This action might not be possible to undo. Are you sure you want to continue?
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:
You can also search more than 175 additional Emerald journals in Emerald Management Xtra (www.emeraldinsight.com) See page following contents for full details of what your access includes.
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 ______________________________________
ingenta.www.com/ copyright Online publishing and archiving As well as current volumes of the journal.oclc.emeraldinsight. How to access this journal electronically To benefit from electronic access to this journal.emeraldinsight.com Web www.swetswise. For further details visit www. your institution will have instant access to all articles through the journal’s Table of Contents page at www. as soon as new material enters the database.com/ ijhcqa. E-mail an article Allows users to e-mail links to relevant and interesting articles to another computer for later use.org/firstsearch SilverLinker www. Access is available via IP authentication or username and password. electronic access to this title via Emerald Management Xtra.j-gate.com/0952-6862. simple system that needs only minimum administration. E-mail alert services These services allow you to be kept up to date with the latest additions to the journal via e-mail.informindia.htm As a subscriber to this journal.com/customercharter Tel +44 (0) 1274 785278 Fax +44 (0) 1274 785201 .com/connections Key features of Emerald electronic journals Automatic permission to make up to 25 copies of individual articles This facility can be used for training purposes.co. making your subscription more cost-effective.com Emerald Customer Support For customer support and technical help contact: E-mail support@emeraldinsight. clear and informative summaries of the content of the articles.minerva.in Ingenta www.com SwetsWise www.at OCLC FirstSearch www.com A set of login details will then be provided to you. However.ovid. please provide these details in your e-mail. Where possible. Once registration is completed. Key readings This feature provides abstracts of related articles chosen by the journal editor. Additional complimentary services available Your access includes a variety of features that add to the functionality and value of your journal subscription: Xtra resources and collections When you register your journal subscription online you will gain access to additional resources for Authors and Librarians. Non-article content Material in our journals such as product information.com is the recommended means of electronic access. as it provides fully searchable and value added access to the complete content of the journal. you can benefit from instant. This only applies to articles of which Emerald owns copyright.emeraldinsight. reference or printing purposes.emeraldinsight. Our web site www. Your access includes a variety of features that increase the value of your journal subscription.com/ijhcqa.emeraldinsight. company news. offering an opportunity for researchers to present their own work and find others to participate in future projects.com/training and take an Emerald online tour to help you get the most from your subscription. seminars etc. Choice of access Electronic access to this journal is available via a number of channels.com/alerts Emerald Research Connections An online meeting place for the world-wide research community. industry trends. course notes. you can also gain access to past volumes on the internet via Emerald Management Xtra. selected to provide readers with current awareness of interesting articles from other publications in the field. Further information about the services available can be found at www. our dedicated Research. Structured abstracts Emerald structured abstracts provide consistent. You can browse or search these databases for relevant articles. In addition. you can also access and search the article content of this journal through the following journal delivery services: EBSCOHost Electronic Journals Service ejournals. or simply share ideas.emeraldinsight. conferences. please contact support@emeraldinsight. case studies and interviews and you can also access Emerald Collections. offering key information and support to subscribers.emeraldinsight. etc. Our web site has been designed to provide you with a comprehensive.htm More information about the journal is also available at www.emeraldinsight.com Minerva Electronic Online Services www. this link is to the full text of the article.ebsco.com Informatics J-Gate www. management interviews and key readings. Emerald online training services Visit www.htm Our liberal institution-wide licence allows everyone within your institution to access your journal electronically. including book reviews. allowing faster evaluation of papers. Reference linking Direct links from the journal article references to abstracts of the most influential articles cited. is available online and can be accessed by users. Should you wish to access via IP. Register yourself or search our database of researchers at www. Teaching and Learning Zones provide specialist ‘‘How to guides’’.emeraldinsight.
Quality Management and Performance Measurement Research Unit. University of Leeds. Centre for Clinical Governance Research. 1. Saudi Arabia Dr Karen Norman Director of Nursing and Patient Servcies. Faculty of Medicine. Ireland Ellen J. University of Strathclyde. University of New South Wales. Quality and Customer Satisfaction. Czech Republic Professor Jeffrey Braithwaite Director. St Bernards Hospital. Universidad Complutense de Madrid. UK Ales Bourek National Board of Medical Standards. USA Professor Jiju Antony Strathclyde Institute for Operations Management. UK 4 Dr Syed Saad Andaleeb Professor and Program Chair. Allied Health Administration. University of Hawaii’i-West O’ahu. Sheffield Hallam University. Australia Ian Callanan Clinical Audit Co-ordinator. 2008 p. 4 # Emerald Group Publishing Limited 0952-6862 . School of Public Health. Belgium Dr Kristina L. Gibraltar Professor Dr Johannes Moeller University of Applied Sciences. Spain Dr Keng Boon Harold Tan Ministry of Health.IJHCQA 21. Faculty of Health Sciences. Hamburg. Bournemouth University and Director of Service Improvement. UK Professor Abdul Raouf Institute of Leadership and Management. Singapore Peter Wilcock Visiting Professor in Healthcare Improvement. Guo Associate Professor. Faculty of Economics and Business Administration. School of Healthcare. Hawaii International Journal of Health Care Quality Assurance Vol. AIAR. Germany Max Moullin Director. USA Paul Gemmel Professor. Healthcare and Services Management. Department of DMEM. Wellmark Blue Cross Blue Shield of Iowa and South Dakota. 21 No. Salisbury NHS Foundation Trust.1 EDITORIAL ADVISORY BOARD Dr Waleed Albedaiwi Quality Management Advisor and Director. Marketing Black School of Business. Penn State Erie. Gaucher Group Vice President Operations. UK Dr Udo Nabitz JellinekMentrum. Pakistan Ulises Ruiz Faculdad de Medicina. Ghent University. Sweden Helen Quinn Senior Lecturer/Academic Lead for Internationalism. King Saud Health Sciences University. St Vincent’s Hospital. The Netherlands Professor John Øvretveit The Nordic School of Public Health.
