46 47 51 96.72 ^ 1.23 ^ 0.2 2.00 ^ 0. 5.4 100 100 100 100 100 100 86. standard deviation.64 ^ 0.9 2.55 ^ 0. 0.001 0.032 13.7 96.98 2.05 ^ 0. Questionnaire items. two-tailed Evaluating hospital service quality 79 Table II.9 Variable (item) n Referring physicians n ¼ 53 % Mean (^ SD) n 2.5 90.93 2. Cooperation with physicians in private practice Medical expertise of the clinicians Accessibility of hospital services in urgent cases Time interval in which medical reports are supplied Significance and informational value of supplied medical reports Availability of outpatient consultations Amount of outpatient service offerings Quantity of available hospital beds Amount of inpatient service offerings Friendliness of hospital staff Education and training offerings for externals Frequency of commendations from recurring patients Reputation of the clinical department Provided regular mail newsletter Notes: SD.29 ^ 0.10 1.15 2.

002 0. b Medical reports: Timea. c Fisher’s exact test. 2.001 0. 9. 12. 1. 14.8 39. 10.3 95.5 27. b Medical reports: Informational valuea Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendationa Reputation Newsletter Referring physicians Clinicians Def.1 77. frequation . and statistical results .022 Table III. Variable * Cooperation Medical expertise Accessibilitya.6 52.2 13.3 45.2 35. two-tailed Notes: Def.2 84.6 39. deficiency frequency.8 45.0 56.4 27.5 36.1 80 Figure 1.IJHCQA 21. Def.9 36. * Areas of improvement with a deficiency frequency .60 per cent are indicated. 7. 6.5 15. Referring physicians’ ratings – proportions of each item No.6 47. 8.8 86.5 3 13 2 1 5 6 11 12 14 6 8 4 8 8 50 9.3 27.0. 11. 3.002 . deficiency frequencies. b detected by clinicians.9 66.3 0.5 40. 5. 4. a detected by referring physicians.3 58. Rank of frequation Rank of frequation priority % priority % p-valuec 5 14 4 2 3 7 11 8 12 9 13 1 10 6 58.1 64.6 4. 13.4 18. Rank of priority.

0. Lack of patient commendation had the highest deficiency frequency (87 per cent) and the second lowest rating in the referring physicians group. 0.022). and . reputation. 0. outpatient services. . p . and the. cooperation.001). There were significant differences concerning average rating values and deficiency frequencies. Average rating values and deficiency frequencies reveal that clinicians’ ratings were remarkably distinct from those referring physicians scores (mean. . However. 0. p ¼ 0:002. cooperation. Furthermore. Evaluating hospital service quality 81 Comparative evaluations As seen in Table II and III. referring physicians criticised staff accessibility in urgent cases (64 per cent). this aspect was supposed to be much higher from the clinicians’ viewpoint ( p .69. Differences were also been found with inpatient resources and inpatient services. which explains nearly 37 per cent of the variance. clinical department’s perceived reputation. is highly correlated with the following variables: . time interval in which medical reports are supplied. SD: 0. medical expertise. . An average mean value for all 14 quality items was calculated for each subgroup: . SD: 0. . friendliness.54. .time in which medical reports were provided following hospital treatment (85 per cent deficiency frequency) and their informational value for referring specialists (66 per cent) were the most common insufficiencies. there were disagreements between the way referring physicians and the way in which clinicians themselves rated some items. clinicians rated newsletters significantly higher than referring specialists ( p . . Our findings suggest these three improvement areas. . referring physicians: 2. deficiency frequency. outpatient consultations. and . clinicians: 2. medical expertise. p ¼ 0:002. hospital staff friendliness. p . Varimax rotation was used to determine what the components represented.001). accessibility in urgent cases. Moreover. Quality features interaction Factor analysis revealed two components that explained nearly 52 per cent of the variability in the original 14 variables.61 revealing a statistically significant difference (p ¼ 0:019). There were no significant differences between referring physicians’ ratings and those made by clinical department physicians concerning: . . and .29.032. . The first component.

0. 12.0.001 .0. were calculated. the number of referred patients was significantly negatively correlated to medical reports’ informational value (p ¼ 0:042). This survey is limited to: . 6. Table IV.001 .001 0. such as cooperation and reputation.0. A further interesting point was to test for correlation between questionnaire items and both geographic range and annual number of referred patients (Table V).001 . particularly when we did not remind respondents or offered an incentive for completion. 0. Variable 1.054 0. .601 0.013 .647 0.428 .001 . Table IV shows that most variables were highly correlated with these two items.528 0.1 82 The second component is highly correlated with inpatient bed capacities and inpatient service offerings.034 .342 0. Discussion Our study described and evaluated the way referring physicians and clinicians rated several quality items from their individual perspectives.539 0.015 0.615 0. It may be speculated that there is a lack of motivation and incentive for private practice physicians to participate. 13. 5.547 0. equal or even lower response rates have been observed from physician samples (MacDowell and Perry. sampling referring physicians via the manually maintained databank.015 0. 3.008 .348 0. Moreover.0.251 0. 4. 2. 9. 0. However. the medical specialty of which the majority of responses were received.594 0.364 0.149 0. 10.0. one geographical region. 0.002 No. 0. and the frequency of patient commendations (p ¼ 0:005).IJHCQA 21. Beltramini and Sirsi. Cooperation Medical expertise Accessibility Medical reports: Time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter Note: * Two-tailed test of significance .001 .505 0.301 0.001 0. Cooperation Reputation Responses Pearson Responses Pearson (n) correlation p-value * (n) correlation p-value * 50 49 50 50 50 47 47 44 44 45 48 46 49 40 1.001 0. sample of referring physicians 8. 11. 7.001 . 0.001 0.471 0. The first component represents a construct with generic attributes that improvement activities cannot influence directly.059 0. 14.465 . This may be caused by a lack of quality management sense.001 .532 0. 1990.0. Significant negative correlations were found between geographic range and hospital staff friendliness (p ¼ 0:039). Correlating quality items representing a generic quality perception.001 0.594 0. An equally important finding is that inpatient capacities and service offerings were not correlated.067 0.001 0. and . Although the study response is low. 1992).001 .595 0.369 0.006 46 47 51 50 50 49 49 45 46 47 49 48 51 41 0.514 1 0. 0. we considered the response rate acceptable.639 0.000 0. in former studies dealing similar questions. Correlation analysis of generic quality perceptions represented by reputation and cooperation with other quality items.

075 20.102 20. 2005). and should address this problem by investing in systematic communication improvement programs. 12. 4. 5. major improvement areas demanding urgent action could be identified. 6. hospital stay. 9. The high importance attached to timely and adequate communication back to referring physician was previously reported in other studies (Cummins et al. which are less tangible.231 0. 7.083 20.131 48 48 49 48 48 46 46 42 43 44 48 45 48 38 20. For interpretation. can be chosen individually for each item and should be monitored over time. Curry et al.007 20.421 20.001 20.032 0.. 13. proposed procedures.005 Note: * Two-tailed test of significance Table V.219 0. and .253 20. Variable 1. 3. 11. such as 80 per cent and more.189 20. 1980. such as medical reports and newsletter articles. 14.120 20. sample of referring physicians Nevertheless. accessibility in urgent cases. discharge. . Moreover. such as providing medical reports and newsletters. .295 20. Cooperation Medical expertise Accessibility Medical reports: time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter Geographic range Number of referred patients Responses Spearman Responses Spearman (n) correlation p-value * (n) correlation p-value * 44 45 46 45 45 43 43 39 40 42 45 42 45 37 20. Using this approach.No.029 20. are major points for satisfaction and perception of adequate cooperation. 10. 2. which represents a further tangible communication and cooperation aspect.039 0. Elija and Marja-Leena. such as reputation and cooperation. hospital administrators and clinicians should pay careful attention to communication tools..150 20. medications.183 20.157 20. In conclusion.079 20.262 20. 8.161 20.037 20. and those variables. Not only do patients expect a seamless healthcare system and continuity of . our survey questionnaire provides a ready-to-use instrument that identifies crucial improvement areas. 1980.059 20.320 20.148 0.042 Evaluating hospital service quality 83 0. Critical deficiency frequencies indicating relevant areas. The present findings suggest that timely and significant information about: .174 20. Correlation of geographic range and number of referred patients with quality items.207 0. has been found to be improvable. it is important to distinguish between variables that can be directly influenced by management activities.055 20.

1983). A second step. Recommendations We cannot have an accurate understanding of how our services are perceived by others without asking them. Before customer satisfaction can be addressed. References Altenstetter. (2003). “Insights from health care in Germany”. utilizing survey results. Vol. pp. hospitals need to understand stakeholder needs. Although the validity of this latter item remains doubtful. was significantly higher. 2003). Private practice and clinician specialists providing health care services at a secondary or tertiary care level have different roles and may often see problems from different perspectives.1 84 care between services but also the physicians who refer patients to higher-level health care institutions. Health care provider images and satisfaction with those providers vary among consumers. which is separated into inpatient and outpatient care sectors with spending caps (Altenstetter. are much more interested in reading and understanding medical reports than physicians who refer a greater number of patients. 2001). However.. expectations and satisfaction. Regular measurement and reporting to hospital staff members and the executive board is mandatory for a quality improvement process. comparative analysis allowed us to conclude that the majority of quality problems are perceived in a similar manner by referring physicians and clinicians. This situation is particularly important in the German health care system. estimated by clinicians. therefore. Working in separate medical realities may diminish understanding for the concerns of others (Kvamme et al. Referring physicians expect management to be shared with their cooperating medical partners. 1993). proposing a strong positive self-image in terms of services they provide. The long-term strategic challenge lies in building creative and sustainable referral networks that promote professional partnership among physicians. clinicians tend to rate quality higher than referring physicians. Another meaningful finding is that if only a small number of patients are referred then the referring physicians rate medical reports’ informational value significantly higher. One may speculate that physicians. Surveying referral physician perspectives is an essential method for gathering information on health care service perception. . American Journal of Public Health. This may be subject to rather infrequent contact. 38-44. Although we found statistically significant disagreements. C. in general. If the distance between referring specialists and hospitals is great then patient commendations decline. but good working relations across all boundaries is required. 1. the frequency of patient commendation was found to be associated with the geographic range.. Not competition between specialists. care levels and care sectors (Javalgi et al. is equally important. An assumable cause may lie in a few but important referrals from the viewpoint of the referring physician.IJHCQA 21. who refer only a few patients to the clinical department. which makes it difficult for referring physicians to give a valid rating. 93 No. We note that the frequency of patient commendation. physicians and the public (Scammon and Kennard.

(1990). “Establishing an effective referring physician network”. Journal of Health Care Marketing.. J. 1974-6. 6 No. and community factors affecting referrals to specialists in Ontario. and Marja-Leena. 1650-2. and Coggins. 288-95. Vol. “Patient.B. 13 No. and Austin. Castle. pp. pp. M. 3.. Vol. Hepner. Mooney. S. physician. pp. Rice. “Variations in primary care physician referral rates”. Vol.Beltramini. “Part II. Javalgi. 323-9. General practitioner-specialist referral process”. Vol. Vol. 9-17. 491-6.. N. pp. 1996-2017. Vol. 19 No. (1999). Joseph. 243 No. 40 No. pp.K.F. pp. A. Journal of Health Care Marketing. Rueter. L. “The referral process: a study of one method for improving communication between rural practitioners and consultants”. Vol. C.A. pp. and Sirsi.R. Vol. J. (2005). Medical Care.. “Factors influencing physician choice of an outpatient surgery and testing facility”. “Referrals from general practice to consultants in Germany: if the GP is the initiator.. “Informational influences on physician referrals”. Evaluating hospital service quality 85 . 6. 54-8. 41 No. K. Gesundheitsokonomie und Qualitatsmanagement. M. Journal of Health Care Marketing.S. (2005).T.biomedcentral. B. Vol. “Communication failure in primary care.. 3. J.A.. Vol. (1992). Journal of the American Medical Association. P. pp. 2. A population-based.W. R. (1996).W. MacDowell. 4. “Home care personnel’s perspectives on successful discharge of elderly clients from hospital to home setting”. 1. Eija. (1980). W. Vol.A. Coulter. 10 No. Health Services Research.M. 1.A. Vol. and Roland. Franks. 10 No.E. M. D. 500-11. 4. Internal Medicine Journal. (1980).O. and Szecsenyi. 34 No. F. Carr-Hill. Rosemann. (2006). Failure of consultants to provide follow-up information”. com/1472-6963/6/5 Scammon. (1990). pp. P. 376-84.D. T. A. Cummins. J. N. Journal of Health Care Marketing. “Managing demand at the interface between primary and secondary care”. R. 312. 101-26. (2005).. N. 6. Olesen. pp. R. Vol. Wensing. Chan. Scandinavian Journal of Caring Sciences. T. 1008-12. 3 No. 8. (2001). 16. “How physicians make referrals”. Vol. and Hays.G. pp. 35 No. Vol. British Medical Journal. Curry. G. Vol. 2. 2. Zwanziger. Quality in Health Care. patients’ experiences are more positive”. BMC Health Services Research. Jr. (2005). providers and administrators”. (1983). Brown. British Medical Journal. “Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP)”.J. and Mulligan. Kvamme. (1998). and Nissen. 10 No. L.. Mackesy. Canada.. A. Smith. 316. “Review of the literature on survey instruments used to collect data on hospital patients’ perceptions of care”. R. R. pp. G. M. W. multi-level modelling approach”. 5. R. 6 No. 10 No.B. ¨ ¨ Braun. 10 No. pp. R.T. Piterman. 33-9. Health Services Research. and Sorbero. 6-17. W. pp. Journal of Hospital Marketing. “Die Bedeutung der Einweiserzufriedenheit fur Krankenhauser ¨ ¨ und ihre erfolgreiche Messung”. available at: www. “Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices”. pp. 67-74. O. and Inui. pp. G. P. and Lester. and Koritsas. and Perry. Crandall..J. (1993). 287-91. (2003).C. Gombeski.. R. L. and Kennard. R. Jr. 2. Vol. J. “Improving health care strategy planning through assessment of perceptions of consumers. The Journal of Family Practice. and Samuelson.

Vol.. 15 No.B.. and von Schrader. Health Services Research. “Variability in physician referral decisions”. The Journal of the American Board of Family Practice. B. 34 No. S. 473-80. (2002). Vol. D. J. (1999). 331-48. 6. P.IJHCQA 21.uni-muenster. B. . C. Or visit our web site for further details: www. Vasey. S.emeraldinsight. and Nag.A. “Medicare physician referral patterns”. Stuart. 86 To purchase reprints of this article please e-mail: reprints@emeraldinsight. pp. Forrest..1 Shea. Nutting. Corresponding author Peter Hensen can be contacted at: hensenp@mednet.

87-103 q Emerald Group Publishing Limited 0952-6862 DOI 10. although showing good internal consistency. mostly because they act on the socio-economic level and serve individuals and organizations that need adequate.The current issue and full text archive of this journal is available at www. patient’s emotions. and The influence of service quality 87 Received 2 November 2006 Revised 13 April 2007 Accepted 3 May 2007 ´ Jose Neves ˆ Instituto Superior de Ciencias do Trabalho e da Empresa (ISCTE). using a revised SERVQUAL scale for service quality evaluation and an adapted DESII scale for assessing patient emotions. such as intangibility. with a sample of 317 patients from six Portuguese public healthcare centres. Portugal. Portugal.emeraldinsight.htm The influence of service quality and patients’ emotions on satisfaction Maria Helena Vinagre ˆ Instituto Superior de Ciencias do Trabalho e da Empresa (ISCTE). Public Sector importance. Originality/value – The research shows empirical evidence about the effect of both patient’s emotions and service quality on satisfaction with healthcare services.1108/09526860810841183 . Montijo. Design/methodology/approach – The approach was tested using structural equation modeling. Their production. Public services cannot detach from this general concern. 21 No. specific characteristics. might be enlarged to other typologies in further research – needed to confirm these findings. forces managers and practitioners to address quality and client satisfaction issues as a priority. Service levels Paper type Research paper Introduction Service quality and customer satisfaction are a major goal in modern organizations. Lisboa. timely and effective responses (Vinagre and Neves. Findings also provide a model that includes valid and reliable measures. however. revealing that all the predictors have a significant effect on satisfaction. These services have. Keywords Customer satisfaction. heterogeneity and inseparability. 2002). expectations and involvement. 1. The results support process complexity that leads to health service Portugal Abstract Purpose – The purpose of this research is to develop and empirically test a model to examine the major factors affecting patients’ satisfaction that depict and estimate the relationships between service quality. Findings – The scales used to evaluate service quality and emotional experience appears valid. Practical implications – Patient’s satisfaction mechanisms are important for improving service quality. especially as a service provider. distribution and consumption are simultaneous processes and they are International Journal of Health Care Quality Assurance Vol. Research limitations/implications – The emotions inventory. 2008 pp. which involves diverse phenomena within the cognitive and emotional domain.