They used SERVQUAL – notably the instruments’ ﬁve dimension – to compare and contrast private and state hospital patient satisfaction. One particular sobering analysis for insurance-based healthcare managers and practitioners is the cost difference between: losing loyal patients. A unique feature in Ramsaran-Fowdar’s article is her needs and wants’ section. 1. and recruiting new ones. dissects and develops SERVQUAL. 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. patient satisfaction remains a popular author and reader topic. which usefully extends and develops Arasli et al. Similarly. 21 No. valid and reliable patient satisfaction measures for use in different settings. manuscript submissions and author downloads steadily increased in 2006-2007. Arasli and his colleagues offer fascinating insights into Cypriot patient expectation and satisfaction. He or she needs to stop smoking to preserve the remaining limb. processes and outcomes Two things prompted us to produce our second special issue this year. a patient needs a lower limb amputation owing to smoking-related peripheral vascular disease. First. Ramsaran-Fowdar too unpicks. The authors remind us that service quality is one of the most important drivers behind customer attraction. In short. 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. Long-in-the-tooth patient satisfaction researchers know this mineﬁeld well. retention and loyalty. The second private patient oriented manuscript emerges from Ramsaran-Fowdar’s Mauritian study. and introduce a middle “process” segment. and her ﬁndings reveal that seven not ﬁve SERVQUAL quality dimensions are needed for Mauritian private health services. readers will be surprised how Editorial 5 International Journal of Health Care Quality Assurance Vol. We wanted to address private and public patient satisfaction. It is harder. Wicks and Chin also concentrate on SERVQUAL but in USA outpatient surgery contexts. The resulting Cypriot health service strengths and weakness ﬁndings are likely to make managers and practitioners worried or proud. Consequently. Unexpected ﬁndings also materialise such as staff social skills’ importance in patient satisfaction. 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.Editorial Patient satisfaction structures.’s commentary. Second. 5-7 q Emerald Group Publishing Limited 0952-6862 . They concentrate on two existing SERVQUAL segments: expectations (or pre-process) and perceptions (or post process). First. That is. 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. 2008 pp. and we are fortunate to publish two private patient satisfaction-oriented studies. therefore. fascinating patient satisfaction issues emerge that are important for health service managers and practitioners. They also spend time carefully explaining methods for modifying existing. to satisfy the patient because he or she does not want this course of action. although it might not be thought possible that new patient satisfaction insights can emerge. Her detailed psychometric explorations relate to both general and private healthcare.
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. He concentrates on elderly patient and elderly care service stakeholder expectation and satisfaction.IJHCQA 21. government accreditation agencies’) and bottom-up (e. Clearly. In common with other authors in our special issue. Readers may not be surprised to learn that pessimistic and hostile patients are less likely to rate care higher. their starting point is SERVQUAL. processes and outcomes when statutory healthcare services are not up to the mark. patient satisfaction is a complex and multi-factorial healthcare outcome. Unusually. Because some patients completed the patient satisfaction questionnaire ten years after answering the MMPI. the authors concentrate on two enduring and stable personality characteristics – pessimism and hostility. combines Minnesota Multiphasic Personality Inventory (MMPI) and patient satisfaction data. Intriguingly. Leventhal uses a case study to illustrate his arguments. process and outcomes. Readers familiar with customer satisfaction literature know that health service researchers usually borrow from industry and commerce.300 patients that answered both questionnaires. elderly patients’ children) inﬂuences on face-to-face care become clear. Might it be possible that patient behavioural and emotional characteristics are equally if not more important satisfaction drivers? The Mayo study.. However. and readers will emphasise with the case study family. the top-down (e. the authors ﬁnish with arguments for modifying their patient satisfaction measure for non-health use. Moreover. Leventhal’s bitter-sweet article is a lesson to service providers. Their customer-provider framework and the way they dissect patient expectation and satisfaction are also useful.g. Moreover. they argue that these two behaviours are more tangible during patient-physician contact – another reason for concentrating on these two personalities. 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. Vinagre and Neves’ related project connects. Portuguese patient service expectation. their warnings about adopting of-the-shelf patient satisfaction studies without adjusting them to suit local culture are salutary. which they modify to ﬁt local culture. other stakeholder pressures cannot be ignored. Discussion around SERVQUAL’s history and development reinforces discussion elsewhere. It showcases poor service structures. Their premise is that we should not assume patient satisfaction or dissatisfaction (as healthcare outcomes) naturally follow healthcare structures and processes. In short. Speciﬁcally. the authors tie SERVQUAL data with a range of patient emotion scores from the Differential Emotional Scale II. The authors extracted almost 1.1 6 relatively unimportant empathy seems to be in the patients’ rankings. which is often used in consumer research but infrequently if hardly ever used in patient satisfaction studies. . 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 are just as likely to recommend a provider to family and friends.. among other things. However. a secondary analysis of archived information. a study we hope to publish later.g. satisfaction and emotions. 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. Readers should ﬁnd their method explanation and discussion educational. despite lower satisfaction scores.
completed an intriguing study and report. for example. 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. Debbi Long. Mallock. Like other articles here. Nevertheless. Referrer behaviour is tangibly observable but variations remain unexplained. the picture is complex since patient complaints in another database levelled in comparison. Another feature readers will notice in this issue is the range of countries included. Unperturbed. They concentrate on “internal customers” (fellow health service professionals) rather than “external customers” (patients). is worrying. comparing complaints and claims information shows that the true adverse event frequency may be underestimated. 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. the stakeholders and gatekeepers) with provider clinician (hospital core staff) service quality perceptions proved fascinating. Peter Nugus. is educational if not instrumental for improving service quality. 20 No. Joanne F. Stakeholder analyses are paramount therefore. 7) and it would pay to read their work in a patient safety context. for example. 21 No. published in the same issue. and despite the low “turn-out”. However. Mary T. Travaglia. Travaglia. Patient commendations are a strong theme in the article and interestingly. For example. 7 was authored by Jeffrey Braithwaite. For example. Merely benchmarking within and between countries and feeding back results. Christine Jorm and Marjorie Pawsey. Also. Debbi Long. What is known.e. Jonnson and Øvretveit’s work is groundbreaking in several ways. Westbrook. Christine Jorm and Rick A. one dataset shows incidents tripling in 25 years. Nadine A. Joanne F. the eight articles include helpful reference lists that should arm patient satisfaction researchers and writers with a valuable resource. In common with other articles in this special issue. important ﬁndings emerge. 20 No. geographically remote patients are less likely to recommend a service to family and friends. In short. Iedema. questionnaire surveys in this context are always on thin ice. readers will beneﬁt from the authors’ thorough and clear method section. provider clinicians have a strong positive image about their services.Jonnson and Øvretveit’s article could just as easily sit in our Patient Safety special issue (Vol. was authored by Mary T. however. Plainly. . they offer explanations and solutions to poor response rates. the implications for practitioners and managers are clear. Speciﬁcally. Finally. Jeffrey Braithwaite. Vol. Rowena Forsyth. clinician response rates are notoriously poor and unfortunately the authors were victims. attitudes and practice” published in Vol. the paper “Promoting safety: longer-term responses of three health professional groups to a safety improvement programme”. Comparing referring physician (i. while referrers’ perceptions are less upbeat. Rick Iedema. 1 materials’ range and depth makes it an essential text for the library shelf. The authors revisit information stored in three complaints and claims databases. Hensen and his German co-authors. Westbrook.
The Hong Kong Polytechnic University. Private hospitals. 21 No.The current issue and full text archive of this journal is available at www. Faculty of Business and Economics. and Salih Turan Katircioglu Department of Banking and Finance. 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. Kowloon. food and the physical environment. professionalism of staff. establish visible and transparent complaint procedures so that inpatients’ complaints can be addressed effectively and efﬁciently. 8-23 q Emerald Group Publishing Limited 0952-6862 DOI 10. Future studies should include the remaining regions in Cyprus in order to increase research ﬁndings’ generalizability. Additionally. Hong Kong. Keywords Customer services quality. Cyprus. These are: empathy. who have recently beneﬁted from hospital services in Famagusta. Turkey 8 Received 21 December 2005 Revised 13 April 2006 Accepted 1 June 2006 Erdogan Haktan Ekiz School of Hotel and Tourism Management.emeraldinsight. giving priority to the inpatients needs.1 Gearing service quality into public and private hospitals in small islands Empirical evidence from Cyprus Huseyin Arasli School of Tourism and Hospitality Management. Findings – This study identiﬁes six factors regarding the service quality as perceived in both public and private Northern Cyprus hospitals.com/0952-6862. New East Ocean Center. Famagusta – (North) Cyprus. 2008 pp. since job satisfaction leads to customer satisfaction and loyalty. hospital administrations need to gather systematic feedback from their inpatients. The instrument contained both service expectations and perceptions questions. Patients. There is considerable lack of literature with respect to service quality in public and private hospitals. including other dimensions such as hospital processes and discharge management and co-ordination may provide further insights into understanding inpatients’ perceptions and intentions. Eastern Mediterranean University. Design/method/approach – Randomly. were selected to answer a modiﬁed version of the SERVQUAL Instrument. 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. Hospitals.1108/09526860810841129 .htm IJHCQA 21. 454 respondents. Hospital managers should also satisfy their employees. Eastern Mediterranean University. relationships between staff and patients. 1. 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. 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. Public sector organizations Paper type Research paper International Journal of Health Care Quality Assurance Vol.
since their structure and functioning are different. have to deal with several service product characteristics such as intangibility. Labarere et al. health and so forth contributed 66. may enhance service quality of speciﬁc healthcare processes (Meehan et al. more attention should be given to the service quality improvement issues. a hospital. Uzun.4 and Private 3. Service quality. far superior to other organizations. Contrary to the above stereotyping in the literature. A strong link has been found in the literature between service quality. It is currently acknowledged that service quality measurement can be used to understand how well a service organization.. 2002). It is also assumed that those inpatients. 1995. understanding inpatients’ evaluations of their hospital service quality performance can help to improve existing health care system output in general and. Cronin and Taylor. could provide valuable feedback that serves to identify the variations in both types of organizations in terms of their service provision. education. The health care expenditures equated to 9. 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. 1990).3 percent of the world Gross Domestic Product (GDP) in the year 2000. 1996. 2004. Vandamme and Leunis. since the competition is unavoidable for them within the free market economic system. the authors could not come to any common conclusion on a conceptualization of service quality and customer satisfaction issues. Deﬁning service quality is complex and necessary for any measurement effort. This feedback could also be used in their overall service quality improvement effort in the industry. 1997) in the USA and European healthcare sectors. 2004). therefore. Yi. such as a clear ¨ deﬁnition of quality service or dimensionality (Gronroos. However. Hasin et al. high risks exist for the private hospitals whilst offering their services in a highly competitive environment dealing with human health. there is no scientiﬁc empirical evidence to indicate that public hospital staff attitude is the same as their private counterparts. as hospital service quality improves. State hospitals. simultaneously. 1985.. This might be true for the private institutions. competitive advantage and. 1990... has become the focus of considerable attention in respect of satisfying and retaining customers in the service industry (Spreng and MacKoy. at the same time. less attention has been paid to the comparative assessment of service quality in public and private hospitals. Tomes and Ng. It has also been claimed that. inpatient satisfaction and practitioner loyalty (Pakdil and Harwood. Reichheld and Sasser. 1990).e. which have experienced services from both hospitals over a speciﬁc period. has functioned in terms of outcomes like service quality over several years (Labarere et al. 2005. Although several scales have been developed and tested to measure service quality (Parasuraman et al. 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. many government hospitals are blamed and Service quality in public and private hospitals 9 . Therefore. like their counterparts. the number of satisﬁed inpatients and. therefore. Moreover. There has been a great deal of service quality assessment research conducted on different industries. However. inseparability and perishability. which involves sensitive decision making and extensive service provision in comparison to other services.. There is a generalization that service organizations. Kara et al. 1999). 2001.Introduction The share of services such as tourism.3 percent (Public 5. 1992. on the other hand. consequently. i. 2003). require a sustainable. Lim et al. 1993. including those in health care. heterogeneity.. however. hospitals. Within the fast developing health care industry. Valdivia and Crowe.9 percent) in the world GNP (World Development Indicators.. 2001. 2005. and the situational factors in different industries.
Speciﬁcally. 1995.IJHCQA 21. is two fold. 2005). the Doctors’ Coalition Minister. 2004. service quality. we can conclude from our personal observations. 1998. Arasli and Ahmadeva. Study context Healthcare services are carried out by both public and private institutions in Northern Cyprus. lack of medical equipment and instruments. their proposed model also provided indicators for overcoming these problems by employing a total quality management (TQM) approach. The foremost aim of this study. Poor service quality has been identiﬁed as a problem for many years. the health care challenges. Anderson. as well as the conceptual relationship between . Withanachchi et al. The contribution of this study to the relevant literature. therefore. and inpatient complaints. is to assess and compare service quality in the Northern Cyprus public and private hospital sector. complained about the inadequate number of personnel in the hospitals’ cleaning. highlighted additional problems such as institutions’ ﬁnancial incapability. 2005). Second. Jack and Phillips. medicine and facilities. The authors primarily stated that both the public and private hospital administrations have little or no concept of systematic data collection about inpatient needs. unprofessional personnel. Celal. 67. 1993). the former Minister of Health and Social Affairs. Gulle.. the Public Personnel Association Head. In other words. The present study’s ﬁndings may also provide hospital managers and government authorities with useful guidelines. corroborated by the above statement. predominantly in legislation. The majority (626 beds. disinterested staff and limited opportunities for patients to choose the doctors they want (Kibris Newspaper. The remaining institutions are also controlled by the government. 2005). They found that. claimed that the sector’s quality and standard are suffering from a lack of structure as well as from employing poorly qualiﬁed. Cyprus hospitals’ service quality using a public opinion survey. Whilst pinpointing service-quality problems. 2004). Arasli and Ahmadeva (2004) empirically measured. Arabacioglu. 2005. although private hospitals conditions are better than those of their public counterparts. Arasli and Ahmadeva. with which to develop some future strategies for the promotion of a quality health care service. 2002). that several ongoing quality problems exist in Northern Cyprus healthcare. 2004. 2003. He also stated that changing circumstances require an urgent major change. This introductory section provides a brief description of the service. Just one year later. Franck et al. 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.9 percent) belong to public hospitals (Arikan. For example. In a recent study. First. poor service quality and of low priority given to the inpatients’ needs. no empirical research exists to our knowledge on service quality. less is known about service quality differences between public and private hospitals (Jabnoun and Chaker. The current Minister of Health and Social Affairs. Caluda. kitchen and service sections (Kibris Newspaper. which has examined the service quality differences by collecting data from users of both types of hospital within a speciﬁed time period. Camilleri and O’Callaghan.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. 2004. for the ﬁrst time. then. long waiting lists... Furthermore. there are nine public and 52 private hospitals. both are still suffering from a degree of low quality equipment.