1987). there is a rather limited body of knowledge on the effects that these different types of services have upon consumer satisfaction. the customer perceives a service in all its production processes and not merely as the result of that production. 1995). Traditionally. regret). Service experiences are the outcomes of the interactions between organizations. Despite the generalized acknowledgment of these differences among service types. Both studies proved the DESII scale’s validity and reliability in consumption settings and show that a number of different positive and negative emotions can be related to satisfaction..g.. Services can also differ in the degree of technical knowledge and skill required. which involves several service dimensions specific to the service delivered. service employees and customers (Bitner et al. Consequently. is perceived as a global consumer response in which consumers reflect on their pleasure level.. price.IJHCQA 21. 1997).. Satisfaction. the features of these services make it difficult to adopt service quality and customer satisfaction evaluation criteria. service experience and involvement. Price et al. in order to explain service quality and satisfaction. Departing mainly from Westbrook’s (1987) and Westbrook and Oliver’s (1991) work. Transactions can thus be open or closed. the emotions linked to service experience and the complementary effect of expectations and involvement on patient satisfaction. Therefore. The wide diversity of services constitutes another factor that poses measurement difficulties. we assume that we can also find differing evaluations of the degree of importance (involvement) attached to the service among the patients. Surprenant and Solomon.g. 1999. the degree of involvement can vary as well as the duration of consumer experience. Bloemer and Ruyter.g. 2000). expectations. From an empirical study in six healthcare centres. Having this in mind. in which customers participate in the production (Gronroos. They are created in buyer-seller interactions and they are essentially ¨ activities or processes. equity. driven by conceptual cues (e.1 88 not storable. Theoretical framework Despite seemingly alike. Focusing on consumer satisfaction with a public healthcare service (in this study we considered patient as a health service consumer). Some studies found a significant relationship between involvement and the level of emotions concerning service experience (e. he suggests that quality is a judgment or evaluation that concerns performance pattern. reputation). several empirical studies revealed that service use has potential to elicit a complex variety of emotional and cognitive responses. however. Quality is believed to be determined more by external cues (e. perceived service quality and consumer satisfaction are distinct constructs that may be defined and evaluated in different ways. Satisfaction is based on service delivery predictions/norms that depend on past experiences.. we intend to evaluate service quality dimensions. only cognitive measures were considered such as disconfirmation or the perceived service performance (Liljander and Strandvik. Oliver (1997) identified a few major elements that differentiate service quality and satisfaction. involvement seems a variable to be considered in patient satisfaction and emotional response analysis. we intend to know the service quality dimensions perceived by patients and the relationship between emotion. Considering healthcare services consumers’ differing needs. Although . Customer satisfaction and customer perceptions are therefore often influenced by those interactions (Bitner et al. related systems/processes.. 1994. 1997). We may need separate criteria to differentiate services mainly on the basis of the sort of experience users have with a particular service.

Mostafa. 1995. In short. although it requires an adaptation to the organization under evaluation (Curry. Service quality Quality has been used to describe diverse phenomena. In this study. they suggest that expectations have a tolerance zone between desired service and adequate or minimal acceptable service level (Berry and Parasuraman. we suggest that service quality should be one patient satisfaction antecedent. 2002. which implies subsequent refinement of quality dimensions relevant to each service. 1988) and validated (e. SERVQUAL is considered a useful and valid instrument to measure service diversity. Gabbie and O’Neill. among others. 1998). it is now conceived from the exterior (or consumers’) point of view. Regarding dimensionality. Among consumer satisfaction theories. some studies confirmed service quality dimensional variability (e. 2004). Accordingly. (1991) acknowledged that normative expectations (“what services should be”) lead to unrealistic expectations. Cook and Thompson. Based on the disconfirmation paradigm the Gap Model developed by Parasuraman’s team in the 1980s is fundamentally a model of service quality analysis and evaluation.. 2005. Although there is general agreement about the influence of customer’s expectations in overall service quality and The influence of service quality 89 . Expectations Consumer expectations are central to satisfaction studies. 2001).perceived service quality may be updated at each specific transaction or service experience. 2000.. 1990) defined service quality as a degree and gap between service perception and consumer expectations.g. assurance. 1999). Vinagre and Neves. empathy and responsiveness – that consumers are assumed to use in a systematic way to perceive services provided. 1991).. Quality is no longer analysed and measured from an internal focus. 2000). Buttle (1995) synthesized some of these criticisms regarding: disconfirmation (disconfirmation paradigm rather than an attitudinal paradigm). The SERVQUAL model includes five service quality dimensions – reliability.. and service quality dimensionality (the universality of the five dimensions are not always confirmed). Subsequently. Nevertheless. 1985. the appropriateness or utility of expectations in SERVQUAL (the meaning of expectations. 1985. the meaning of P-E gaps and the contribution of the expectation scores). Regarding expectation criticisms. As an alternative to the universal SERVQUAL five-factor structure. Zeithaml et al. we consider a contingent approach in which dimension numbers vary according to. tangibles. Wisniewski and Wisniewski. it tends to last longer than satisfaction. 1990. researchers dispute the relationship between perceived service quality and satisfaction (Ting.. which is understood as being transitory and merely reflecting a specific service experience (Martinez-Tur et al.. Service quality studies at the consumer level have a decisive impact on the type of research that has been developed ¨ (Gronroos. 1988. 2005. Zeithaml et al. Conclusions drawn from their exploratory study helped them to develop an evaluation and service quality measurement known as SERVQUAL – an instrument that has been improved (Parasuraman et al. different authors (Parasuraman et al.. Cook and Thompson. 1996). Some authors criticise SERVQUAL. Parasuraman et al.g. Parasuraman et al. Donnelly. service type (contextualized dimensionality). 1991. they redefined expectation in predictive terms “what a client may expect from an excellent service”.

It comprises ten subscales with three items each representing the frequency with which individuals express each of ten basic emotions. if the discrepancy between the consumer’s expectations and perception is small then perceptual judgment will reduce this difference. The DESII instrument is a discrete emotions inventory. 1993). It is assumed that consumers create expectations prior to their service experience against which performance is evaluated. “contrast effect” occurs. They state that expectations cause an assimilation effect while discrepancy causes a contrast effect. Involvement Involvement is linked to studies on consumer satisfaction. 1995). Within consumer psychology. considerable work remains to be done regarding the exact way this process takes place (Coye. we assume that a patient is involved when the . According to the assimilation theory. he or she attempts to reduce this space. Several studies found a separate effect of expectations and disconfirmation on satisfaction (e. 2004). 1993). Consequently. In this latter case. individuals tend to respond according to their expectations because they are reluctant to admit wide discrepancies. Oliver and DeSarbo (1988) mention theoretical support for those effects. High levels of satisfaction may include positive and negative emotions (Arnould and Price. Assimilation effect corresponds to a narrowing of the gap (leading to an assimilation of expectations with perceptions) while the contrast effect is the opposite. However if disconfirmation is too strong then the consumer may strengthen his or her negative perception thus widening the gap. However. The role of expectations as an assimilation agent provides. as emotions are context specific. Perception can disconfirm expectation (either for “worse” or “better”) or confirm it (“neutral” comparison).. Different scales have been used in consumer emotion studies. originally conceived to measure an individual’s emotional state.1 90 customer satisfaction.IJHCQA 21. self-administered. measured on a five-point Likert-scale. as Richins (1997) highlights. 1980).g. the mechanism by which expectations may influence satisfaction directly (Oliver. therefore. 2005). Although involvement represents a more complex construct (Kim. designed to measure basic emotions or combinations of emotions experienced by the individual. 1991). involvement is viewed as a motivational construct that influences subsequent consumer behaviour (Dholakia. difficulties may arise when DESII is used for consumer behavior research. 2000. Generically.. if the discrepancy is too large then we need to obtain a contrasting perception (Bridges. However. while DESII is a measure of emotional experience frequency at a given period and is often used in consumer-experience research. Dube and Menon. Emotions and consumer experience Emotions refer to a set of responses occurring especially during consumer experience (Westbrook and Oliver. 1997).. Price et al. because these are measures developed in other contexts. 2001). DES is a measure of emotional state intensity. Izard’s (1977) Differential Emotions Scale (DES). is used to measure emotional experience or emotional reactions perceived by the individual during a time period. 2000. When the consumer acknowledges a gap. which implies that we should consider ´ examining positive and negative emotion effects separately (Babin et al. Andreassen. 2005. Oliver. some emotions experienced in the context of interpersonal relationships may be different from those experienced during a consumption experience.

Satisfaction predictors: theoretical model of analysis Acknowledging that consumer experience is complex. considering the interaction between the two in service experience. service quality is considered mostly a cognitive construct while satisfaction has been considered a more complex concept that includes cognitive and affective components (Oliver. or that conceive involvement as a mediator of disconfirmation (e. Consequently. 1991). Involvement has also been operationalized distinctly (e. involvement is similar to importance. perceived service quality can also include dimensions that are mostly relational.service is relevant according to the service’s characteristics and the patient’s needs. Negative emotions have a negative effect on patient satisfaction. it corresponds to a product’s or service’s perceived importance (Mittal.. the involvement effect is insufficiently explored compared to other satisfaction predictors. H4. there should be a greater tendency to evaluate aspects relating to attention received during the interaction established along the service experience (Shemwell et al. In these cases. attachment and/or motivation.g. Therefore. H3. However. 1997). 1998) and emotional aspects. values and interests (Zaichkowsky. Usually. Despite studies that relate involvement with satisfaction. an individual may be interested in a service or activity even though that service or activity may not be important to him or her. 1995). 1997). interest. Expectations have a positive effect on patient satisfaction. Services with more qualified or more credential properties imply that a consumer’s capacity and ability to evaluate the service provided is reduced. Acknowledging potential expectation effects. For example. 1992).. Positive emotions have a positive effect on patient satisfaction. In this respect. Zaichokowsky. we depart from the more restricted conception of involvement: the degree of importance attributed to the service by the patient. it is foreseeable that expectations are related to the frequency with which patients experience positive or negative emotions. Within this context. 1993). opposing the purely cognitive nature of service quality evaluation. these may be considered distinct. Therefore: The influence of service quality 91 . especially at the service level.. Some researchers argue that emotional versus cognitive saliency depends on the type and nature of service transactions. The mere possibility that emotions can be present across all interactions between consumers and service providers makes it difficult to separate emotions from service quality evaluations (Liljander and Strandvik. these relational dimensions are permeable to a strong emotional influence. we assume an interrelation between cognitive variables in forming emotions and satisfaction (Westbrook and Oliver. However. 1985) and despite “involvement” semantic distinctions. 1993. The diversity of emotional experiences is explained as a function of emotion-cognition interactions resulting in cognitive-affective structures (Izard. service quality and emotions on satisfaction.g. Bridges. Service quality has a positive effect on patient satisfaction. we hypothesized that: H1. 1985). In our study. Bridges. calls attention to the important role emotions may play when associated with other cognitive variables that explain these phenomena. H2.

we expect that in a healthcare service there is a high level of involvement given the degree of importance it has for the patient and in which there is a direct relation between the degree of involvement. Expectations have a negative effect on negative emotions. We presume that service involvement motivates patients to initiate a more positive service-interaction. Patient involvement has a positive effect on expectations. These assumptions led us to make the following predictions: H7. H9. A self-administered form instructed patients to fill in the questionnaire in two phases: their expectations before experiencing the service and their perceptions after the service had been provided. H8. Consequently. Methodology Sample We used a convenience sample composed of individuals attending targeted healthcare centres during approximately one month in each. Expectations have a positive effect on positive emotions. Patient involvement has a positive effect on positive emotions.IJHCQA 21. satisfaction and other predictors such as expectations and emotions. We obtained 317 valid responses from patients in six healthcare centres. Research model . Patient involvement has a negative effect on negative emotions H10. H6. Patient involvement has a positive effect on patient satisfaction.1 H5. These variables and measures were adopted: 92 Figure 1. The research model and the expected effects are represented in Figure 1.

(P16) “I feel safe in my relationship with my doctor”. Kilbourne et al. We asked respondents to predict the degree of anticipated satisfaction (“what would you expect from this service”: “to feel satisfied with this medical consultation”. Following recommendations in the literature (e. 1990. “to feel satisfied with the service performance” and “to feel physically better”) in a Likert five-point format from “completely disagree” (1) to “completely agree” (5). Following Oliver’s (1981. Using the same 28 items. The scale contains 27 adjectives that present the frequency with which patient experienced each of nine considered basic emotions over service healthcare experience (“how often do you have these feelings in your relationship with this healthcare centre”) on a five-point scale from (1) never to (5) very often. 1992) to measure expectations and perceptions. Expectations. what they thought – on the basis of their experience – what could be expected from services provided in a healthcare unit. This scale ´ was developed by adapting Donavan and Hocutt’s (2001) and Dube and Menon’s (2000) items on the relationship between patient’s emotions during hospitalization and their satisfaction. Patients were asked. 1987. Emotions. We chose to use a satisfaction scale composed of four items (assertions) measured in a five-point Likert-scale format from “completely disagree” (1) to “completely agree” (5). (P18) “I feel safe in my relationship with the auxiliary staff”. The influence of service quality 93 . (P26) “My doctor understands my specific needs” Satisfaction measure. We considered the existing measures’ diversity in the literature. 1991) but not particularly in healthcare services. Westbrook. this scale asked patients how they considered services that were provided. In order to obtain the users’ emotional reactions to the services provided. We used a five-point Likert scale ranging from “completely disagree” (1) to “completely agree” (5). “Generally I am satisfied with the level of services performed”. we used a satisfaction expectation measure focusing on the service to be provided. we used an adapted SERVQUAL scale (Parasuraman et al. (E15) “My doctor instils me with confidence” (E19) “Nurses would be always courteous with me”. This instrument includes 28 items for the expectations scale and 28 items for the perceptions scale. Vandamme and Leunis. Westbrook and Oliver. “Generally I am satisfied with the services of support”. 1988) for the particular healthcare sector contexts.Service quality. 1992. “Generally I am satisfied with the nurses”. (P17) “I feel safe in my relationship with nurses”. taking into account a series of hospital service characteristics. (E24) “The doctor would give me personal attention”. 2004.. (E21) “My doctor would have a good professional preparation”.g. Consumer satisfaction is the main dependent variable in our study. Examples include (E3) “Staff would have good appearance”. 1997) proposal. we adapted Izard’s (1977) “Differential Emotions Scale” – DESII – used and validated in consumer studies (e. Service expectations quality scale. “Generally I am satisfied with this healthcare centre”.. We included positive and negative emotions scales but we excluded the “surprise” item owing to its ambiguity. Babakus and Mangold. Service perceptions quality scale. (E5) “They would fulfil their promised service at the time they promise to do so”.g.. This scale consists of five items and includes: “Generally I am satisfied with my doctor”. Examples include: (P4) “Materials and documents are clear and visually appealing”. before consultation. Carman. (P8) “They provide services at the promised time”..

e. Factorial structure identification with an exploratory factor analyses performed on the items for each scale (according with the procedures adopted by Mano and Oliver. In a second step. applying Varimax Rotation and deleting items not satisfying the following criteria: loadings equal or above 0. Following Hoyle and Panter’s (1995) recommendation. with means and intercepts estimate owing to missing data and indication of the saturate and independent model measures of fit. Results Service quality measure According to extant literature. service quality results 94 . suggesting that indices’ characteristics depend on data. Questionnaire pre-testing An initial questionnaire draft was submitted to a critical analysis to three professors and academic investigators on service quality or quality in healthcare services that analysed the questionnaire’s construction and language clarity. which is less sensitive to sample size and non-normality and Tucker-Lewis Index (TLI) also a type 2. 1997. Thus defined. we adopted the Incremental Fit Index (IFI) type 2 index. the revised questionnaire was pre-tested on a sample of healthcare public service users in order to test its consistency. it is cautious to use more than a single index when substituting the chi-square. Then. Measures showed a good internal consistency with Cronbach’s alpha around 0. Internal consistency analysis (Cronbach’s alpha). Was measured in a direct way with a single item that intended to identify the degree of service importance to the patient by the healthcare centre (“The services given in this healthcare centre are very important for me” in a Likert five-point format).IJHCQA 21. and Verbeke and Bagozzi. The first step consisted of verifying the model’s fit to the data through fit-measure analysis. adopting theoretical criteria for retaining factors with Eigenvalues higher than 1. Data analysis Psychometric measure validation followed the recommended procedures: . sample size and selected estimation method. Given the controversy regarding the indices that one should use in evaluating the model fit in SEM.1 Involvement.90 for the expectations scale and 0. positive and negative emotions) are treated as observed components of the respective constructs. 2000). 1993. a type 3 index and the Root Mean Square Error of Approximation (RMSEA). the Comparative Fit Index (CFI). Our analysis was done using structural equation modelling (SEM) by means of AMOS 4. we used the estimation method of free parameters in structural equations employing Maximum Likelihood (ML) that presents better performance in less favourable analytical conditions (e.6 in the dominant factor and cross-loadings below 0. sample size. the significance of the structural model parameters were analysed (path coefficients).4 in the remaining factors.. . Internal consistency analysis of the factor structure found. or no normality). Once the models were specified and estimated. the service quality factors (i. In this model. a service is considered to be quality whenever perceptions exceed user’s service expectations.g.97 for the emotions scale. .0. Considering Hoyle and Panter’s (1995) recommendations. Liljander and Strandvik. results were analysed.