They found that the public hospital inpatients were more satisﬁed with service quality than their private hospital counterparts. 2004. inpatient satisfaction and recommendations and some background information about Northern Cyprus public and private hospitals. (4) assurance – the knowledge and courtesy of employees and their ability to inspire trust and conﬁdence. for example. Lam et al. 2003. The scale’s founders contended that whilst each service-producing industry is unique. tangibles. Originally. Boulding et al. Asubonteng et al. 1990). there are ﬁve common characteristics. credibility. 1992. health care. Literature review Parasuraman et al. 1991. Moreover. compared service quality practices between the private and public hospitals in the United Arab Emirates. such as tangibles. insurance. which included twenty-three items representing six dimensions (empathy. (2) reliability – ability to perform the promised service responsibly and accurately. many researchers and practitioners replicated. Jabnoun and Chaker (2003). After Parasuraman et al. Uzun. Sultan and Simpson. Sohail. security. 1993.. access. 1993. 2000. equipment and the presence of personnel. Babakus and Mangold. The seven-point Likert scale is used by some researchers while others use the ﬁve-point format. reliability. 2005. 1996. Carman. credit card services and car maintenance (Arasli et al. Gabbie and Neill. The main aim at that time was to develop general criteria for measuring service quality in various service organizations in different sectors. (1985) initially developed the SERVQUAL scale. level of administrative response and support skills).. Parasuraman et al. 1997. Half were aimed at measuring service user expectations and the remaining half measured perceptions. They originally identiﬁed ten service quality factors generic to the service industry. Through the use of a modiﬁed SERVQUAL scale. and (5) empathy – caring and understanding. 1992). the SERVQUAL scale contained 22 pairs of items. Coyle and Dale. banks. 2005.service quality. 1996. 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. responsiveness. competence. Parasuraman et al. Kilbourne et al. which used the SERVQUAL scale speciﬁcally in the public and private health care industry. (1988). 1994. 1995. communication and a willingness to understand the customer.. tourism. communications.. Lam and Zhang. Lim and Tang (2000) attempted to determine the expectations Service quality in public and private hospitals 11 . developed an instrument and validated it across various service environments. which a company provides and/or offers its customers in terms of its individualized and personalized attention (Parasuraman et al. Fick and Ritchie. (1988) replaced the former version of the service quality measurement. developed and integrated these reformed scales into the various service industry sectors (Pakdil and Harwood. such as higher education. 1999. courtesy... At a later stage. Thus there are a limited number of studies. 1988). Babakus and Boller. which could be applicable to service organizations: (1) tangibility – facilities. 1999. dentistry. Mehta et al. 2001.. Nelson and Nelson. reliability.. which enjoy greater government patronage and funding. (3) responsiveness – willingness to provide help and a prompt service to customers.
In total. empathy.IJHCQA 21. In order to collect quantitative data for the study. 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. Private Hospitals are no more successful than public hospitals in providing health care services for inpatients. as well as their effectiveness in meeting the expectation of their inpatients. assurance. a total of 650 questionnaires were printed and distributed to respondents. accessibility and affordability dimensions. Sample There is one public and 12 private hospitals that include large-scale clinics in which surgery is carried out.8 percent – a percentage we deemed acceptable. with 25 items representing ﬁve aspects of service quality (responsiveness. Finally. A modiﬁed SERVQUAL scale. Both public and private hospitals do not meet inpatients’ expectations. H3b. H1b. H2b. H2a. assuming that errors of judgment in the selection will tend to counterbalance one another”. Private hospitals are more successful than public hospitals in providing health care services for inpatients. 2005). H3a.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. Andaleeb (2000) compared the quality of services provided by private and public hospitals in urban Bangladesh. 454 four usable responses were obtained for a response rate of 69. There is no difference between public and private hospitals concerning their service quality. . Analysis covering 252 inpatients revealed that there was an overall service quality gap between in-patients’ expectations and their perceptions. (1991. The total bed capacity in these hospitals is 294 of which 180 are public and 114 are private (Kobat. 136) deﬁned judgmental sampling or purposive sampling as “picking cases that are judged to be typical of the population in which we are interested. There is a difference between public and private hospitals concerning their service quality. communication. responsiveness. Results also indicated that both groups have room for improvement. Method We primarily develop and test a modiﬁed SERVQUAL scale for public and private hospitals in Northern Cyprus. An analysis covering 216 inpatients revealed that private hospitals provide better services than public hospitals in respect of service quality. discipline and baksheesh (devotion or dedication)). assurance. Based on the above discussion and arguments. We also aim to compare both types of hospitals’ service quality. reliability. p. 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. Judd et al. Both public and private hospitals meet inpatients’ expectations. Improvements were required across all six dimensions. we hypothesize that: H1a.
Jabnoun and Chaker (2003). other dimensions may be added and adopted. The reliability of the scale was tested using Cronbach’s alpha. It is important to note. (1998).2 percent) were married and although occupations were widely dispersed. This was individually distributed to 15 families in the Famagusta district. Expectation scores The mean expectation scores were high when compared to the perception scores – ranging from 3. Results Table I demonstrates respondents’ demographic breakdown. 1978). 2004. (6) physical environment (nine items). (4) professionalism of staff (ﬁve items).Measures A questionnaire was developed based on the studies of Parasuraman et al. in the future studies. which I had asked for was given to me” (mean 3.6 percent) and professionals (14. This low expectation level may be the result of previous experience or negative word of mouth Service quality in public and private hospitals 13 .1 percent). 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).2 to 5.914 was achieved indicating a good internal consistency for the forty-eight item scale. housewives (15. The majority (57. however. Arasli and Ahmadeva. the results of explanatory factor analysis showed that all factor loadings were above the recommended cut-off value of 0. (3) giving priority to inpatient’s needs (eight items).46 for the private hospitals. (5) food (six items). The lowest public hospital expectation score was obtained from question 44: “the food. Responses to all items were elicited on a seven-point Likert scale ranging from 1 ¼ strongly disagree to 7 ¼ strongly agree. (2) relationships (nine items). 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. and ﬁnally. The quantitative survey was produced based on a synthesis of the literature we studied. More than 64 percent of the respondents were between the ages of 38-57 who were almost equally distributed in terms of their gender. which showed that dimensions like food and the physical environment were often studied.5 (Nunnally. However.0 for Windows was used to analyze our data. A survey instrument of 48 components was used in order to measure Famagusta hospital service quality.32 for the public hospitals and from 4. Analysis The SPSS 12. A high alpha value of 0. the popular ones were: agriculture/animal related (27. Lim and Tang (2000) and Andaleeb (2000). that these dimensions may not represent all service quality aspects.2). if required.19 to 6. Approximately 71 percent had either high school or vocational school education.1 percent). There were six dimensions in the present study: (1) empathy (ten items). Moreover.
9 37.9 5. had disappointing experiences with the quality of food or the limited choice of food.32).5 3.0 9.0 2.2 39.7 28.5.4 13. this is not signiﬁcantly lower than other items in the questionnaire.1 5.4 49.2 100.2 454 260 179 15 454 64 27 45 23 25 5 123 61 71 10 454 % 10.0 50. 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” (4.0 14.4 10.5 1.IJHCQA 21. The highest public hospital expectation score was statement 12: “doctors were capable of performing tests and procedures on me” (5.6 2.0 13.3 34. thus it can be evaluated as a high expectation score.7 33.19).4 3.4 15. This high . perhaps. 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 9.1 6.7 100. However.1 13.0 14 Table I.0 57. it is slightly above 3. Sample demographics communication from family members or friends who.1 27.4 100.8 100. Although question 5 has the lowest expectation score.6 100.
15 0.77 3.08 0.02 0.14 0.780 3.12 5.782 5.48 0.824 3.93 4.Statements Variance exp: ¼ 22:0%/a ¼ 0:92 0.792 5.95 3.821 4.700 4.41 0. I had enough conﬁdence in my doctor to discuss my very personal matters 0.97 5.774 0.06 0.82 0.07 Variance exp: ¼ 21:9%/a ¼ 0:87 0.21 4.32 5.20 0. Doctors made me feel comfortable even when they were not really successful in treating me 3.748 4.741 0.27 0.16 4.17 0.819 4. Factor loadings.91 4. My personal concerns were of utmost importance for the hospital 23. I was taken care of as an individual not like a customer 12.08 0.75 3.809 5.04 5. Doctors took care of me as soon as I arrived on the ward 4.70 3.802 3.43 -0.08 0. In hospital.04 0. In hospital.15 5.27 0.80 0.769 0.73 3. Gap FL Gap Private hospital Exp.708 0.64 0.723 5.08 0. expectations.21 5. Empathy 15. I had complete trust in my doctor 30.33 0.19 0. perception and gap scores in public and private hospitals .80 0.727 0.747 0. Nurses were polite while speaking with me and my family 27.11 4.786 0.704 0.17 0.34 0.12 -0.55 0. Per. I was presented with choices when doctors were deciding about my medical treatment 33.57 0.05 3.17 0.24 0.795 4.22 0.780 0. Per.07 0.92 5.28 0.79 0. Whenever I asked for help.74 0.04 0.92 0.44 0. the nurses did not pay attention (R) 16.748 0.23 -0.74 0. Doctors were capable of performing tests and procedures on me 24.773 4.86 4.26 0.68 6.790 0.15 5.23 5.67 4.15 0.771 5.74 5.32 4.56 5.23 4.768 5. Doctors did their best to make me emotionally comfortable 14.41 5.74 0.00 3.09 (continued) 15 Service quality in public and private hospitals Table II.95 3. Doctors spent extra time with me to discuss my fears and concerns 18.11 0.89 5.779 0.82 3.752 5.27 5. Nurses talked to me in order to get to know me better in their “spare” time 32.56 0.12 0.34 5.21 3. I was treated with respect 19.17 0.32 4.17 0.89 3.91 3.762 5. Doctors spent enough time examining me 28.763 0.21 4.87 5.779 0.790 4.70 5. Doctors were courteous while speaking with me and my family 26.783 4.36 0.787 3.737 Variance exp: ¼ 12:0%/a ¼ 0:89 0.70 5.19 0.776 0. I was involved in the planning of medical treatment 25.13 0.727 5.48 5.09 0.16 3.76 3.05 FL Public hospital Exp. Doctors worked hard to prevent me from worrying 29.69 4.10 0.24 0.89 5.89 3. Doctors discussed after discharge medical issues with me Giving priority to inpatient’s needs 21.77 3.11 0.34 5.841 4.81 5.81 5.77 Variance exp: ¼ 40:7%/a ¼ 0:89 0.12 3.21 0.40 5.59 0.