01 per cent of total variance.. it seems justifiable that service quality construct dimensionality is focused on the gap between perceptions and expectations (Vinagre and Neves. The extracted factors are interpretable and allow us to identify four service quality dimensions: (1) Reliability.95. 2007.g. Measure of emotions in service experience The DESII scale showed high internal consistency for all 30 items (a ¼ 0:91). 1992. By analysing the saturation matrix after Varimax rotation (Table I). it integrates all items from the Reliability factor plus two more from the Response Capacity factor in the original scale. The influence of service quality 95 .60 are also used in the literature (e. Cronbach alpha varied from 0. (3) Employee’s assurance.72 to 0. (2) Physician’s assurance. The global service quality scale presented a Cronbach alpha of 0. Parasuraman et al. it integrates all items concerning medical performance. With factor loadings ranging from 0. With factor loadings above 0. Regarding the theoretical model. With factor loadings ranging from 0. 1991). 2002. Considering that the scale comprehends differing and opposite valences. W So.76.. nurses and auxiliary staff. so alpha could be lower in scales with fewer items. 2002). (4) Tangibles. we fused Reliability and Response Capacity.67 for the Physical Elements scale (which also has fewer items) to 0. Alpha coefficient is dependent not only on the magnitude of correlations among items but also on the number of items in the scale. Aspy et al. Using Kaiser’s criterion (“Eigenvalue” . it integrates items from the Assurance factor concerning Nurses and Auxiliary staff. we intended to identify service quality scale structure through Principal Component Analysis (PCA). we checked subscale validity and consistency.84 to the gap between user perceptions and respective expectations.69.7 to be an acceptable reliability coefficient but lower values as 0. Vandamme and Leunis. 1992. Although with fewer items. we eliminated 11 items owing to cross-loading. Babakus and Mangold. it groups two items from the physical elements. With factor loadings ranging from 0. grouped by valence (positive and negative emotions within the emotional experience). we used the SPSS “compute variable” function to calculate 28 new variables representing the result of the numerical expression (perception – expectation) for each item. 1). Nunnaly (1978) indicated 0. The scale presented a high internal consistency (a ¼ 0:97). are disaggregated in two groups corresponding to distinct occupational groups: physicians. Considering the construct’s multidimensional nature. both concerning specifically the relation with the service provider. the Physical Elements dimension was kept. The Empathy and Assurance dimensions. The scales showed a good internal consistency. 2004.97 for Reliability.64.68. From this point of view..77 to 0. In order to identify variables concerning service quality. Wright. we extracted four components that explained 67. comprehending simultaneously in the same factor the Assurance regarding their professional competency and empathy towards the patients.

17 0.31 0.90 for “Enjoyment” (in Izard’s.37 0.83 for “Interest” and 0.22 0.27 0.73 0.82 0. Negative emotions Our PCA on the seven DESII negative valence subscales revealed four interpretable components (Varimax rotation with Kaiser criterion) explaining cumulatively 78.23 0.73 0. they show sincere interest in solving it QS11 They give me a prompt service QS9 They insist on error-free records QS15 My doctor instils me confidence QS26 My doctor understands my specific needs QS24 The doctor gives me personal attention QS16 I feel safe in my relationship with my doctor QS21 My doctor has a fine professional training QS17 I feel safe in my relationship with the nurses QS19 Nurses are always courteous with me QS18 I feel safe in my relationship with the auxiliary staff QS4 Materials and documents are clear and visually appealing QS3 Staff has good appearance % Explained variance (with rotation) % Explained variance (with rotation) Factor internal consistency (Cronbach alpha) Factor internal consistency all items (Cronbach alpha) Positive emotions Our PCA of two DESII positive valence subscales matched factors in the theoretical model (Varimax rotation with Kaiser criterion) explaining cumulatively 79.95 0.23 0.32 0.27 0.15 0.15 0. The internal consistency analysis showed a Cronbach alpha of 0.72 10.37 0.88 per cent of total variance.33 0.23 0. Cronbach alpha for these subscales was 0.08 0.25 0.26 0. 1977 study.76 0.73 0.33 0.56 Tangibles 0.13 0.IJHCQA 21.3 0.22 0.35 0.72 0.82 0.34 0.12 0.18 0.19 0.87 respectively) and 0.28 0.84 for the total scale.75 0.06 18.64 0.35 14.14 0.21 0.12 0.37 0.76 and 0. Service quality’s factor structure: rotated component matrix (Varimax) They fulfil their promised service at the time they promise to do so QS8 They provide me the services at the promised time QS10 They give accurate information as to when services will be provided QS7 They perform the service right the first time QS6 When I have a problem.22 23.3 0.69 67.09 0.11 0.67 96 Table I.25 0.22 0.27 0.77 0.01 0.66 0.69 0.21 0.22 0.17 0.68 0.7 0.21 0.93 Components Physician’s Employees’ assurance assurance 0.15 0.1 Statement number code QS5 Text Reliability 0.28 per .73 0.88 0.77 0.28 0.84 0.23 0.24 0.3 0.76 0.21 0.33 0.27 0.

86 0.08 0.18 0.24 0.37 0.57 The influence of service quality 97 Items Downhearted Sad Discouraged Feeling of distaste Disgusted Feeling of revulsion Contemptuous Scared Fearful Afraid Sheepish Bashful Shy Guilty % Of explained variance (with rotation) % Of explained variance (with rotation) Factor internal consistency (Cronbach alpha) Factor internal consistency all items (Cronbach alpha) Disgust 0.23 Fear 0.27 0. thus confirming our global satisfaction scale’s one-dimensionality hypothesis.11 0.16 -0.40 0. good internal consistency with alpha values ranging from 0. Factor “Shame” absorbs one factor item that had disappeared (namely.14 0.90. 0.12 0.27 0.24 0.22 0.96 0. Components Shame Distress 0. All the remaining factors were maintained.60 78.84 per cent of total variance with a Cronbach alpha of 0.81 0.10 0.08 0.12 0. In a second phase.30 0.29 0. Satisfaction measure In order to verify the measure’s one-dimensional character we developed a PCA with five composing items. p .73 0.22 0.37 0.16 0.87 0.001.19 13.19 0.28 0. IFI ¼ 0:99. the second item in Guilty).19 0.85 0.90 0. “shame”.27 0.39 0. By applying the Kaiser criterion we extracted a single factor that accounted for 71.25 15. imposing two co-variances has shown to improve the fit indices (x2 ¼ 106:89.24 0.74 0.07 0. Negative emotion’s factor structure: rotated component matrix (Varimax) . The subscales we found presented. TLI ¼ 0:99.92 for the total scale.72 0.88.92 0.03 0.16 0.09 0.66 17.13 0.21 0.84 0.23 0.27 0. df ¼ 51.79 0.85 0.88 Table II.25 0.87 to 0.83 0. in order to validate the latent variables.77 0. However.cent of total variance. the hypothesized model was evaluated. Seven items had to be discarded in the rotated matrix owing to unacceptable cross-loading (Table II). Satisfaction expectation scale Three items composing this measure revealed a high Cronbach alpha of 0.20 0.96 for the subscales and 0. Structural model Following Anderson and Gerbing’s (1988) recommendations regarding Structural Equation Modelling. Our results indicated that items composing “Aversion” and “Despise” factorise into a single factor. we started with the measurement model factorial structure analysis as well as its adjustment to data. The measurement model was estimated without mistakes or warnings (from the program built in control processes) and presented good fit indices.33 0.18 0.86 0.34 31.84 0. “distress” and “fear”.89 0.21 0. Factors extracted allowed us to identify four negative emotions: “disgust”.

Results showed that the structural model has good fit (x2 ¼ 134:46. indicating that latent variables were actually depicting different constructs. All estimated parameters were significant. Estimated structural model . TLI ¼ 0:99. The predictors we considered had a direct effect on patient satisfaction. df ¼ 54. Results showed that the model explains 61 per cent of the satisfaction variance (R 2 ¼ 0:61). Figure 2 presents the estimated structural model with the respective parameter values. As the measurement model revealed good fit. The estimated structural model corroborated our hypotheses. The perceived service quality.001. CFI ¼ 0:98 and RMSEA ¼ 0:061). Figure 2. p . IFI ¼ 0:99. we proceeded to analyse the structural model (that integrates the measurement model) and the causal relations between the variables that depicted the hypotheses under analysis.IJHCQA 21. 0.1 98 CFI ¼ 0:99 and RMSEA ¼ 0:052).

These modifications may have. Physician’s assurance.001). Employee’s assurance and Tangibles. considering several studies developed by other researchers. considering that the evaluations done by individuals should comprise a multiplicity of levels (the organizations and the individuals) as well as a multiplicity of service providers (physicians. 0. 0. In our study. p .the expectation and the emotions (especially the positive ones) all predicted satisfaction. We thus verified that positive and negative emotions were partially mediating the effect of expectations and involvement on satisfaction. The remaining two dimensions seemed to be specific to this type of service. “assurance with the nursing and auxiliary staff”. lowered the likelihood of finding similar results. The influence of service quality 99 . (1988): reliability. responsiveness. We departed from the assumption that this multidimensionality was equivalent to five quality dimensions proposed by Parasuraman et al. This phenomenon is surely related to the required modifications made in the original instrument in order to adapt it to the specific type of service as Parasuraman et al. From the PCA we identified four dimensions: Reliability. all the remaining measures refer to the human element linked to service performance. auxiliary staff. nurses. p . Conclusions and recommendations In our initial discussion. a multiplicity of events of service and interactions.001).001) and an indirect effect (b ¼ 0:12. (2002) highlighted. two dimensions were clearly kept: “reliability” and “tangibles”. Expectations had a direct effect (b ¼ 0:37. administrative staff) and consequently. We believe that this approach is preferable to the idea of the five-factor universal structure present in the SERVQUAL scale. somehow constrained the possibility of replicating the study and. The involvement also had a direct effect on satisfaction (b ¼ 0:15. p . 0. p . 0. However. the type of the service. we acknowledged that these dimensions lacked stability as well as the possibility that variations may occur depending on the characteristics of each service. therefore. assurance. as they relate directly to the service providers’ occupational level: physicians aggregate Assurance and Empathy dimensions for this professional group and all the other occupations aggregating respective items from Assurance dimension. we considered that the service quality construct is multidimensional. (1991) acknowledged. Service quality measures have shown that with the exception of physical elements. 2002) and that it is necessary to adopt a contingency approach in which the number of dimensions varies according to.(1988). As predicted. the interaction/intervention element’s importance has been acknowledged by many researchers. empathy and tangibles. given the healthcare services’ credential. Regarding the dimensions proposed by Parasuraman et al. so the interaction dimensions gained greater saliency: “assurance and empathy with the physician”. patients have no “skill” to evaluate exactly the service’s technical reliability. As Sureshchandar et al. SERVQUAL was minimally altered to guarantee its adaptation to Portuguese public healthcare centres’ context. among others. This result is also consistent with Donabedian’s (1980. 1989) statement that patients often are in no position to assess care process technical quality and they are sensitive to interpersonal relationships. This study provides further support for the idea that service quality construct dimensions vary (Vinagre and Neves.001) and an indirect effect (b ¼ 0:28.

Some limitations have to be considered in our study. E. 26 No. T. 156-75.1 100 The scale used to evaluate the emotional experience appears valid. The involvement also had a direct and significant effect on emotions: the more important the service is to the individuals the higher the number of positive emotions and the lower the number of negative emotions they experience.B. pp. 411-23. References Anderson.C. K. “Structural equation modelling in practice: a review and recommended two-step approach”. and Marshall. Aspy. pp. (2004). mainly positive ones. which involves diverse phenomena within the cognitive and emotional domain. Andreassen. satisfaction levels may be affected if the providers of these services disregard the patient’s emotions and if. one should keep in mind that besides seeking to provide high standards in terms of service quality.IJHCQA 21. S. E. “Adapting the SERVQUAL scale to hospital services: an empirical investigation”. HSR Health Services Research. 1980). and Mangold. 34 No. pp. pp. Vol. Future research could develop the idea of dimension variability regarding the service quality dimensions and test whether emotions experienced in specific service contexts (e. higher the tendency to feel satisfied with the service provided. .F. (1988). B. These results support the assimilation effect of expectations.. The higher the individual involvement. (1993). Therefore. and Price. Vol. Yong-Ki. and Griffin. 6. Journal of Services Marketing. “River magic: extraordinary experience and the extended service encounter”. and Gerbing. Arnould. L. Journal of Consumer Research. Our study highlighted the effect of emotions. “Antecedents to satisfaction with complaint resolution”.g. Eun-Ju. more or less qualified.W. Results also supported the process complexity that leads to satisfaction with a service. (2000). Babakus. operating like a self-fulfilling prophecy. on the patient’s satisfaction. pp.W.. Oman. 767-86. greater or lesser degree of involvement) are also operating within these dynamics.. although showing good internal consistency. a more open or closed transaction.. Journal of Counseling and Development. Even when performance is perceived as high quality.L. 3. consequently. McLeroy. 133-9. 20. Vol. 19 No.G. R. Babin. pp. (2005). C. 24-45. 103 No. it is necessary to take into account relational aspects between the service provider (physicians. the results showed that individuals experience pleasant or unpleasant emotional states following expected levels of satisfaction. D. 2. Vesely. Vol. (1992). From a management view point. 3.. W. K.J. Psychological Bulletin. J. European Journal of Marketing. S. is not extended to typologies proposed by other authors. M.K. The pattern of emotions associated with service experience showed the coexistence of diverse emotions linked to the service experience. they do not know how to manage those emotions. Vol. “Adolescent violence: the protective effects of youth assets”. L. The emotion’s inventory we used.. L. nurses and auxiliary) and the patients and the goodness of interpersonal skills in patient patient’s satisfaction (Donabedian. Expectations also have a direct effect on emotions: the higher the expected satisfaction the more individuals tend to experience positive emotions and. Our study highlights the importance of relational and emotional aspects in patient satisfaction. the less they tend to experience negative emotions. Rodine. Satisfaction also varied with the involvement seen as the importance level of the service to the patients.J. 3. 82 No.. Vol. “Modelling consumer satisfaction and word-of-mouth: restaurant patronage in Korea”. 268-76.

Vol. ¨ Gronroos. 3-28. pp. Donabedian. 11. 54-71. John Wiley and Sons Ltd. V. European Journal of Marketing. Vol. F. L. pp. Coye. pp. Vol. Journal of Academic Librarianship. 287-304. C. 7. Ann Arbor. J. Donnelly. Manchester. Bitner. 1. 35 No. 9 No. International Journal of Public Sector Management. 33-55. (2000). New York. Journal of Business & Industrial Marketing.R. 66 No. Curry. MI. R. ¨ Gronroos. (1999). A. (2000). “Services attributes: expectations and judgments”. B. NY. 3. C. K. (1995). 293-306. “A motivational process model of product involvement and consumer risk perception”. (1989). International Journal of Service Industry Management. “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. 3-11. E. and Thompson. (1997).A. pp. and O’Neill. (1995). “Critical service encounters: the employee’s viewpoint”. NY. (2000). 15-20. (2004). Vol. A. O. Vol. Donabedian.. B. Service Management and Marketing: A Customer Relationship Management Approach. Hubbert. Vol. 6. Free Press. 315-30. Bitner. ´ Dube.L. Gabbie. L. Marketing Services: Competing through Quality. (1999). “The definition of quality: a conceptual exploration”. C.J. and Menon. International Journal of Service Industry Management. Journal of Quality Management. pp. The influence of service quality 101 . “Managing customer expectations in the service encounter”.T. Bloemer. pp. “Multiple role of consumption emotions in pot-purchase satisfaction with extended service transactions”. Journal of Retailing. “Institutional and professional responsibilities in quality assurance”. M.Berry. 8 No. (2001). (1994). Vol. L. M. Buttle. Managing Service Quality. (1998). A. New York. 1340-62. and Zeithaml. and Mohr. International Journal of Service Industry. Journal of Marketing. 1 No.. Health Administration Press. 6 No. 248-58. Cook. Vol. 3. pp. Working Paper No. 294. 185-97.M. Vol. 10. D. (1996). p. Vol.T. 15 No. pp. 180-90. A. 3. Faranda. and Ruyter. pp. 1. (1990). J. “Reliability and validity of SERVQUAL scores used to evaluate perceptions of library service quality”. pp. 26. pp. 4. Bridges. “Customer contributions and roles in service delivery”. 8 No. 95-106. 58 No. 193. “Customer evaluation of service employee’s customer orientation: extension and application”. 25-32. pp. 4. 1. 4. Vol. pp. Vol.A. pp. 322-38. Managing Service Quality. “Measuring service quality in local government: the SERVQUAL approach”. and Parasuraman. “Marketing services: the case of missing product”.A. (1993). Quality Assurance in Health Care. A. “Is there a role for expectations in SERVQUAL?”.H. 6 No. (1991).M. and Hocutt. W.A.W. Vol. M. 15 No. 1.J. M. 13 No. Journal of Marketing Management. University of Manchester. K. Donavan. “Innovation in public service management”. Vol. U.D. Carman. “Customer loyalty in high and low involvement service settings: the moderating impact of positive emotions”. pp. 11 No. M. Booms. Psychology and Marketing.. Explorations in Quality Assessment and Monitoring: The Definition of Quality and Approaches to its Assessment. 2. (2001). Vol. Vol. (1980). “SERVQUAL and the Northern Ireland hotel sector: a comparative analysis – Part 1”. Dholakia.

and Panter.A. Kilbourne. A. Journal of Retailing. “A comparison of four recent measures of consumer involvement”. multiple-item scale for measuring service quality”. Psychological Review. Madrid. New York. 83-97. Vol. V. H.1 102 Hoyle. J. and Zeithaml. 12-37. (1978). Vol. Boston. 17. 207-20. Mostafa. International Journal of Service Industry Management.E.L. 20 No.L.J. Parasuraman. (1977). Vol. Liljander.A. Journal of Marketing. R. A. Vol. 14. 41-50. (1992). NY. Oliver. “Response determinants in satisfaction judgments”. W. A. and DeSarbo. International Journal of Service Industry Management. pp.H. Journal of Retailing. “A cognitive model of the antecedents and consequences of satisfaction decisions”. (1988). . (1993). 663-82. pp. Vol.L. P. Psychometric Theory. L.E. H. E. Vol. pp. International Journal of Health Care Quality Assurance. pp. pp. Shemwell. “Writing about structural equation models”. Psychology and Marketing. Yavas. C. 524-33. and Berry. MA. Izard. Vol. and Bilgin. M. Journal of Retailing. 2. 18 Nos 6/7. 3. G. 148-69.M. relations among emotions. Berry. Journal of Marketing. 2. Parasuraman.P. “Assessing the dimensionality and structure of the consumption experience: evaluation. NY. J. L.. V. R. 8 No. (1997). Silla. 495-507. J. Zeithaml. 99 No. Journal of Consumer Research. R. London. Vol.E. (1998). 155-68. “Refinement and reassessment of the SERVQUAL scale. 7. Richins. Vol. (1995). Satisfaction – A Behavioural Perspective on the Consumer. Duffy.IJHCQA 21. pp. (1988). New York. “An empirical study of patients’ expectations and satisfactions in Egyptian hospitals”. 561-5. U. (1981). Vol. Mittal.. feeling and satisfaction”. 59 No. V. 57 No. (1985). Izard.. pp. 25-48. Journal of Fashion Marketing and Management. 127-46. (1997). Oliver.L. pp. Price. ´ Martinez-Tur. 12 No. and Strandvik. L. 3. pp. Sage. 18 No.A. Oliver. Journal of Services Marketing. Duffy. Zeithaml. R.. R. 2.. (1995). 2. (1995). in Hoyle. T.H. and Berry. “Basic emotions. McGraw-Hill. Vol. Parasuraman.. “Emotions in service satisfaction”. (2001). “Going to extremes: managing service encounters and assessing provider performance”. Journal of Consumer Research. Vol. (2005). Oliver. 460-9. C. Plenum. M. Arnould. R. Irwin/McGraw-Hill. pp. V. J. “SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality”. and Giarchi. Vol.L. pp. pp. and emotion-cognition relations”. Vol. and Ramos. L. pp. Calidad de servicio y satisfaccion del cliente. 3. “Consumer profiles of apparel product involvement and values”.M. 24. (2004).L.). Structural Equation Modeling – Concepts.T. D. 4. “Customer-service provider relationships: an empirical test of a model of service quality. (1991). Journal of Marketing Research. Vol. 451-66.J.L. pp. B. “Measurement and evaluation of satisfaction processes in retail settings”. 9 No. Z. Mano. pp. “A conceptual model of service quality and its implications for future research”. Human Emotions. Issues and Application. 516-32.L. Journal of Consumer Research. 67 No. 7. “The applicability of SERVQUAL in cross-national measurements of health-care quality”.L. Kim. “Measuring emotions in the consumption experience”. 4 No. 4. satisfaction and relationship-oriented outcomes”. 64. (Ed.L. pp. and Tierney. Nunnaly. Vol.A. pp. R. M.. W.-S. V. 9 No.. (1997).S. and Oliver. 158-76. ´ Sıntesis. (1980). A. (2005). 420-50.

W. 10. Journal of Marketing. 3.E.. pp. New York. J. (1992). 407-20. R. Vol. B. Percursos da investigacao em Psicologia Social e Organizacional. 67 No. 86-96. 22 No.P. pp. “The dimensionality of consumption emotion patterns and consumer satisfaction”.S. Vol. 258-70. (2007). 30-49. 18 Nos 2/3. International Journal of Service Industry Management. (2004). 18. Vinagre. H. 217-28. Or visit our web site for further details: www. (1991). 271-90. . “Measuring the involvement construct”. (2002). Public Administration Review. “Development of a multiple-items scale for measuring hospital service quality”. pp. “Acupuncture outcomes. Journal of Marketing. M. (1985). “Sales call anxiety: exploring what it means when fear rules a sales encounter”.. Surprenant. pp. R. L. 84-91. 1. (2002). (1990). M. 92 No. “Measuring service quality in a hospital colposcopy clinic”. Wisniewski. Westbrook.). The influence of service quality 103 To purchase reprints of this article please e-mail: reprints@emeraldinsight. R. International Journal of Bank Marketing. Vol.A. Vol.L. Corresponding author Maria Helena Vinagre can be contacted at: helenavinagre@gmail. Rajendran.Sureshchandar. and Wisniewski. R. Zeithaml. and Oliver. Delivering Quality Service: Balancing Customer Perceptions and Expectations.H. (2002). V. “Medicao da qualidade de servicos em autarquias locais”. Parasuraman. Vol. pp. 16 No. “Predictability and personalization in the service encounter”. and Leunis. Verbeke.L. pp. Vol. 24. D.A. Journal of Consumer Research. “Determinants of customer-perceived quality: a confirmatory factor analysis approach”. Journal of Marketing Research. and Neves.. M. ¸˜ Lisboa. 64 No. W So. expectations. 4 No. and Berry. 88-101. 51. A. (2005). “Product/consumption-based affective responses and post-purchase processes”. Vol. International Journal of Health Care Quality Assurance.F.G. pp. Vol. “Service quality and satisfaction perceptions: curvilinear and interaction effect”. and Solomon. D. Vandamme.L. (1987). Journal of Services Marketing. 3. Westbrook. (2000). G. R. pp. R. Vol. and Anantharaman. C. Journal of Consumer Research. J. 9-34. Ting. J.N. pp. “Public service and motivation: does mission matter?”. Vol. 54-64. and the placebo effect: implications for health promotion”. C.H. 6. Zaichkowsky. and Bagozzi.emeraldinsight. 12. in ¸˜ ¸ Colibri (Ed. (1987). Wright. 1662-7. NY. pp. patient-provider relationship.R. American Journal of Public Health. Free Press. 341-52.A. 1. Vol. pp.

praising the firm. Mauritius Paper type Research paper 104 Received 28 November 2006 Revised 23 April 2007 Accepted 12 May 2007 Introduction Ensuring services benefit not only patients but also healthcare providers are important. or . Keywords Health services. 2008 pp. Service levels. healthcare providers have much to gain if they can understand what patients expect since this assists them by serving their patients better and building long-term relationships. .1108/09526860810841192 . social needs for belongingness and affection and individual needs International Journal of Health Care Quality Assurance Vol.1 The relative importance of service dimensions in a healthcare setting Rooma Roshnee Ramsaran-Fowdar Faculty of Law and Management. Patients who perceive they are content with services are likely to exhibit favourable behavioural intentions that are beneficial to the healthcare provider’s long-term success. . preferring the company over others. University of Mauritius. increasing their volume of purchases. 104-124 q Emerald Group Publishing Limited 0952-6862 DOI 10. 1. Findings – A new service quality instrument called PRIVHEALTHQUAL emerged from the study. Clancy and Schulman (1994) calculated the cost of attracting new customers to be approximately five times that of keeping current customers happy. Therefore. Human needs are states of felt deprivation such as physical needs for food. Originality/value – Adds to the existing body of research on service quality and demonstrates that SERVQUAL is not a generic service quality measure for all industries. based on factor and reliability analysis. 21 No. Reduit. agreeing to pay a price premium. Zeithaml and Bitner (2000) described how customers express such intentions in positive ways: .com/0952-6862. If a healthcare service provider is to maintain itself as a viable entity in today’s competitive market then great care must be taken to not only identify patients’ needs and wants but also ensure that these needs and wants are satisfactorily met. customer dissatisfaction may lead to unfavourable behavioral intentions such as negative word-of-mouth. On the other hand. The “reliability and fair and equitable treatment” factor was found to be the most important healthcare service quality dimension. Private hospitals.htm IJHCQA 21. Mauritius Abstract Purpose – The paper aims to focus on an augmented SERVQUAL instrument that was used to measure private patients’ service expectations and perceptions. Retaining customers may be more profitable than attracting new ones.The current issue and full text archive of this journal is available at www. Design/method/approach – A questionnaire was administered to 750 and 34 per cent responded. clothing and safety.emeraldinsight. doing less business or switching to alternative service providers.

research on consumers’ multi-expectations. Spreng and Singh. (4) assurance. 1993. Recently. 1993. There is research that service quality is contingent upon service type (Babakus and Mangold... 1990). Importance of service dimensions 105 . Between these two expectation levels lies “tolerance zones” that represent a performance range consumers consider acceptable. Parasuraman et al. desired expectations as a comparison against which service performance is assessed. Wants are the form taken by human needs as they are shaped by culture and individual personality. It also illustrates the difference between perceived service and desired service – known as the Measure of Service Superiority (MSS) and the difference between perceived service and adequate service – labeled as the Measure of Service Adequacy (MSA).. This model proposes that service expectations can be separated into an adequate standard and a desired standard (Zeithaml et al. which consists of five essential service quality dimensions: (1) tangibles. One of these criticisms is SERVQUAL’s inappropriateness as a generic measure for all service settings. and (5) empathy. Brown et al. Office aesthetics. 1990. Although SERVQUAL proved to be a robust service quality measure. healthcare can be considered a “credence” good – an offering that consumers will never be able to evaluate owing to a lack of medical knowledge (Bloom and Reeve. (1988) used a single expectation standard. (3) responsiveness. 1994). 1989). 1993b). it has been subject to criticisms conceptually and methodologically (Babakus and Mangold. Within each dimension there are several items (22 in total) measured on a seven-point scale from strongly agree to strongly disagree. Cronin and Taylor. staff appearance. Carman. Since SERVQUAL was generated outside healthcare and has limited examination in the healthcare literature. 1993. 1989. Parasuraman et al. patients are likely to look for cues or “signals” that are redolent of treatment quality they are likely to receive (or do receive) from a provider. 1993a. These service quality surrogate indicators can be used by patients to assess service provider efficaciousness. (2) reliability. In their popular measuring service quality framework. researchers proposed that multi-expectation standard approaches may be more appropriate for service quality models (Boulding et al. 1992. This framework not only provides better comprehension of the multiple expectations that consumers use in evaluating services but also gives practitioners an opportunity to optimise resource allocation when attempting to meet/exceed customer expectations (Walker and Baker. Given healthcare’s credence.. Exactly what are consumers’ needs and wants in a healthcare context? By and large.for knowledge and self-expression. relationship between patient and doctors and the punctuality of appointment among others may be medical care quality indicators.. there is a need to test if SERVQUAL is a comprehensive patient evaluation of healthcare service quality measure or if additional dimensions are needed.. additional research is necessary to gauge its applicability to healthcare services. 1993. However. The most widely accepted measurement scale for service quality is SERVQUAL (Parasuraman et al. Zeithaml et al. Specifically. 2000). 1993). Teas. 1988).

Singapore and other developed countries where average life expectancy is above 75 years and infant mortality rates is below seven. Indeed. The number of doctors registered has declined over the years since these professionals prefer to work overseas where they are better remunerated.089 inhabitants. Similarly.9 per cent in Belgium. 2002). many nurses have migrated. new measures are needed to improve its performance to reach the levels achieved by places such as New Zealand. The total number of beds in government institutions was 3. Although Mauritius is doing well. Often. 2003). there were 1. One reason for this difference in health status may be the relative level of investment in the health services in different countries. employs over 400 doctors and provides primary and secondary services in 14 private clinics. All impede patient service delivery in the public sector. the government allows public doctors to practise privately as part of its staff retention strategy.8 per cent in France and 13 per cent in the USA (Ministry of Health and Quality of Life. one bed for 315 inhabitants or 3. patients have to wait in long queues in the public hospitals. that is. The private sector.3 per cent in Singapore. MSS and MSA is in the exploratory stage. representing one doctor for every 1. Mauritius spends about 2.8 per cent of its Gross Domestic Product on health compared to 3. Consequently.700 nurses.000. the public healthcare system is perceived negatively by the general population and some people prefer private physicians and services who charge fees ranging from US$6 to US$25 depending on the doctor and his/her medical expertise. in comparison to developing countries. Mauritius has made remarkable progress addressing citizens’ healthcare needs.2 million residents (Central Statistics Office. private medical services were identified as a suitable study setting to explore professional service quality and its evaluation from the clients’ perspectives.1 tolerance zones. Given the physician shortage.9 per cent in Seychelles. 9. for instance. Compared to other African countries. which absorbs 32 per cent of the country’s total health expenditure. Private general practitioners (GPs) were selected because they deal with patients on a long-term basis. 8 per cent in New Zealand.000 population in Mauritius is significantly below that found in countries with better levels of health. Mauritian medical care is freely provided by the state and there is also a well-established private sector. 2001.716 at the end of 2001. At the end of 2001. Consequently. 5. In the past thirty years the average life expectancy has increased from 63 years to 71 years while infant mortality fell from 64 to 14 deaths in the first year of life for every 1. The private sector has 588 beds of which 283 are single rooms (Ministry of Health and Quality of Life.2 beds per 1.IJHCQA 21. Furthermore. Nevertheless. 8. there is a serious demoralisation problem among hospital employees resulting from cumbersome workload. low working life quality. Presently.107 doctors in Mauritius. The Mauritius healthcare system The Republic of Mauritius has a total area of 720 square miles and a population of 1. poor remuneration. Healthcare service performance is also relatively low in Mauritius compared to other countries because of staffing differences. People at the bottom of the socioeconomic ladder obviously cannot access paid services. the number of doctors and nurses employed per 100. 2002). The public sector employs over 690 doctors (including about 245 specialists) and around 2. inability to take initiatives and poor leadership. the majority of people consuming private health care services are fully self-paying patients and very few are covered either partially or fully by their private employers or by private 106 .000 live births.