87 5.83 3.721 3.784 0.03 4.819 4.17 4.71 3.98 5.1 .19 5.785 0. Gap Variance exp: ¼ 15:3%/a ¼ 0:84 5.16 -0. Per.19 0.23 0.94 4.13 0.69 4. The use of each procedure and test was explained to me before they were done 17.831 0.28 Professionalism of staff 9.810 Relationships 13.776 0. Doctors explained frankly to me the reasons for tests and procedures Variance exp: ¼ 20:7%/a ¼ 0:87 0.01 3.25 0.815 0.14 5.06 3.769 0.34 -0.99 3.29 0. The nurses were kind.12 5.58 5. Gap FL Private hospital Exp.763 0.11 0.09 0.34 5.820 0.783 0.11 0.39 0.10 6.13 0.818 0.87 4.14 5.07 Variance exp: ¼ 8:2%/a ¼ 0:93 0.03 0.20 0. a ¼ 0:91 0.22 3.07 0.21 4.09 3.89 5.46 5. Doctors carried out my tests completely and carefully 10. My doctor was interested in not only my illness but also me as a person 7. Doctors asked my permission before performing any test on me 31.48 0. Doctors spent extra effort to make sure that I understaood my condition and its treatment Table II.824 4. I had a clear understanding of my condition during my stay in hospital 2.15 0.19 0.94 4.65 0.775 0.20 0.745 0.86 3.45 4.06 0.79 4.24 4.60 3.12 0.01 3.02 5.750 0.12 0. Doctors gave me medical advise in a simple way that I can understand 11. The nurses asked my permission before performing any test on me 20. gentle and sympathetic at all times 6. I was treated with dignity and had adequate privacy during my treatment 1.38 0.774 0.12 4.03 0.25 5.16 Statements Variance exp: ¼ 9:3%.04 4.745 0. FL Public hospital Exp. Per.02 5.21 5. The nurses spent time with me to discuss my concerns about my condition 5.776 0.73 3.71 4.841 6.09 6.819 0.13 0.66 0.17 (continued) IJHCQA 21.02 4.29 0.90 5.79 4.745 0.16 0.731 0. Doctors talked to me frankly and politely 8.90 4.82 0.98 5.90 5.714 0.97 0.58 3.97 5. The ward rules and regulations were explained to me 22.803 5.821 4.12 0.90 0.767 5.
05 0.66 0.754 4.20 0.88 5.09 3. The ward was clean at all times 37.46 0.03 0.856 3.28 0.09 3.18 0.768 5.34 0. 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.58 3.89 0.20 3.91 6. The ward was well furnished and decorated 39.67 0.03 0.815 5.94 0. There was adequate number of bathrooms and toilets in the ward 41. The ward was well ventilated 34.807 4.98 0.784 6.46 6.68 0.37 0.22 5.843 3.32 0.738 5.19 0.01 3.35 0.45 0. 46.14 0. The screens were drawn around my bed.82 4.10 0.21 0.84 0.782 4.52 3. while medical procedures and examinations were carried out Notes: Each item is measured on a seven point Likert scale.77 0. The bathrooms and toilets were always clean and pleasant to use 38.14 FL Public hospital Exp.13 Variance exp: ¼ 29:4%/a ¼ 0:93 0.61 5.25 0.09 0.Statements Variance exp: ¼ 15:9%/a ¼ 0:90 0.02 5.824 4.43 6.41 0.47 3.21 3.23 0. .12 3. Gap Food 45. Per.724 0.69 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 0.51 0.18 0.15 0.98 0.772 6.76 0.732 0.37 0. Inside the ward.861 4.87 5.24 0.87 4. 48.76 4.12 4.849 4.21 0.805 3.749 6.761 5.14 0.712 4.44 0. 43.49 Variance exp: ¼ 18:8%/a ¼ 0:94 0.22 4.17 5.72 6.64 3.817 0. Outside noises were kept to a minimum 42.861 4.17 0.37 0. Per. Gap FL Private hospital Exp.64 0.39 4.19 3.16 3.04 5.08 Physical environment 40.29 0.15 0. noises were kept at minimum level during night times 36.850 3.796 6. 47.719 5.818 0.717 5.16 3.869 4.14 0.831 4. 44.865 4.34 5.91 4.64 3.44 0. The beds.52 0. pillows and mattresses were comfortable enough 35.45 0.23 0.788 4.25 3.84 0.50 0.33 0.
but vital issue like the number of ward bathrooms and toilets. occurred in the food construct statements. still most expectations were not met in private hospitals.1 18 expectation level may be the result of a lack of trust in the doctors. it seems that people are dissatisﬁed with public hospital doctors’ competency level. The largest gap (0.12). The highest private hospital expectation score was related to: “the bathrooms and toilets were always clean and pleasant to users” (6. This item’s expectation score was again highest in public hospitals. food (15. there are differences between the two types of hospital services. and relationships (9 percent) important in the public hospitals.46). It was followed by gaps in ward cleanliness (0.64).28) and portion size (0.12 for the public hospitals and from 4. inpatients put their priorities differently in public hospitals as: food (33.7 percent).8 percent).4 percent). the inpatients consider professionalism (20. in which the lowest and the highest expectations are reported.7 percent variance in the private.” Like public hospitals all these gaps come under the physical environment construct. 27) explain: “Apart from the visits. Tomes and Ng (1995. Table II also shows that although the overall expectation levels were comparatively higher than public hospitals. none was met in public hospitals. The empathy dimension had the highest priority in both types of hospitals with 22 percent variance in public hospitals and 40. Gap scores Table II shows that although overall expectation levels were low.IJHCQA 21. therefore. All these gaps came under the physical environment construct. Therefore. The lowest perception score in public hospitals was obtained from statement 44: “the food which I had asked for was given to me” (3. ranging from 3. giving priority to patient needs (12 percent). This conﬁrms that private hospitals do not meet expectations about food. The highest expectation score in private hospitals was obtained from statement 41 “the bathrooms and toilets were always clean and pleasant to use” (6. physical environment (18. are rejected. while H3a is accepted.68) was observed in statement 38: “the beds. It seems that respondents are not satisﬁed with the public hospital food menu since both their expectation and perception mean scores were low. Giving priority to patience needs (21.37).37 for the private hospitals. interestingly. Perception scores The mean perception scores were lower compared to the expectation scores. showing that public hospitals are suffering from a lack of cleanliness and comfort.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” (4.12 to 6. physical environment (29. private investment encourages high expectations even on a simple. The largest gap (0.34) was observed in statement 44: “the food. .3 percent). therefore. Signiﬁcantly. about the only thing the inpatient can look forward to are meals to break the monotony.1 percent). The hypotheses H1a and H2a. Of course. and relationship (15.66) and bathrooms/toilets (0. Interestingly. The largest quality gaps. especially those in the public hospitals. which is a tangible quality factor. pillows and mattresses were comfortable enough”. both the lowest and the highest perceptions occurred in the same question. which I had asked for was given to me”.24).9 percent). Hence food becomes an important factor.9 percent). When we compared public and private hospital inpatients (Table II). which are the tangible quality factors. p.03 to 5. It was followed by the gaps related to food service (0.12). The highest perception score in public hospitals was obtained from the statement 12 “doctors were capable of performing tests and procedures on me” (5. However.