Zeithaml (1988) later defined service quality as the consumer’s assessment of overall excellence or superiority of the service. and . Parasuraman et al. Our purpose. examination room and medical equipment. service quality characteristics and the criteria used by customers when assessing service quality. Parasuraman et al. therefore. Along the same line. Technical quality can relate to the surgeon’s performance. (1985) study was the most extensive research carried out into customer service Importance of service dimensions 107 . Interactive quality involves contact between the customer and service personnel. for example. discussed three kinds of quality: (1) physical. which refers to the degree and direction of discrepancy between customers’ perceptions and expectations.e. (1985) defined service quality as an overall evaluation. 2000). Physical quality includes structural aspects associated with services such as the reception area.e. we seek to accomplish the following specific objectives: . (2) interactive.’s. while functional quality may consist of the doctor’s waiting credit card. product repair and maintenance). what is offered and received).e. The study revealed that customers used the same general criteria to arrive at an evaluative judgement regarding service quality. Literature review Different theoretical perspectives on service quality were developed during the 1980 s. Topics discussed with focus group members included the meaning of quality in the service’s context. ¨ Groonroos (1982). (1985) using twelve consumer focus-groups in four industries (banking. to identify the most important service quality dimension in a healthcare setting. similar to but not the same as an attitude. distinguished two types of service quality: (1) technical quality refers to core service delivery or service outcome (i. and (3) corporate. was to conduct empirical research on service quality frameworks. customers’ expectations) with the seller’s actual service performance (Parasuraman. From these earlier writings. doctor’s office hours and secretary’s behaviour. on the other hand. to measure service quality in a private healthcare setting. securities brokerage. Addressing the major issues discussed above. Corporate quality includes image and reputation. how the service is offered and received). This idea was supported by exploratory research conducted by Parasuraman et al. while (2) functional quality refers to service delivery processes or the way in which the customer receives the service (i. which correspond to the ¨ dichotomy proposed by Gronroos (1982) and to the “physical” and “interactive” quality characteristics identified earlier by Lehtinen and Lehtinen (1982). “outcome” quality and “process” quality. The researchers also identified two inter-related service quality dimensions. Consequently. Olshavasky (1985) also viewed quality as a form of overall service evaluation similar in many ways to attitude. Lehtinen and Lehtinen (1982). it can be seen that service quality notions arise from a comparison of what customers feel a seller should offer (i.

other studies (Carman. They suggest that environment. (1985) defined service quality as the difference between what a service company should offer and what it actually offers or the discrepancy between expectations and perceptions of the service performance. Respondents considered reliability as the most important and tangibles the least important dimension. repair and maintenance. For example. One main criticism is the applicability of the five SERVQUAL dimensions to different service settings. (1990) reported.1 108 quality perceptions.. 1990. Despite its widespread use. Because some service quality determinants are perceived generically. However. 1990) in a dental school patient clinic. Lately. two insurance companies and a long-distance telephone company. Zeithaml et al. followed by responsiveness. Groonroos (1982) conceptualised service quality as a two dimensional construct comprising technical and functional quality. the instrument has been criticised conceptually and methodologically. Turner and Pol (1995) also reported that quality dimensions are not equally important. 1994) suggest that multi-expectation standard approaches may be more appropriate in service quality models. physical and corporate quality.’s (1985) five service quality dimensions. Attempting to capture the essence of various comparison standards. (1993) and Parasuraman et al. (1988). They revealed only three underlying elements: tangibles. 1993) demonstrated that service encounter situational characteristics such as customers’ prior experience. (1990) reported service reliability as the most critical dimension perceived by customers. some researchers such as (Boulding et al. (1993. empathy and tangibles. (1991) as a reliable and valid service quality measure with relatively stable dimensions that apply across many service industries. motor care tire centre and acute care hospital. developed by Parasuraman and his colleagues. replication studies by other investigators failed to support the five-dimensional factor structure obtained by ¨ Parasuraman et al. McDougall and Levesque’s (1994) study also did not support Parasuraman et al. in their study of credit-card. On the other hand. Lehtinen and Lehtinen (1982). Moreover. The SERVQUAL instrument is described by Parasuraman et al. Mowen et al. contractual performance (outcome) and customer-employee relationships (process). Babakus and Mangold (1989) argue that SERVQUAL’s dimensional instability results from the type of service sector under investigation. The 22-item SERVQUAL instrument.IJHCQA 21. 1992) and up to nine (Carman. In Parasuraman et al. that customers rated all five SERVQUAL dimensions important. research indicates the possibility of two public utility sector dimensions (Babakus and Boller. business school placement centre. a single expectation standard. defined service quality as three constructs: interactive. Zeithaml et al. which underpin service quality. This finding consistently cropped up in other studies such as Zeithaml et al. Zeithaml et al. long-distance telephone and retail banking services. assurance. included five service quality dimensions described above. Parasuraman et al. (1993) pooled insights from past expectation . That is.’s (1985) well-known SERVQUAL model. In a study of 1936 customers in two banks. while others are industry. customer’s physical or emotional status and other non-medical characteristics can influence customers’ service quality perceptions. however. desired expectations (what the consumer feels a service provider should offer) was used as a comparison against which service performance was assessed. time or day of the week or whether customers are given an expectation about waiting time may affect the relative importance of various quality dimensions.or situation-specific. (1990).

most customers are realistic and understand that company staff cannot always deliver the preferred service level. therefore. Separating these two expectation levels is a “tolerance zone” that represents a service performance range a customer would consider satisfactory. (2) service level adequacy. Parasuraman et al. Convergent validity is the extent to which the scale correlates positively with other measures of the same construct. (Berry and Parasuraman. On the other hand. 2000). A performance level above the tolerance zone (or above the desired service level) will surprise and create customer delight and strengthen their loyalty (customer franchise). the tolerance zone is a service range within which customers do not pay explicit attention to performance. The three-column format (Table I) involved obtaining separate desired. The latest SERVQUAL modification. As mentioned earlier. A performance below the tolerance zone (or below the adequate service level) will engender customer frustration and dissatisfaction and decrease customer loyalty (competitive disadvantage). 2004). (1994) modified SERVQUAL’s structure to capture the MSS and MSA gaps. The new model separates expectations into an adequate standard (which is influenced by predicted expectations) and a desired standard that customers use to evaluate service quality. Additionally. three values (on a nine-point scale) are measured: (1) customers’ desired service level. For each SERVQUAL attribute. In other words. incorporates this expanded expectation conceptualisation. The tolerance zone thus not only improves multiple expectation comprehension that consumers may use in service evaluations but also provides practitioners better opportunities to optimise resource allocations in their continual attempt to meet or exceed customer expectations (Walker and Baker. customers also have an expectation threshold. and (3) a specific company’s perceived service. adequate and perceived service ratings using Importance of service dimensions 109 . the tolerance zone provides detailed and probably more accurate managerially diagnostic information and thus better strategy decisions (Teas and DeCarlo. However. If the correlation between two measures is high then the initial measure is said to have predictive validity. 1991). termed adequate service. (1994) found that tolerance zone measures had convergent and predictive validity. desired and predicted expectations along with perceived performance. Moreover. Predictive validity is assessed by comparing data on the scale at one point in time and data on the criterion at a future point in time. or the minimum level of service customers are willing to accept without dissatisfaction. This service quality framework combines adequate. The tolerance measures were also less susceptible to response errors compared to single expectation measures. Parasuraman et al.conceptualisations with findings from a multi-sector focus-group study to develop an integrative customers’ service expectation model. They also developed three alternative service quality measurement formats among which the three-column format seemed most useful and demonstrated where appropriate improvement efforts should be made if identifying critical service deficiencies is the principal objective. Hence. A desired service is defined as the level representing what customers hope to receive or a combination of what customers believe “can be” and “should be” provided. customers will be satisfied if performance falls within their tolerance zone (competitive disadvantage).

110 IJHCQA 21. . 1 2 3 4 5 6 7 8 9 1 Modern-looking equipment Table I. Three-level format Column 3 My perception of XYZ’s service My minimum service level is: My desired service level is: performance: Low High Low High Low High No opinion 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 N Column 1 Column 2 . .1 When it comes to.

sex. (1994). access to care. user-friendly forms). life saving. specialists. Gabott and Hogg (1994) reported six factors that affect consumer satisfaction: (1) service range (e. human involvement. Healthcare sector service quality Previous SERVQUAL tests in health care settings yielded mixed findings. parking. on the other hand. The “caring dimension” implied a “personal. helpfulness. “professional competence” and “communications” as factors significant for both physicians and patients in service quality evaluation.g. side-by-side scales. Parasuraman et al. Importance of service dimensions 111 . number of doctors). one practical problem with the three-column format is that it calls for three separate ratings that respondents may find more time-consuming. (2) empathy (e. (3) physical access (e. appointment time convenience). receptionist’s manner. waiting room facilities. (1993) separated service attributes into three factors using factor analysis: (1) staff behaviour (friendliness.g. and (3) examination comfort (physical comfort and time in the examination room). Additionally. waiting room. facilities for disabled). Using principal components analysis and Varimax rotation. On the other hand. office visit. A GP (1) (2) (3) (4) satisfaction study by Drain (2001) yielded four factors: care provider.three identical.g.g. reported two major additional dimensions not captured by SERVQUAL: caring and patient outcomes. “service customisation” and “knowledge of the professional” dimensions. Bowers et al. age. and (6) responsiveness (time spent with doctor and time spent in waiting room). research conducted by Haywood-Farmer and Stuart (1988) suggested that SERVQUAL was inappropriate for measuring professional service quality since it excluded “core service”. Peyrot et al. (4) doctor specific (e. home visits). Babakus and Mangold (1992) found the instrument reliable and valid in hospitals. (1994) concluded that if the primary goal was to maximise the variance explained in overall service ratings then the perceptions-only scale appeared to be the best. and personal issues.g.g. bedside manner. The perception-only ratings (Column 3) were found to have the most predictive power. explanation). However. (2) pre-examination comfort (e. access by public transport. decoration). waiting time. with emotions approaching love for the patient” and an “outcomes” dimension that included “pain relief. (5) situational (e. anger or disappointment with life after medical intervention”. Brown and Swartz (1989) identified “professional credibility”. The perceived – desired and perceived – adequate differences were used to calculate MSS and MSA respectively.

(2) doctor-patient relationship. Most important dimension in healthcare service quality In many quality studies the reliability dimension – the ability to perform services dependably and accurately – stands out as the most important customer service quality perception determinant. Kilbourne et al. Recently. reliability and empathy. however. overall (second order) service quality factor. In short. (2) tangibles. Morrison et al. tangibles. maternal and child health centres): (1) assurance.IJHCQA 21. However. Loaded together these dimensions accounted for approximately 68 per cent of the variance in both settings. 1994b) reported that SERVQUAL was a consistent and reliable one-dimensional scale. (4) advising.’s (2004) study also showed that SERVQUAL captures service quality multidimensionality: . it is hypothesized that: H1. and (5) empowering patients to make decisions. it is believed that the core medical outcome is not part of the “reliability” dimension and represents the most important criterion patients look for when visiting a GP. studies show that SERVQUAL does not cover all healthcare services dimensions that are important to patients.1 112 Dean (1999) identified four stable dimensions using SERVQUAL to compare service quality dimensions in two different healthcare settings (medical centre. which implies that one generic service quality measure is inappropriate for all services. research indicates that perceived service quality is contingent upon service type. as well as an . Therefore. and (4) reliability and responsiveness. using factor analysis. few studies including Babakus and Mangold (1992). Although Berry and Parasuraman (1991) argued that the SERVQUAL “reliability” dimension is the outcome of service performance representing the core service. Lam (1997) and Taylor (1994a. (3) same gender as the patient. responsiveness. . (2003) identified five main service attributes that explain people’s GP service preferences: (1) communication. A different argument is proposed for consideration in a healthcare environment. . (3) empathy. Core outcome is the most important healthcare service quality dimension. there has been limited recent published work on service quality dimensionality after the mid 1990s. However. Therefore. .

address. occupational status. A convenience sample was used by choosing people working at the Mauritius University. target respondents. Our modified SERVQUAL-type questionnaire for use in the healthcare sector was constructed by retaining some items from the updated SERVQUAL dimensions: tangibles. ethnicity. age. newspapers. each item investigated was checked once again before verbally and structurally being changed to reflect our research needs. Importance of service dimensions 113 . their friends and other associates. These scales add strong diagnostic value and the three-column format possesses comparable reliability and validity to other formats studied.’s (1994) three-column format was used with three identical desired. reliability. our questionnaire consisted of three sections: (1) Section A included 47 statements on different aspects of GP services. response format. (2) Appealing materials such as pamphlets. gender. Service quality questionnaire items (1) Ability to get an appointment at a convenient time to me. Detailed notes were taken during interviews and these were eventually compiled into a report. All service quality items were ordered alphabetically to later identify the underlying quality dimensions and those items that are highly related to the same dimension using factor analysis. personal income and marital status diversity. monthly household income and private healthcare payment mode. after carrying out in-depth interviews on healthcare quality with patients. including gender. Next. and used the regression purposes. (1994). Respondents were subjected to a set of open-ended questions on their quality perceptions of services provided by private GPs. 1996). Their choice best reflected their desired and minimum service level expectations. respondents were asked to rate the overall quality of GP service on a seven-point Likert scale. The in-depth interviews were conducted with twelve patients over a period of three weeks to probe their needs and the benefits they hoped to obtain from private GPs.Method We used a cross-sectional quantitative research design. Parasuraman et al. (3) Section C covered respondent demographics. question wording and questionnaire sequence into consideration (Kinnear and Taylor. empathy and assurance from Parasuraman et al. Respondents were chosen to achieve age. magazines. Respondents circled the appropriate number on a seven-point scale from Low (1) to High (7). Our questionnaire was designed taking preliminary considerations such as the research questions. (1994). Selected items were refined and paraphrased in both wording and contextual applications as appropriate to suit our research purposes. marital status. education level. This separate question for measuring overall service quality using the average measured gap helped to measure multi co-linearity. Consequently. the 47 service quality items measured on a seven-point scale from low to high. adequate and perceived service scales. residence. and their GP service ratings. hypothesis. The list below summarises the questionnaire’s 47 service quality items. All items were phrased positively as suggested by Parasuraman et al. responsiveness. posters and so on. occupation. (2) Section B consisted of a question that measured respondents’ overall service quality evaluation. Additionally.

Reliability in handling the patient’s problems. Knowledgeable and skilled GP. GP’s emphasis on prevention of health problems. Courteous and friendly support staff. chairs. Honesty and integrity of physician. Courteous and friendly doctor. Willingness to help patients. Visually attractive and comfortable physical facilities (e. . Professional appearance/dress of the GP. Maintaining accurate and neat records of the patient’s medical history. GP accessibility by phone. Modern medical equipment. Knowledgeable and skilled support staff. GP’s readiness to respond to the patient’s questions and worries. GP’s medical qualifications. GP making patient feel good emotionally and psychologically. Uniform fees and other charges for all patients. Careful diagnosis of the patient’s problems. GP’s familiarity with latest advances in medical field/products. Highly experienced GP. Convenient clinic location. Ability of support staff to inspire trust and confidence in patient. waiting room. GP accessibility at odd hours in case of emergencies. tables and amenities). Convenient hours of operation.IJHCQA 21. Clear display of GP’s qualifications. GP’s willingness to listen carefully to patients. Professional appearance/dress of the support staff. GP’s emphasis on patient education. Ability of GP to inspire trust and confidence in patient. Physician reputation.1 114 (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) Availability of prescribed medicines at the pharmacy.g. Physician compliance with hygienic and other precautions. GP having patients’ best interest at heart. Punctuality of appointment. Prescription of affordable medicines. Prompt service without an appointment.

First. our 34 per cent response bettered the Mauritian 15-25 per cent national response-rate average. the response rate achieved was Importance of service dimensions 115 .e. (1999) suggest that. The latter were instructed to administer the questionnaires to one male and one female (since the 2000 census enumerated the sex ratio at all ages to be 981 males per 1. They were requested to ask visiting patients to fill in the questionnaire when waiting for the doctor’s consultation. Owing to the relatively large University and other contact commuter base. Completed questionnaires were then collected by the researcher over a period of two months. Basilevsky (1994) and Hair et al. 600 questionnaires in batches of two were distributed to Mauritius University undergraduate and postgraduate students. Positive medical outcome of treatment. They were asked to ensure that each was an immediate family member. Quality of GP’s referral contacts (i. schools. This allowed recollections of their visit experience in order to be able to remember and answer the purchase and post-purchase situations and feelings appropriately. a survey must achieve a rate of response that includes at least 30 per cent of the patients whose opinion was sought. Physician’s willingness. A total of 750 questionnaires were distributed and administered in two stages. other relative or associate.(39) (40) (41) (42) (43) (44) Maintenance of patient confidentiality. Sample The study population was defined as all patients 18 years or older and who had visited a private GP at least once within the past year for their own or family needs. if necessary. contacts with specialists. there should be at least four or five times as many observations (sample size) as there are variables. Sommers (1999) reports that for scientific validity. (45) Reassuring the patient about the recovery. Response rate From 750 questionnaires distributed over a period of five months in 2003. three were omitted from our data analysis owing to incomplete or missing information – a final response rate of 34 per cent. laboratories). Second. Physicians making patients feel safe and relaxed during their visits. pharmacies. the sample was considered to represent the population and was large enough to accommodate the number of variables in the study as well as cell sizes involved. hospitals. Completion instructions were given to each receptionist. to refer the patient to a specialist. We used a convenience sample. Respondents must also have visited a private GP during the preceding year and be over 18 years of age. Thus. a total of 260 were completed and returned. Since there is a maximum of 47 items. Therefore. a sample size of 188 to 235 respondents would have been appropriate. (47) Thoroughness of explanation of medical condition and treatment. Questionnaires were also sent to workplaces. as a rough guideline. Personal conduct and manners of the GP. (46) Remembering names and faces of patients. 2003).000 females (Central Statistics Office. families and friends. Moreover. 150 questionnaires were hand-delivered to the receptionists in five randomly selected private GPs. every attempt was made to randomise the data collection process. Of these. neighbour.

therefore.3 per cent of the variation in overall service quality and MSA scores 9. Cronbach alphas. principal component analysis was used to extract the maximum variance from our data. To test instrument scale validity. eigenvalues. We can. the MSS format was found to be superior. The same conclusion was reached when comparing the Cronbach alphas. A comparison of two possible formats is needed to determine which should be used to decide the factor structure for further analysis. 1994). There could be a nonlinear relationship between them that is not captured by R 2. Factor structure reliability was tested for internal consistency after items were grouped. a regression analysis was performed to assess the questionnaire’s convergent and predictive properties. with maximum likelihood method. Although MSS and MSA scores produced fairly low R 2 values.’s (1994) recommendation. was chosen for our factor analysis second stage. Only factors with Eigenvalues greater than one were retained and a decision rule of factor loadings in excess of 0.8 per cent. while MSS (sum of MSS means of 44 service statements retained from MSS construct divided by 44). McDougall and Levesque. Data analysis We examined dimensionality using factor analysis. Moreover. the factors derived from the MSA construct were slightly superior to the MSS score format. empirically supporting the superior predictive power of this scale compared to the difference-score measures (Babakus and Mangold. According to Table III. Three different regressions were done. Comparing individual factor Eigenvalues revealed that results were relatively equivalent. The Varimax rotation technique.1 considered adequate for the study. Therefore. MSS scores explained the item loadings in a better and sound conceptual way. Nevertheless. Both MSS and MSA scores from 47 service quality items were factor analysed using Parasuraman et al. Table II provides a summary of the respondents’ demographics. Findings and discussion Table III shows that the perceptions-only scale had higher R 2 value than the other two measures. Based on the total variance explained.IJHCQA 21. In the initial stage of factor extraction. confirm the service quality scale’s convergent and predictive validity. and . 1992. 1989). Results are illustrated in Table III. The resulting respondent profile was deemed to be encompassing and fairly well distributed. MSS scores explained 19. MSS convergent and predictive validity were superior compared to the MSA format (Table IV) by the higher R 2. MSA (sum of MSA means of all 46 service statements retained from MSA construct divided by 46) and perceptions-only ratings (overall) from the dimension factor means were used as independent variables. Table IV summarises two factor analysis results derived from MSS and MSA scores based on: . Cronin and Taylor. Factor rotation maximises the loadings’ variance on each factor thus minimising factor complexity (Tabachnick and Fidell. Raw data were initially organised into MSS and MSA. the total variation explained. 116 .40 was considered. Overall service quality ratings were used as the dependent variable. 1992. . it does not mean that these constructs are unrelated to overall service quality.