Possible reasons for this gap. Lim and Tang. academics and other related parties in the Northern Cyprus health services. Northern Cyprus hospitals suffer from a number of quality problems. and doctors did their best to make me emotionally comfortable (Q. relationships between staff and patients. Please note that the expectation for an empathetic response of both hospitals’ inpatients got the highest priority in rank. The biggest service quality gap occurred in the “physical environment” dimension. inpatients seem to have preconditioned themselves to expect different health care service in both types of hospitals. Results show that expectations in both hospital types were not met. which brings us to the important assumption that privatization would offer higher performance in Northern Cyprus’ health services sector. 2005. who examined SERVQUAL in both public and private hospitals. At the micro level. doctors took care of me as soon as I arrived in the ward (Q. (1998). While comparing public and private hospitals.. 2004. 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. North Cypriot inpatients perceived public hospitals to be inferior in the quality of their service provision. Our ﬁndings also revealed that there are signiﬁcant quality differences in employee related hospital activities. it may be difﬁcult for inpatients to accurately evaluate quality. 1996). 25). and facility-related activities. patients’ expectations were not met in the private hospitals regarding the physical environment and the food quality served to them. Healthcare services were found to be better in the private hospitals with the exception of choice of food on the menu (Q. Our ﬁndings have important implications for private hospital owners. managers. Kara et al. Hospital managers should also satisfy their employees. 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. professionalism. private hospitals were found to provide a better service than their public counterparts. Hoel and Saether (2003) and Angelopoulou et al. mentioned by the previous researchers such as Hariharan et al. 15). 2004).. our results contradict Jabnoun and Chaker (2003). showers. it is interesting that there were variances in inpatients priorities. giving priority to the inpatients’ needs. since job satisfaction leads to customer satisfaction and loyalty (Rust et al. hospital managers should ﬁrst be committed to delivering superior service quality and the achievement of inpatient satisfaction (Arasli and Ahmadeva. the physical quality of equipment and facilities (toilets. 2005). 2005. such as the quality of the service provided by doctors and nurses. 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. Results derived from this study should be carefully considered by healthcare managers in both the Northern Cyprus public and private hospitals. This result is consistent with the previous empirical investigations (Withanachchi et al. Broadly. Kibris Newspaper. Interestingly. Jabnoun and Chaker. However. the instrument has been found to have face and convergent validity as well as acceptable reliability coefﬁcients. government ofﬁcials. 43).Discussion and conclusions Our empirical ﬁndings reveal that the study instrument provided sound psychometric properties. except for the empathy dimension. (2004).) were perceived to be better in private hospitals. who found that public hospital inpatients were more satisﬁed with service quality than their counterparts in United Emirate private hospitals. Our study has identiﬁed six service quality factors as perceived in both Northern Cyprus public and private hospitals: empathy. Speciﬁcally. such as building infrastructure and new equipment. However.. wards etc. Therefore. which is aligned with the majority of recent study ﬁndings (Pakdil and Harwood. Moreover. 2003. etc. etc. food and the physical environment. Regarding the other dimensions. 2000)..
L. Replication studies using large samples elsewhere would be useful in order to corroborate our study ﬁndings.. Anderson. Until further studies are conducted. although this may create difﬁculties contacting respondents just before their treatment and just before they are discharged from hospital. positive relationships. The Journal of Services Marketing. “Customer service quality in the Greek Cypriot banking industry”. 1999). Mehtap-Smadi. Third. p. food and the physical environment as the determinants of service quality in hospitals. (2005). (2004). S. Angelopoulou. (2000). S. 1. including their complaints. 14-20. (1995). Vol.. K. 32-7. P. the expectation and perception sections should be separated. Health Policy.. McCleary. the present study ﬁndings and our recommendation are inconclusive and tentative. Ministry of Health. International Journal of Health Care Quality Assurance. (1996).E. Asubonteng. Including other dimensions such as baksheesh (extra payments in many Bangladesh services). pp. for the researchers’ convenience. 1. Finally. References Andaleeb. the present study lacks a sample power calculation to detect differences between the respondent groups. professionalism.. 2. E. 41-56. the study questionnaire included both expectation and perception questions. Most customers are reluctant (Ekiz. S. return intention and word-of-mouth communications about the institution. discharge management and co-ordination (Labarere et al. Vol. and Babis. personal interview. Thus. “Service quality in public and private hospitals in urban Bangladesh: a comparative study”.A.S. Arasli. P. 25-37. 29). this study used empathy. (1998). 10 No. 135-45. it was conducted in a limited geographic region (Famagusta. H. 10 March. although the opportunity to do so is clearly provided in order to promote and create a healing environment.J. 2001) provided further insights into understanding inpatients’ perceptions and intentions. Arasli. 2004) even patient satisfaction and return intentions (Hasin et al. pp. Vol. In future. 62-81. 2004) to make their needs and expectations explicit.T. International Journal of Health Care Quality Assurance. 3.IJHCQA 21. Nicosia. “Private and public medicine: a comparison of quality perceptions”. P. 17 No. 11 No. 8 No. and Swan. and Ahmadeva. Vol. “No more tears! A local TQM formula for health promotion”.. (Andaleeb. giving priority to the needs of the inpatient. 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. 2000. Limitations and further research implications There are several limitations to our study. Vol. 6. H. 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. H. pp. International Journal of Health Care Quality Assurance.1 20 complaint procedures so that inpatients’ complaints can be addressed effectively and efﬁciently. pp. Arikan. (2005). pp. Second. G.. “SERVQUAL revisited: a critical review of service quality”. pp. hospitals’ processes (Lim et al. Kangis. future studies should include the remaining regions in order to increase the research ﬁndings’ generalizability. J. Vol. and Katircioglu. First. 15 No. Managing Service Quality. Future studies should also investigate the effects of service quality dimensions on the patient’s satisfaction. . “Measuring service quality at a university health clinic”. Future studies can conduct these calculations to be conﬁdent about the sample’s representativeness. 53. Northern Cyprus).