0 0.0 44 56 40.2 51.2 3.000 Rs 10.6 3.4 12. of primary education) O level/SC A level/HSC/diploma Degree Postgraduate Others Marital satus Single Married without children Married with children Widowed/divorced/separated Gross monthly household income Below Rs 10. etc.1 61.9 Importance of service dimensions 117 Table II.2 44.001-50.1 6.8 8.0 17.000 Rs 10.9 25.8 50.3 14.Frequency Gender Male Female Age 18-29 years old 30-49 years old 50 to 64 years old 65 years or older Ethnic group Hindu Muslim Chinese Other Place of residence Rural region Urban region Occupational status Unemployed/student/housewife/retired Clerical/factory worker/and other white collar jobs Executive/managerial/professional (teacher.001-20.4 49.) Self-employed Others Highest level of education completed CPE (cert.0 11.0 8.5 7. Respondents’ demographic profile .8 1.000 Rs 40.7 24.001-20.2 15.4 3.9 20.1 16. lawyers.000 Rs 30.001-40.9 14.1 5.3 36.000 Mode of payment for private healthcare Fully self paying patient Self-paying patient through private insurance Self-paying patient covered partially by employer Self-paying patient covered fully by employer 128 129 133 83 38 3 157 41 23 36 113 144 105 66 62 16 8 10 52 131 45 18 1 126 29 94 8 88 114 31 14 8 2 187 21 39 10 % 49.1 3.000 Above Rs 50.1 0.2 3.1 34. doctors.2 51.8 32.8 72.

098 Adjusted R 2 0.87 0. managers should not continue to ignore consumer expectations.545 df 1 1 1 Sig.094 F 102. Although some dimensions were relatively equivalent.6 Cronbach Alpha 0. therefore.6 3. Proportion of variance in overall service quality (dependent variable) Perceptions-only (overall) MSS (overall) MSA (overall) R2 0.4% Eigenvalues 9.81 2 0.337 0. which demonstrates that SERVQUAL is not a service quality generic measure for all industries. From our comparisons it can be said that an augmented and modified SERVQUAL instrument can be used in a private healthcare context.76 4 5 2 2 4. which were obtained using factor and reliability analyses on data from private healthcare settings.193 0.7% Total variance explained Dimensions Assurance/empathy Core medical services/professionalism/ skill/competence Responsiveness Responsiveness/tangibility Tangibility/image Image/fair and equitable treatment Reliability/fair and equitable treatment Reliability Equipment and records Information dissemination No.IJHCQA 21.94 0. an understanding of both adequate and desired expectations is necessary to avoid service shortfalls and achieve better resource allocations.189 0.000 MSS format 63.95 0.91 0. Moreover. Our study adds to the large body of service quality research.294 21.8 0.5 0. which largely explain the total variance: “Core Medical Services/Professionalism/Skill/Competence” and “Information Dissemination”. there were two additional dimensions with high Eigenvalues and Cronbach alphas. our study provides evidence that expectations drive service quality diagnostic evaluations by consumers and.000 0.092 47. Clearly.2 4 7.4 3. of items 13 8 9 4 Eigenvalues 6.000 0.9 4 Cronbach Alpha 0.340 0. “Fairness and treatment equity” was also associated to the “reliability” dimension.75 0.72 No. Comparison between MSS and MSA score formats . One way to test core outcome ` dimension importance (vis-a-vis other service quality dimensions) is to examine its Independent variable used Table III.1 118 Proposed service quality scale for private healthcare Table V compares service quality dimensions generated from the MSS format we used with Parasuraman et al. of items 19 5 15 MSA format 65.2 1. We also show a need to examine current tools that measure service standards in the professional services domain.72 Table IV.97 0.9 0.1 4. 0.2 6. Consequently.8 1.’s (1988) SERVQUAL dimensions. we named our new service quality instrument PRIVHEALTHQUAL.

Empathy – caring. 4. Assurance – courtesy and knowledge of staff and their ability to inspire trust and confidence 5. The Pearson product-moment correlation coefficient (r) indicates the degree that quantitative variables are linearly related in a sample. accurately. individualised attention provided to patients by physicians Core medical services/ professionalism/skill/ competence – the central medical aspects of the service: appropriateness. individualised attention provided to customers 5. Here. equipment and appearance of personnel Service quality dimensions in private healthcare (PRIVHEALTHQUAL) 1. SERVQUAL Dimensions versus service quality dimensions generated from factor and reliability analyses correlation with a global measure of service quality and satisfaction. we shall use the PRIVHEALTHQUAL scale derived from the MSS scores. caring.SERVQUAL dimensions 1. 4. knowledge. Table VI lists the results. The significance test of r evaluates whether there is a linear relationship between two variables in the population. 2 Reliability – ability to perform the expected service dependably and accurately 3. Tangibility/image – physical facilities. fairly and equitably Responsiveness – willingness to help customers and provide prompt service Assurance/empathy – the ability of the physician and staff to inspire trust and confidence and courtesy displayed by the physician. Tangibility – physical facilities. Table V. 6. technical expertise. effectiveness and benefit to the patient. 7. amount of training and experience Equipment and records – physical equipment used by physician and accurate records of medical history Information dissemination – provision of information by physician Importance of service dimensions 119 2. image and appearance of GP Reliability/fair and equitable treatment – ability to perform the service dependably. The square of the correlation gives the proportion of criterion variance that is accounted for by its linear relationship with the predictor. Responsiveness – willingness to help customers and provide prompt service 3. .

and physician’s willingness to refer patients to a specialist if necessary”. we suggest that seven service quality dimensions are applicable to private healthcare. is not supported – consistent with many studies including Zeithaml et al.113 255 120 MEDEREL MEDERES MEDEASS MEDECORE MEDEEQUI Table VI. This new dimension included items such as “uniform fees and other charges for all patients”.’s (2003) studies.098 0. (two-tailed) n Pearson correlation Sig. therefore. However. Thus. overall service quality evaluation and satisfaction MEDEINFO Note: * Correlation is significant at the 0. which demonstrates that SERVQUAL is not a generic service quality measure for all industries and that “reliability” is the most important dimension in a healthcare context. Correlations between service quality dimensions.100 0. .IJHCQA 21. was associated with the “Reliability” dimension. (two-tailed) n Pearson correlation Sig. our research adds to the large body of previous research on service quality.122 255 0. Consequently.1 MEDETAN Pearson correlation Sig. In fact. Our study supports Carman’s (1990) argument – that SERVQUAL scale items/dimensions need to be modified to suit particular industry settings. we conclude that core outcome is not the most important dimension in health care service quality. consistent with Sureshchandar et al. (two-tailed) n Pearson correlation Sig.213 * 0. a new dimension “Fair and Equitable Treatment”. (two-tailed) n Pearson correlation Sig. (two-tailed) n What is your evaluation of the overall service quality you receive from your GP? 0. ‘GP’s medical qualifications’.247 * 0.175 * 0. (two-tailed) n Pearson correlation Sig. Hypothesis H1 given earlier.01 level (two-tailed) From Table VI.001 255 0. (two-tailed) n Pearson correlation Sig. the dimension “Reliability/Fair and Equitable Treatment” is the most important. followed by the “core outcome”.005 255 0. “Reliability” includes “careful diagnosis of the patients’ problems”. “assurance/empathy” and “equipment and records” dimensions. (1990).001 255 0. This reflected patients’ views that everyone should be treated alike by their GP.’s (2002) and Hellier et al. Berry and Parasuraman (1991).097 0.210 * 0.119 255 0.000 255 0.

Recommendations A number of issues limit our findings’ generalisabilty. The sample, for instance, consisted of university students, their friends and relatives, patients and their friends and neighbours at a few private GPs medical clinics. There is a risk, therefore, that our sample might not represent the population served by private Mauritian GPs. However, a counterargument is that our sample was geographically spread since university students came from all over the island. Therefore, results might be generalized for the whole island. Nevertheless, our reesults may not be replicable outside Mauritius in that patients’ cultures, private GP practices abroad and other factors including the healthcare system are likely to be different. The sample size (257 usable responses) can be argued to be moderate. However, this number more than satisfied the criterion laid out by Basilevsky (1994) and Hair et al. (1999). Another limitation is that a longitudinal study would provide greater diagnostic value than our cross-sectional design. Changes in perceptions and expectations could thus be tracked over time. This research was also limited to the Mauritian private healthcare sector. Further research, therefore, could also focus on studying other service settings.
References Babakus, E. and Boller, G.W. (1992), “An empirical assessment of the SERVQUAL scale”, Journal of Business Research, Vol. 24, pp. 253-68. Babakus, E. and Mangold, W.G. (1989), “Adapting the SERVQUAL scale to health care environment: an empirical assessment”, in Bloom, P., Weitz, B., Winer, R., Spekman, R.E., Kassarjian, H.H., Mahajan, V., Scammon, D.L. and Leay, M. (Eds), AMA Summer Educators’ Proceedings: Enhancing Knowledge Development in Marketing, American Marketing Association, Chicago, IL. Babakus, E. and Mangold, W.G. (1992), “Adapting the SERVQUAL scale to hospital services: an empirical investigation”, Health Services Research, Vol. 26 No. 6, pp. 767-86. Basilevsky, A. (1994), Statistical Factor Analysis and Related Methods: Theory and Applications, John Wiley, New York, NY. Berry, L.L. and Parasuraman, A. (1991), Marketing Services: Competing through Quality, The Free Press, New York, NY. Bloom, P.N. and Reeve, T. (1990), “Transmitting signals to consumers for competitive advantage”, Business Horizons, Vol. 33, July-August, pp. 58-66. Bowers, M.R., Swan, J.E. and Koehler, W.F. (1994), “What attributes determine quality and satisfaction with healthcare delivery?”, Health Care Management Review, Vol. 19 No. 4, pp. 49-55. Boulding, W., Karla, A., Staelin, R. and Zeithaml, V.A. (1993), “A dynamic process model of service quality: from expectations to behavioural intentions”, Journal of Marketing Research, Vol. 30 No. 1, pp. 7-27. Brown, S.W. and Swartz, T.A. (1989), “A gap analysis of professional service quality”, Journal of Marketing, Vol. 53 No. 4, pp. 92-8. Brown, T.J., Churchill, G.A. Jr. and Peter, J.P. (1993), “Improving the measurement of service quality”, Journal of Retailing, Vol. 69 No. 1, pp. 127-39. Carman, J.M. (1990), “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”, Journal of Retailing, Vol. 66, Spring, pp. 33-55. Central Statistics Office (2003), Housing and Population Census 2000, Ministry of Economic Development, Financial Services and Corporate Affairs, Port-Louis, April.

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Clancy, K.J. and Schulman, R.S. (1994), “Breaking the mold”, Sales and Marketing Management, pp. 82-4. Cronin, J.J. Jr. and Taylor, S.A. (1992), “Measuring service quality: a reexamination and extension”, Journal of Marketing, Vol. 56 No. 3, pp. 55-68. Dean, A.M. (1999), “The applicability of SERVQUAL in different health care environments”, Health Marketing Quarterly, Vol. 16 No. 3, pp. 1-15. Drain, M. (2001), “Quality improvement in primary care and the importance of patient perceptions”, Journal of Ambulatory Care Management, Vol. 14 No. 2, pp. 30-46. Gabott, M. and Hogg, G. (1994), “Uninformed choice”, Journal of Health Care Marketing, Vol. 14 No. 3, pp. 28-34. ¨ Gronroos, C. (1982), Strategic Management and Marketing in the Service Sector, Swedish School of Economic and Business Administration, Helsinki. Hair, J.F. Jr., Anderson, R.E., Tatham, R.L. and Black, W.C. (1999), Multivariate Data Analysis, 5th ed., Prentice Hall, Upper Saddle River, NJ. Haywood-Farmer, J. and Stuart, F. (1988), “Measuring the quality of professional services”, in Johnston, R. (Ed.), The Management of Service Operations, Proceedings of the Third Annual International Conference of the UK Operations Management Association, University of Warwick, Coventry. Hellier, P.K., Geursen, G.M., Carr, R.A. and Rickard, J.A. (2003), “Customer repurchase intention – a general structural equation model”, European Journal of Marketing, Vol. 37 Nos 11/12, pp. 1762-800. Kilbourne, W.E., Duffy, J.A., Duffy, M. and Giarchi, G. (2004), “The applicability of SERVQUAL in cross-national measurements of health care quality”, Journal of Services Marketing, Vol. 18 No. 7, pp. 524-33. Kinnear, T.C. and Taylor, J.R. (1996), Marketing Research: An Applied Approach, 5th ed., Mc-Graw-Hill, New York, NY. Lam, S.K. (1997), “SERVQUAL: A tool for measuring patients’ opinions of hospital service quality in Hong Kong”, Total Quality Management, Vol. 8 No. 4, pp. 145-53. Lehtinen, U. and Lehtinen, J.R. (1982), “Service quality: a study of quality dimensions”, unpublished research report, Science Management Group, Helsinki. McDougall, G.H.G. and Levesque, T.J. (1994), “A revised view of service quality dimensions: an empirical investigation”, Journal of Professional Services Marketing, Vol. 11 No. 1, pp. 189-209. Ministry of Health and Quality of Life (2001), Ministry of Health and Quality of Life Health Statistics Annual, Ministry of Health and Quality of Life, Port Louis. Ministry of Health and Quality of Life (2002), Ministry of Health and Quality of Life White Paper on Health Sector Development and Reform, Ministry of Health and Quality of Life, Port-Louis. Morrison, M., Murphy, T. and Nalder, C. (2003), “Consumer preferences for general practitioner services”, Health Marketing Quarterly, Vol. 20 No. 3, pp. 3-19. Mowen, J.C., Licata, J.W. and McPhail, J. (1993), “Waiting in the emergency room: how to improve patient satisfaction”, Journal of Health Care Marketing, Vol. 13 No. 2, pp. 26-33. Olshavasky, R.W. (1985), “Perceived quality in consumer decision making: an integrated theoretical perspective”, in Jacoby, J. and Olson, J. (Eds), Perceived Quality, Lexington Books, Lexington, MA.

Parasuraman, A. (2000), “Superior customer service and marketing excellence: two sides of the same success coin”, Vikalpa, Vol. 25 No. 3, pp. 3-13. Parasuraman, A., Berry, L.L. and Zeithaml, V.A. (1991), “Refinement and reassessment of the SERVQUAL scale”, Journal of Retailing, Vol. 67 No. 4, pp. 420-50. Parasuraman, A., Berry, L.L. and Zeithaml, V.A. (1993), “More on improving service quality measurement”, Journal of Retailing, Vol. 69 No. 1, pp. 140-7. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), “A conceptual model of service quality and its implications for future research”, Journal of Marketing, Vol. 49, Fall, pp. 41-50. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), “SERVQUAL: A multi-item scale for measuring consumer perceptions of service quality”, Journal of Retailing, Vol. 64, Spring, pp. 21-40. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1994), “Alternative scales for measuring service quality: a comparative assessment based on psychometric and diagnostic criteria”, Journal of Retailing, Vol. 70 No. 3, pp. 201-30. Peyrot, M., Cooper, P. and Schnapf, D. (1993), “Consumer satisfaction and perceived quality of outpatient health services”, Journal of Health Care Marketing, Vol. 13 No. 1, pp. 24-33. Sommers, P.A. (1999), Consumer Satisfaction in Medical Practice, The Haworth Press, Binghamton, NY. Spreng, R.A. and Singh, A.K. (1993), “An empirical assessment of the SERVQUAL Scale and the relationship between service quality and satisfaction”, in Cravens, D.W. and Dickson, P. (Eds), Enhancing Knowledge Development in Marketing, Vol. 4, pp. 1-6. Sureshchandar, G.S., Rajendran, C. and Anantharaman, R.N. (2002), “Determinants of customer-perceived service quality: a confirmatory factor analysis approach”, Journal of Services Marketing, Vol. 16 No. 1, pp. 9-34. Tabachnick, B.G. and Fidell, L.S. (1989), Using Multivariate Statistics, 2nd ed., Harper Collins Publishers Inc., New York, NY. Taylor, S. (1994a), “Waiting for service: the relationship between delays and evaluations of service”, Journal of Marketing, Vol. 58 No. 2, pp. 56-69. Taylor, S.A. (1994b), “Distinguishing service quality from patient satisfaction in developing health care marketing strategies”, Hospital and Health Services Administration, Vol. 39 No. 2, pp. 221-36. Teas, R.K. (1993a), “Consumer expectations and the measurement of perceived service quality”, Journal of Professional Services Marketing, Vol. 57 No. 4, pp. 18-24. Teas, R.K. (1993b), “Expectations, performance, evaluation and consumers’ perceptions of quality”, Journal of Marketing, Vol. 57, pp. 18-34. Teas, R.K. and DeCarlo, T.E. (2004), “An examination and extension of the zone-of-tolerance model- a comparison to performance-based models of perceived quality”, Journal of Service Research, Vol. 6 No. 3, pp. 272-86. Turner, P.D. and Pol, L.G. (1995), “Beyond patient satisfaction”, Journal of Health Care Marketing, Vol. 15 No. 3, pp. 45-53. Walker, J. and Baker, J. (2000), “An exploratory study of a multi-expectation framework for services”, Journal of Services Marketing, Vol. 14 No. 5, pp. 411-31. Zeithaml, V.A. (1988), “Consumer perceptions of price, quality and value: a means-end model and synthesis of evidence”, Journal of Marketing, Vol. 52, July, pp. 2-22. Zeithaml, V.A. and Bitner, M.J. (2000), Services Marketing: Integrating Customer Focus Across the Firm, 2nd ed., McGraw-Hill, New York, NY.

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V.L. A. A. and Parasuraman. Berry. Parasuraman. L. 1. 60. The Free Press. Vol. pp. NY.. Journal of Marketing. 21 No. pp. (1993).emeraldinsight. A.A. Further reading Zeithaml. (1996).com Or visit our web site for further details: www. 31-46. V. 21.. and Berry. Corresponding author Rooma Roshnee Ramsaran-Fowdar can be contacted at: rooma@uom. 1-12. Zeithaml. L.. and Parasuraman. “The behavioural consequences of service quality”. Journal of the Academy of Marketing Science.1 . New York. “The nature and determinants of customer expectations of service”. Berry.A. Delivering Quality Service: Balancing Customer Perceptions and Expectations. (1990).mu 124 To purchase reprints of this article please e-mail: reprints@emeraldinsight. Vol. L.L.

Until now. a committee that is responsible for world-wide humanitarian policy and consists of heads of relevant UN and other intergovernmental agencies. Sri Lanka and Sudan among many others involve substantial psychological and social suffering in the short term. The guidelines have been developed by staff from 27 agencies through a highly participatory process. “These new IASC guidelines are a significant step towards providing better care and support to people in disaster. most individuals have been shown to be remarkably resilient. While this is increasingly recognised.News and views Edited by Jo Lamb-White News and views World Health Organization New guidelines to improve psychological and social assistance in emergencies Keywords Human rights. The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings clearly state that protecting and promoting mental health and psychosocial well-being is the responsibility of all humanitarian agencies and workers. Effective healthcare outcomes i International humanitarian agencies have agreed on a new set of guidelines to address the mental health and psychosocial needs of survivors as part of the response to conflict or disaster. Red Cross and Red Crescent agencies. when communities and services provide protection and support. These can threaten peace. The guidelines address this gap. Community healthcare. They identify useful practices and flag potentially harmful ones. The guidelines have been published by the IASC. many actors identified the need for a coherent. Assistant Director-General for Health Action in Crises at the World Health Organization. the consortium of USA-based international NGOs. Indonesia. Vice President for Humanitarian Policy and Practice of InterAction. said Dr Ala Alwan. people’s human rights and development.and conflict-affected areas worldwide”. and clarify how different approaches complement one another. and NGO consortia. Recent conflicts and natural disasters in Afghanistan. “Drafting the guidelines has been a joint effort of a broad range of key actors in the diverse sectors of humanitarian aid and we are happy to see the synergy and commitment”. . Yet. systematic approach that can be applied in large emergencies. which if not adequately addressed can lead to long-term mental health and psychosocial problems. many people involved in emergency response have viewed mental health and psychosocial well-being as the sole responsibility of psychiatrists and psychologists. The guidelines lay out the essential first steps in protecting or promoting people’s mental health and psychosocial well-being in the midst of emergencies. said Mr Jim Bishop.

Healthcare improvement The European Society for Medical Oncology (ESMO) is proud to announce that it is collaborating closely with the Portuguese EU Presidency on a key European meeting on health care issues. ESMO . Affected populations can be overwhelmed by outsiders.IJHCQA 21. The guidelines have a clear focus on social interventions and supports. The guidelines include attention to protection and care of people with severe mental disorders. For further information: www.” “These guidelines now need to be transferred from paper into concrete action at the field level so that those affected by disasters and conflict will benefit from the work done on them. health workers. including severe trauma-induced disorders.” said Ms Manisha Thomas. acting Coordinator of the International Council of Voluntary Agencies. as well as access to psychological first aid for those in acute distress. Quality healthcare. They emphasize the importance of building on local resources such as teachers. focusing on the topic of health and migration. where cancer will be an important part of the agenda. healers.who. These guidelines give sensible advice on how to achieve that. Dr Bruce Eshaya-Chauvin. remarked: “Achieving improved psychosocial support for populations affected by crises requires coordinated action among all government and non-government and humanitarian actors. The guidelines stress that the way in which humanitarian aid is provided can have a substantial impact on people’s mental health and psychosocial well-being. Deputy Director. and local contributions to mental health and psychosocial support are easily marginalised or Europe Future oncology healthcare strategy on the agenda of the Portuguese EU council presidency Keywords Healthcare strategy.1 ii “The new guidelines present a major step forward to much better protect the mental health and psychosocial well-being of displaced persons using an integrated approach in collaboration with all partners” said Ms Ruvendrini Menikdiwela. Treating survivors with dignity and enabling them to participate in and organize emergency support is essential. and women’s groups to promote psychosocial well-being. NGOs can play a major role in this regard. Head of the Health and Care Department at the International Federation of Red Cross and Red Crescent Societies. They focus on strengthening social networks and building on existing ways community members deal with distress in their lives. The “Round Table on Health Strategies in the European Union” is one of the most important initiatives launched by the EU Portuguese Presidency within the context of the EU strategy on health policy. Division for International Protection Services at the Office of the United Nations High Commissioner of Refugees. Coordination of mental health and psychosocial support is difficult in large emergencies involving numerous agencies.

with prominent participation of Dr Marija Seljak. ESMO. ESMO President. The meeting will open with a welcome address by Professor Hakan Mellstedt. Director of the ESMO Political Office in Brussels. said Pascale Blaes. News and views iii . “It will certainly be complicated but is highly challenging”. including a comprehensive overall strategy. for the prevention and control of cancer. to be a key partner in this meeting for aspects related to cancer. Cancer is one of the major causes of disease. ESMO. health determinants. acknowledged Professor Mellstedt. as well as newcomers”. “The impact of this meeting will influence the future oncology healthcare strategy throughout the European Union”. we will be able to achieve the expected relevant outcome: survival. “The interactive format of the meeting. he said. . member of the MAC (Members of the European Parliament Against Cancer). Slovenian Public Health Director. “ESMO is proud to be associated with the Portuguese Presidency Workshop on Cancer and we are sure that it will contribute to the development of a framework for health benefits in Europe”. population-based cancer registries. the experts and the key forces gathering in Lisbon will call upon the European institutions to put cancer on the political agenda as a priority and will request the national governments to develop policies. Professor Mellstedt continued. “ESMO is convinced that it is time to send a strong political signal for a broad alliance and concerted actions for the benefit of patients in Europe and worldwide and considers this event a tangible means for the Portuguese Presidency in this direction”. and its connections with other specific and global issues under discussion. together with the Portuguese Presidency. a service that touches the lives of every single EU citizen. will stress the following instruments: . cancer remains a huge public health challenge and a tremendous threat.has been invited by Dr Joaquim Gouveia. “Only by sharing expertise and exchanging best practices in Europe. and Mr Alojz Peterle. said Professor Mellstedt. this Round Table will address crucial issues in terms of the EU health agenda. such as facing specific health problems. and by advocating together to get support and the appropriate political commitment. Appropriate tools will need to be identified for the proposed policies to be effectively implemented. The Round Table session on cancer will be chaired by Dr Joaquim Gouveia. “The selection of such topics reflects the importance politicians place on assuring best quality healthcare. morbidity and mortality worldwide. better quality of life. and . comprehensive cancer control plans consisting of a variety of activities and strategic approaches. “The Portuguese representatives. National Coordinator of Oncological Diseases in Portugal. Professor Mellstedt said. Although great scientific progress has been achieved in oncology and continues to be achieved. Under the broad theme of creating a “European Health Strategy”.” The common objective of the meeting will be to create capacity building for developing and implementing effective policies and programs. which are built on large coalitions and involve the necessary sectors. screening programs. As a main actor in the field. and patient satisfaction”. with a wide expertise. health services and patient mobility.

the leading independent provider of healthcare information. said: “There is considerable interest within the health service in the potential of PROMs – patient-reported outcome measures.medicalnewsblog. the charity which is a leading authority on capturing patient and staff feedback and using it to improve services. correlate activity performance data with patient health and patient experience. said: “This combination will provide a patient-focused picture of the quality and effectiveness of the service provided by a clinical specialty over time. “Patient Driven Quality”. the EQ5D patient-reported outcome measure compared to a major new normative database. By staging the measurements hospitals will be able to judge the impact of quality improvement measures through the litmus test of what difference they are making for patients. The new service. We intend to make PROMs directly useful to clinicians and managers in their efforts to gain continual quality improvement and to achieve the developmental standards in ‘Standards for Health’”.IJHCQA 21. target and evaluate quality improvement initiatives. Healthcare standards. Clinicians will be able to see how their own activity compares to the health outcomes reported by patients. Hospitals will be able to measure the three sets of indicators. external relationship manager at CHKS. is being developed jointly by CHKS. for the first time. over time. and what patients say about their experience of receiving that care and treatment. . business manager at the Picker Institute.” The data tools included are: CHKS’ admitted patient care data set. Quality improvement measures UK hospitals can now combine their clinical data with both patient-reported health outcomes and a measurement of patient experience.” ESMO will continue to support the Portuguese efforts to make this initiative a turning point in the fight against cancer in Europe and the first step towards the hoped for recognition by the national and European authorities of the recommendations agreed upon by the experts gathered together for this meeting. and the Picker Institute. For further information: www. Paul Robinson.1 iv will guarantee a high value contribution to the global debate on cancer and health in Europe. and bespoke patient experience questionnaires developed to national standards by the Picker Institute. . The combination of performance data. outcome data and patient experience data gives UK hospitals the ability to: .info/ UK Quality improvement: patient-reported outcomes and experiences now integrated with clinical data for the first time Keywords Patient feedback. and judge them against national benchmarks. applied to particular clinical specialties. Kay Usher.

Performance standards.. was “very clean” or “fairly clean”. More patients said they waited six months or less for planned admissions. Chief Executive of the Healthcare Commission. answering calls for v Patients give vote of confidence in overall care provided by NHS hospitals in largest national survey Keywords Patient satisfaction. . mixed-sex accommodation. . These include the standard of food. Just 2 per cent of patients said the overall care they received in hospital was “poor”. There was variation in how trusts scored on single-sex accommodation. Quality improvements Patients have given a vote of confidence in the overall care provided by NHS hospitals with nine out of ten people surveyed by the Healthcare Commission rating it as “excellent”. Of the patients who indicated that they needed help eating. There were 30 trusts where one in five. demonstrate efforts to meet standards for better health. the biggest test of the experiences of patients in NHS hospitals in England. The findings are from the Commission’s inpatient survey. these figures varied between 2 per cent and 42 per cent. And compared with the Commission’s previous inpatient survey in 2005. 80. 84 per cent in this survey compared with 78 per cent in 2005. The survey highlights include: . few patients rated the food as “poor” – just 2 per cent in one trust. patients rated the food as “poor”. The results also highlighted considerable variation in the performance of acute trusts on a range of issues relating to dignity in care. But in most other trusts. 11 per cent of patients nationally said they shared a room or bay with a patient of the opposite sex. This compares with 92 per cent in the 2005 survey. “very good” or “good”. and benchmark their own performance and reputation against the national data set. There were encouraging signs on cleanliness with 93 per cent of patients saying their room or ward. . Among trusts. Anna Walker.pickereurope.000 patients at 167 acute and specialist trusts responded to the survey. or more. coordinated on behalf of the Commission by the Picker Institute. In autumn 2006. 20 per cent said they did not get enough. Looking at planned admissions only and excluding those who stayed in critical care units. but we must never forget that most patients . more people responded positively to questions about cleanliness and efforts to control infection through handwashing. said: “We all hear a lot of negative comment about the NHS. . and assistance with eating. News and views For further information: www. .

which will form one of the Clinical Governance requirements. (1) Print. The NPA will have member support ready as soon as the announcement is made. It is also clear that for a significant minority of patients. When the requirement is introduced. “Patients have the right to expect all hospitals to get the basics right. to be published later in the year. PSNC and the Department of Health are deciding on the finer detail of the survey and an announcement is expected soon. trusts need to improve the patient’s journey through all parts of the hospital. For further information: www. “The results also suggest that we need a fresh drive to tackle a set of issues related to treating patients with dignity. but as yet there is no compulsion to conduct such a survey. As part of this. the NHS is performing below standards on segregated accommodation. Completion will therefore be mandatory. But. expertise and resource in-house to cope with a survey.” The Commission will feed the results of the inpatient survey into its annual assessment of NHS trusts. Options (1) and (2) would only be recommended if a contractor had the time. “Looking at waiting times. like offering help with eating and answering calls for assistance. (2) Print and implement your own survey and outsource the analysis of results and reports. where there are problems it seems as if there are a minority of trusts that are letting the rest down. which uses information to target inspections and ultimately leads to an annual performance rating. all contractors will be asked to complete an annual patient satisfaction survey.IJHCQA 21. it has inspected 23 trusts where performance data raised particular questions. There are likely to be two or three options available to contractors. evaluation and reporting of results. Continuous improvement Under the new community pharmacy contract in England and Wales. too many patients still say they wait a long time while being admitted. The independent watchdog is also preparing a national report on dignity in care for older people. Staff should remember this as it shows that patients value the good work they do. Patient satisfaction surveys made easy: Department of Health Keywords Clinical governance.1 vi have consistently rated the overall quality of their care as good or excellent. . There may be scope to reduce this by looking at delays in admissions units. For example. Results should be fed in to PCTs by the end of the financial year – therefore the first set will be due by March 2008. the National Pharmacy Association (NPA) will be offering its members three levels of support to match these options. (3) Outsource the print. implement and evaluate the survey yourself. from arrival at A&E to Patient experience.

. analyse and evaluate the results of the survey. The entire survey process. Results are returned to contractors within the next five days. The completed questionnaires will be analysed and the results fed back to the contractor. Ministers also hope it will lead to detailed data on clinical outcomes being published – to date only heart surgeons reveal performance statistics. (CFEP) UK Surveys. However. hospital ratings and general cleanliness. please contact us on r. A new web site is being launched in an attempt to strengthen patient choice. available in various languages. we are confident that the feedback members will gain from their patients will mean that they gain a high return on their investment. NPA Commercial Manager adds: “Patient surveys are completely new to community pharmacy so the NPA wants to ensure that the route members choose when carrying out a patient satisfaction survey suits their needs. The NPA has also commissioned CFEP to produce a resource pack to guide its members through the complex area of patient surveys. CRT simply delivers the device to the pharmacy and collects it two weeks later. We are confident that these three levels of service will provide every member with what they need to meet their obligations under the pharmacy contract.” Raina Jordan. This is a practical guide showing how to design. will be validated. NPA Commercial Director. including benchmarked data and patient comments will then be produced. The service includes the supply of an appropriate number of questionnaires. in-store materials to explain the survey to patients. implement. an independent company that specialises in producing patient feedback surveys for healthcare professionals. Simon Ellison. If you would like advice on which level of support may be best for your needs or to register your interest in readiness for the announcement. The £3. A high quality report of the results. Patient empowerment Patients are being given more choice over where they are treated. provides pharmacy contractors with a validated questionnaire which focuses on the five domains of patient experience as defined by the Department of”. says: “A resource pack will be available to members free of charge. It is aimed at helping patients choose where they want to be treated when they need non-emergency surgery.6m NHS Choices web site will include information on issues as varied as waiting times. Healthcare standards. we are aware that members may need different levels of support and the NPA is committed to providing services to meet those needs as precisely as possible. News and views vii NHS web site aims to boost choice Keywords Patient choice. from encouraging patients to complete the questionnaire to the analysis and actions arising from the results. sealable envelopes to ensure patient confidentiality. a ballot box.jordan@npa.The STANDpoint system from Customer Research Technologies conducts all the research electronically and provides speedy analysis More than that. pens and a large self-addressed envelope in which to return the completed questionnaires.

with the internet age resisting progress is fruitless. Primary Care Trusts (PCTs). It is publishing the plan in direct response to concerns from members and patients and in advance of a Department of Health Review of “urgent” care services. One of the problems with the internet is that some of the information about health is top quality and some of it is rubbish. which was already available via a Healthcare Commission web site. Health Secretary Patricia Hewitt said: “We know patients and the public are thirsty about getting information on health. The health secretary said: “We now have to do this with other procedures.1 viii Patients have been given a choice of where they can go to be treated for non-emergency treatment since last year. Healthcare assessment Doctors’ leaders have produced a ten point plan to help patients navigate their way through the “maze” of out-of-hours (OOH) services. patients are given a choice of at least four local hospitals and the top-performing foundation trusts. Service delivery. . While the RCGP recognises that good quality urgent care exists in some areas. The RCGP plan recognises the pivotal role of GPs and includes across-the-board recommendations for the Department of Health.” For further information: www.” Ms Hewitt is also hoping the web site will push doctors into releasing information about the results of treatment. GP practices and health organisations to improve urgent care services for patients. of highly variable quality and that urgent action is needed to restore confidence in out-of-hours Signposting the way to better out of hours services for patients Keywords Healthcare information. Other specialities have been reluctant to follow suit because of concerns over case mixes – the most experienced surgeons and doctors tend to take on the most difficult cases and therefore crude data could suggest they have the worst outcomes. . At the moment. It has detailed information on 40 of the most common diseases and also uses data compiled by the Healthcare Commission on hospital performance. Later in the year people needing hip and knee operations will be able to choose from any hospital.nhs. And that will be extended to all specialities by April next year. The web site includes death rate data from individual heart units. The Royal College of General Practitioners says that services are confusing. including ratings and MRSA rates. fragmented. Patients – and doctors – say out of hours services have been a cause of confusion since 2004 when the new GMS contract was introduced and PCTs took over responsibility for commissioning out of hours care in England. The multi-media web site has sections giving advice on healthy lifestyles and also allows users to carry out an online health check. “What NHS Choices will do is give the public access to the best information about health. it highlights a clear need for better signposting as patients are often unable to determine .IJHCQA 21.

It has also identified concerns about variation in quality of out of hours services. they should champion optimal levels of urgent care for their patients and practices must have systems in place for alerting urgent care providers to patients with complex healthcare needs. the RCGP will shortly launch a national Out of Hours Clinical Audit Toolkit. walk-in centres and minor injury units to foster integration and co-ordination of care between providers. Athough no longer contractually responsible for out of hours work. emphasising the necessity for high clinical standards. PCTs must make efforts to engage and involve GPs in out of hours care: some PCTs have already managed to do this effectively. The action plan calls for: (1) Care to be configured around the needs of patients with better signposting for access.the most appropriate service to access. a practising GP in Leicester. which will enable PCTs to monitor clinical outcomes. To address this.” The RCGP ten point action plan recommends that services are designed around the clinical needs of patients who should expect to receive a consistent and rigorous assessment of their needs and an appropriate and prompt response to that need – regardless of who is administering their care. and training opportunities in urgent care for GP Registrars. (7) The Department of Health to make urgent care a priority and set a clear national strategy. and to kickstart action in improving urgent care services. (10) Primary care educators to ensure that the quality of urgent care training receives a high priority and establish a systematic approach to the training of News and views ix . planning and support for urgent care and out of hours services. (6) Stronger multidisciplinary urgent care teams whose members have been trained to nationally agreed standards. (4) Quality standards including clinical outcomes to be monitored and enforce. (5) Engagement with local GPs and recognition of their key role in leadership.” “Nonetheless we acknowledge that this has been a difficult issue for the profession and that many GPs agonised over their decision to opt out of 24 hour contractual responsibility. RCGP Chairman Professor Mayur Lakhani. said: “We are concerned that GPs are being blamed unfairly for the state of out-of-hours services when the responsibility for commissioning and providing OOH services resides with primary care trusts and not GPs. GPs are still involved in OOH rotas and a large proportion of OOH is still provided by GP co-operatives. (3) PCTs to develop Urgent Care Networks comprising GP practices. (2) All GP practices to have a system for responding to and dealing with urgent care during surgery hours. (8) Emergency care practitioners to be trained to a defined national standard including an assessment of competence. (9) The Healthcare Commission to ensure that the quality and safety of urgent care is monitored and to make recommendations for improvement based on their findings.

and this plan will go a long way towards demystifying the maze that currently exists. but it is also turning out to be a Godsend to hospital administrative staff who seek to strengthen the position of their hospitals for the upcoming publication of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey results in 2007. Professor Lakhani said: “A step change in policy is needed. “We are aware of excellent service provision in some areas but also have significant concerns about fragmentation of care and a lack of signposting to services.1 GP Registrars.” For further information: www. Financial management. says Laura Fortin. “The majority of care is still provided by GPs. hospitals can improve survey responses. Urgent care competencies should also be incorporated within GP appraisal and CPD.” Ailsa Donnelly. Chair of the RCGP Patient Partnership Group. said: “Patients are very confused and bewildered about which services may be available to them outside GP surgery appointments. Such high-percentile marks can help increase census counts and ultimately the financial position of the hospital as patients patronise those facilities that they perceive to provide the best care. We urge that PCTs be held to account for the quality of their out of hours services. Clear signposting to appropriate care is essential. Healthcare environment The Hospital Consumer Assessment of Healthcare Providers and Systems survey shows better management of environmental services yields improved patient satisfaction with the hospital experience Cleanliness may be next to Godliness. Through an increased reliance on management companies who provide environmental services (EVS) to help enhance the patient experience. Chief Nursing Officer and . but we see HCAHPS as an opportunity”. It is imperative that primary care providers work together to address these problems – access to good quality urgent care should be the preserve of all. it is important that GPs have a strong influence on urgent care. Being ill in the middle of night is frightening experience and patients need to be sure the NHS will be there for them. As the proven experts in providing urgent x Americas Outsourcing improves patient satisfaction Keywords Patient experience. not the lucky few. Any attempt to downgrade the role of GPs will lead to further diminution of quality and put pressure on other parts of the NHS. “Everyone has struggled with patient satisfaction and the surveys in general.medicalnewstoday.IJHCQA 21. Some PCTs have managed to get it right so why not others? “The Out of Hours Toolkit will help to ensure that the spotlight remains on high standards of patient care – measurement of clinical quality is essential.

News and views xi . Any hospital that wishes to remain in the running must act now to position itself as a leader among survey respondents.” The challenge of improving EVS Coupled with the typically low retention rate of EVS employees and hospitals traditionally lacking systematised processes for this department.Chief Operating Officer at the 1. “There are studies out there that show a definite correlation between patient satisfaction and your bottom line. administrators at some hospitals are increasingly turning to management companies and consultants who. “I believe each facility is unique. and upping the “cleanliness” factor is an effective means of enhancing the perception of competency.” Composed of 27 items that encompass critical aspects of the hospital experience – such as the responsiveness of hospital staff. McKee is part of the Phoenix.USA. “EVS is an important part of the patient’s experience in the hospital”. Colorado. and cleanliness of the hospitalthe HCAHPS survey provides a standardised instrument and data collection methodology for measuring patients’ perspectives on hospital care. “Patients can definitely assess how clean their room is. states St Joseph’s Fortin. so housekeeping definitely has a role”. and EVS plays a key role in patient satisfaction. In response. an increasingly astute patient population will be able to make direct comparisons between competing acute care facilities and subsequently exercise their influence in selecting the facility that will render services to them. Celebrating its 30th birthday. At that point. uncertainty and a feeling of scepticism about the people and services being provided. which encompasses 20 hospitals and other facilities that offer an array of medical services. so we work really well together”. by virtue of the fact that they specialise only in healthcare EVS. Typically. “Clean areas invoke a sense of confidence and a positive feeling about the people and services.2 million ft2 St Joseph Medical Center in Houston. accomplishing gains in EVS often proves elusive. and how nice the person was who cleaned their room – these are things they can easily quantify on a survey. Medi-Dyn is a privately held corporation providing environmental and laundry management services exclusively to the healthcare industry. a contract management firm like Medi-Dyn will offer a range of services so that administrators can tailor the available services to fit the needs of their particular facility. Founded in 1979 and based in Englewood. Texas. and management has to seek out what is best for their operation”. many administrators and operating officers are opting for quick solutions. “It made sense for us to go with Medi-Dyn because we share a similar vision and value system with them. Arizona-based Banner Health organization. can transform that facet of hospital operations into a high-scoring asset when surveys get filled out. Assistant Administrator at McKee Medical Center in Loveland. Colorado. agrees Marilyn Schock. comments Fortin. continues Schock. Given such a short timeline. St Joseph was one hospital who chose this route. “Cleanliness is an important part of the healing and caring environment”. quietness. EVS plays a crucial role in meeting the patient’s expectations of excellent patient care. Dirty places tend to trigger a sense of doubt.

says Fortin. Texas. In other situations. “We only utilise Medi-Dyn for its management services – the employees are our own but they report directly to the Medi-Dyn manager”. At the McKee Medical Center. administrative reporting procedures and financial accountability. really believes in this and understands what we are trying to accomplish within our EVS department. This allows hospital administration to concentrate on other facets of patient care and improving the facility’s ratings. so effective training in meeting patients’ expectations must extend to all levels of the department. maintaining EVS as the hospital’s top-scoring department. That was up from the 70th percentile on courtesy and the 65th percentile on cleanliness when Medi-Dyn began the contract in June 2003. notes Schock. When EVS “shines”.” “Medi-Dyn’s expertise combined with our culture of excellence ensures a seamless teamwork approach. you can’t fail”. physician questionnaires. is phenomenal. “We started a competition between departments: nursing competes against each other on scores each month. “and housekeeping has blown all other departments off the map. is the fact that it can yield a return on investment that is often superior to managing the department from within. . When you have that. for example. Other hospitals that chose the same option as St Joseph and McKee include Memorial Hermann Hospital in The Woodlands. One of the lesser-known benefits of turning to an EVS management expert to help enhance HCAHPS results. and its managerial staff from eight to four. Bill Walles.1 xii In a management-only structure. so they are doing something right”. the level of quality can consistently improve over time. Fortin reiterates. one particular hospital reduced its full-time-equivalent EVS staff from 72 to 46. “The Medi-Dyn Director here. department head inspections.000 per year while improving quality of service. so do HCAHPS surveys Early positive returns on patient surveys from hospitals that rely on EVS management experts prove hard to ignore.” “In the selection of any vendor. the key is to get the right management person”. and. it is the EVS worker who frequently comes into direct contact with patients. as well as ancillary departments”. Under the guidance of Medi-Dyn. EVS staff represents a tough population for retention. where more than 99 percent of patient responses have ranked EVS services as good or excellent since 2001. Natchez Community Hospital in Mississippi. both managers and all direct labor staff are employed by the contractor under a full-service option. Intermediate levels of integration also exist. Gains in EVS management can even possibly influence capital outcomes. where patient satisfaction scores for EVS are consistently above the 95th percentile. Through such feedback mechanisms as: patient interviews.IJHCQA 21. The attainment of such successes hinges on proven quality control systems. “Typically. Press Ganey scores in third quarter of 2006 for “courtesy” and “cleanliness” were in the 99th percentile. At the same time. the contractor provides the on-site management needed to effectively lead daily operations. He is very involved in patient satisfaction. exposing new hires to our goal of improving the patient experience. saving over US$350.

As of August 2006. North Carolina based healthcare services company that owns and operates general acute care hospitals in partnership with leading physicians throughout the USA. and the ‘face’ that you want to put out there is one of cleanliness”. agrees Schock. recalls Fortin. a Charlotte. does not end with just good ‘H-caps’ scores. “The cleanliness definitely affected their overall impression of our facility”. but the customer-service gains you achieve. For further information: www. St Joseph’s became a part of Hospital Partners of America. “Perception is everything. “EVS plays a key role in how your hospital is rated. it improves the possibility a patient will return or recommend your services”.healthservicetalk.“When our hospital was up for sale. every person that came in that was interested in buying the hospital could not believe how clean it was”.coml News and views xiii .

Facilities. A. F. Horne. and meets a growing demand for educational approaches that address the perspectives of patients and carers. McAndrew. J. Patients as teachers: utilising patients in classroom teaching. Hepworth. A long term affair. Contents include: . Nursing. McAndrew. or in the training of health care practitioners. student-centred learning in community and primary care nursing. H. Professional education Current health policy places an emphasis on the greater involvement of health service users and carers in all aspects of their care. . Using patients’ experiences in medical education: first steps in inter-professional training?. Simpson. xiv Using Patient Experience in Nurse Education Edited by Tony Warne and Susan McAndrew Palgrave Macmillan ISBN 9781403934017 Keywords Healthcare policy. Healthcare improvement.i. Warne. Beyond the tick box: providing a strategic direction to patient involvement in education. these are not reviews of titles given. carers. Stronach . This book fills that gap. Samociuk and S. education and professionalisation in a contemporary context. They are descriptions of the books. McGregor. E. . Looking back. Patient-centred. . E. D. based on information provided by the publishers. P. S. G. Skidmore.1 Recent publications Please note that unless expressly stated. However. the focus is usually on “after the event” accounts . including planning. J. McAndrew. . Kilminster. Nursing policy paradoxes and education implications.e. Warne and S. A. Stark and I. . S. Bringing User Experience to Healthcare Improvement: The Concepts. There is little patient involvement in “before the event” experiences such as planning to meet health care needs. ISBN 13 9781846191763 Keywords Patient experience.stepping forward. Thislethwaite and B. . provision and evaluation. The person as a life expert: this is not a love song. Collins and S. Patient involvement. O’Neill. . . Ewart. Quality standards Experience Based Design (EBD) is a new way to bring about improvements in healthcare services by being user-focussed. Methods and Practices of Experience-based Design Paul Bate and Glenn Robert Radcliffe Oxford ISBN 10 1 84619 176 9.IJHCQA 21. Costello and M. Canham. S. J. healthcare professionals. when individuals have become consumers of health care services. Morris.

. This is a must for all health care staff. methods and practices of EBD. The intellectual roots of experience design. particularly directors of service improvement in hospitals and directors of nursing. Practices: The ‘how of experience-based design: a case study for practitioners Evaluating patient experience and experience-based design (and a brief word about patient satisfaction surveys. . Patient satisfaction In today’s health care environment. Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty explains why understanding and meeting patient expectations is not only nice to know. Patient groups and national organisations. . “Can you imagine what it would be like if we moved from a health service that does things to and for its patients to one which is patient-led? Where the service has been specifically designed by patients and staff together so that it provides the best experiences you could hope for. Bringing the user experience to health care. Experience-based design: tools for diagnosis and intervention. So what’s different? . Methods: becoming a disciple of experience. It will be of great interest to health and social care management. Contents include: . Through anecdotes and real-life examples from practicing physicians. you will learn . it’s need to know! It gives you action steps in all areas of the practice. too will find the book and friends are all involved in the patient experience and systems and policies need to adapt to take this into consideration. . . It offers recommendations for the future and many interesting points for discussion. . . Recent publications xv Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty Anne-Marie Nelson Jones & Bartlett ISBN 0834209225 Keywords Healthcare evaluation. this exciting guide offers a unique approach to healthcare customer satisfaction. having satisfied patients just is not enough you are now being judged by payers and compared to other providers.” Lynne Maher. This compelling book illustrates a new approach to redesigning health systems so that they truly meet the needs of patients and staff. . Future directions for experience-based design and user-centred improvement and innovation. Concepts: a quiet revolution in design. health and social care policy makers and shapers.). patient satisfaction is a big part of that evaluation. the very people who are experiencing them. Patient expectations. By exploring the underlying concepts. Using stories and storytelling to reveal the users’-eye view of the landscape Patterns-based design: the concept of “design principles”. and quality improvement and organisational development specialists in healthcare.

.1 xvi how to develop higher patient satisfaction. Success is a team effort. . Eighteen ways to learn what patients want. Winning practices for loyal patients. How do you rate when you’re face to face with your patient? . For practice administrators and managers only: how to gain physician participation. How to earn raves from patients and payers. Want compliant patients? Communicate and educate. Making wrongs right. Lighting and leading the way. but patient expectations remain the same. . .IJHCQA 21. . . Create a schedule that satisfies everyone! . . a more productive and committed staff. Motivation: it takes more than a paycheck. . The telephone connection. The diversity imperative hits health care. Now is the time to create loyal patients and winning practices. Where does clinical quality fit in the picture? . . Some things change. . . Want to communicate better? Listen well. . Contents include: . and practical techniques to increase patient satisfaction in this updated edition. . . . more compliant patients. . Set standards for a great first and last impression. Empowerment? It’s just plain old trust! . Empower your patients with knowledge.

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