387-400. 1. 290-9. (1990). Dey. Eastern Mediterranean University. Service Management and Marketing. Hariharan.A. 22. 302-12. 767-80.S. 33-55. S. pp. Vol.J.A. Lexington Books. P. Fick. Hospital & Health Services Administration. (1991). pp. E. “Comparing public and private hospital care service quality”. 17 No. 8 No. Vol. 5-20. Cronin. 4.M. Famagusta.. Vol.kibrisnewspaper.E. and Aynsley-Green. M. Seeluangsawat.. Vol. 2. and Mangold.. (1992). 17 No.A. M.. Vol. S. Jr. “Quality assurance for clinical research: challenges in implementing research governance in UK hospitals”. Judd. Vol. Babakus. Journal of Marketing Research. 30. (2004).com (accessed 14 March 2002). (1992). R.. N. and Boller. pp. Vol. H. A. Service quality in public and private hospitals 21 .. International Journal of Health Care Quality Assurance. Lonial. 127-33. and O’Callaghan.. and Shareef. International Journal of Health Care Quality Assurance. 14 No. S. (2003). M...B. V. 253-68. 6. Coyle. Moseley. M. 6-13.. Kibris Newspaper (2002). Vol. and Phillips.A. International Journal of Hospitality Management. A. M. 4. “SERVQUAL and Northern Ireland hotel sector: a comparative analysis – Part 1”. TX. 599-616. Hoel. (1996). “Public health care with waiting time: the role of supplementary private health care”.P. pp.R. C. G. B. D.L. 2. E. 7-27. Smith. Preece. Journal of Health Economics. Vol. G. unpublished Master of Business Administration thesis. Managing Service Quality. 13 No.K. and Zeithaml. Gronroos. M. and Ritchie. (2004). L. 38 No. Faculty of Business and Economics. pp. MA. Vol. Kara. and Zaim. pp. 55-68. Camilleri. Carman.A. Boulding. Vol. 26 No. “Public-private partnership organizations in health care: cooperative strategies and models”. M. S. Kalra. Staelin.Y. “Comparing the quality of private and public hospitals”. Pittam. 6th ed. Pendleton. pp. Hasin. Vol. pp. Jabnoun. 12 No. International Journal of Health Care Quality Assurance. W. Vol. Tarim. E. “Organizational responses to customer complaints in hotel industry: evidence from Northern Cyprus”. 141-53.A. Gabbie.. pp. 30 No. “Statistical measures of customer satisfaction for health care quality assurance: a case study”.M. and Gora. 6. pp. R. 5. 239-47. (1992). Lexington. M. pp. pp. and Neill. 1. J. (2005). Fort Worth. 17 No. Kumar.Babakus. 24. A.W.G. Managing Service Quality. Ekiz. available at: www. “A dynamic process model of service quality: from expectations to behavioral intentions”.R. (2003). pp. (2004). M. pp. pp. “A paradox of service quality in Turkey: the seemingly contradictory relative importance of tangible and intangible determinants of service quality”. International Journal of Health Care Quality Assurance. Journal of Travel Research. “Quality in the hospitality industry: a study”. M. Vol. 66 No. Franck. E.S. L. Health Service Research. Jack. and Chaker. “A new tool for measurement of process-based performance of multispecialty tertiary care hospitals”. Rinehart and Winston Inc. and Saether. “An empirical assessment of the SERVQUAL scale to hospital services: an empirical investigation”. W. B. H.H.. Vol. J.. C. A. Research Methods in Social Relations. R. “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. and Dale.. and Taylor. 56. Vol. (1993). 2-9. J. (1993). Journal of Retailing. Journal of Marketing. 5. and Kidder. (1990).R. E. “An empirical assessment of the SERVQUAL scale”. Journal of Business Research. “Measuring service quality: a reexamination and extension”. (1991). 3. pp. (1998). 11 No. 1. “Measuring service quality in the travel and tourism industry”.G.M. 306-11. European Business Review. J. O. (1993). (2001).
Medical Doctor in Ministry of Health and Medical Center. “An empirical examination of a model of perceived service quality and satisfaction”.1 22 Kibris Newspaper (2005). J. and Zhang. “The satisfaction and retention of frontline employees: a customer satisfaction approach”. “A conceptual model of service quality and its implications for future research”.com (accessed 10 February 2005).C. (1985). (1997). and Sasser. (2003). (1988).Q. Parasuraman. Vol. F. pp. Vol. pp. 36. L. Wong. and Berry. 290-9. 15-30. S. K. Australian and New Zealand Journal of Psychiatry. and Berry. “Monitoring consumer satisfaction with inpatient service delivery: the inpatient evaluation of service questionnaire”. Zeithaml. J. A. Vol. Spreng. pp. 64 No.S. P. “A study of inpatients’ expectations and satisfaction in Singapore hospitals”. and Harwood.L. T. 197-206. S. . T. Fourny. L. “Measuring service quality in clubs: an application of the SERVQUAL instrument”. and Stedman. 5. 7 No. 1. P. McGraw-Hill Book Company. 3. V.N. 341-9. V. “The applicability of SERVQUAL in cross-national measurements of health-care quality”. “An innovative framework for health care performance measurement”. 72 No. R. 7-14. Vol. Duffy. T. and Durvasula. pp.R. Stewart. Vol. Journal of Hospitality Marketing.. 49. pp. NY. Vol.A. Vol. N. F. Vol. D. New York. and Jackson. Meehan. Jr.. H. (1994). Famagusta.A. 105-11. (2005). Vol. and Nelson. “Reﬁnement and validation of a French inpatient experience questionnaire”. The Journal of Real Estate Research.T. M. and Yeung. pp. pp. pp. L. Journal of Marketing. and Pielack. 201-14.E. pp..L. Nunnally. (1999). Lim. Lim. T. “Reassessment of expectations as comparison standard in measuring service quality: implications for further research”. M. available at: www. (1995). R. 58.D. Journal of Marketing. Vol. (1996). 13 No. International Journal of Health Care Quality Assurance.kibrisnewspaper. Vol. (1990). Miller. (1999). Vol. 10 No. T. pp. Rust. Tourism Management. H. pp. 7.A. Journal of Retailing. 41-50. 111-24. (2004). and Patrice. Managing Service Quality. The Journal of Services Marketing. Vol. (2005). 12-40. Total Quality Management.. 4 No. 62-80.C. Reichheld. Journal of Services Marketing.L. 2. 807-11. S. H. Mehta. W. A.. Kobat.. pp. S.K. (1996). International Journal of Health Care Quality Assurance. 17 No. and Giarchi. (2002). 15 February. R. “SERVQUAL: a multiple-item scale for measuring consumer perception of service quality”. Lam. 9 No. 17-25. Lam. F. personal interview.C.L. and Berry.L. (2004).. Vol. P..E. Tang. pp. Duffy. Jean-Phillippe. and Tang.A. 99-114. T. and MacKoy. Zeithaml. Managing Service Quality. pp. S. Vol. “RESERV: an instrument for measuring real estate brokerage quality”. Pakdil. 132-50. Vol. Zeithaml. 2... 7. G. Kilbourne. N. Psychometric Theory. 13 No. 1. W. 423-33. Journal of Retailing.K. M. V. Vol. A.. (1999).. pp.H. 13 No. pp. Labarere. “Testing the SERVQUAL scale in the business-to-business sector: the case of ocean freight shipping service”.. Nelson. 16 No. Sohail. Parasuraman. J. 1. 1.H. “Zero defecting: quality comes to services”. pp. “Inpatient satisfaction in a preoperative assessment clinic: an analysis using SERVQUAL dimensions”. 18 No.A.. Marin-Pache.M. “Service quality of travel agents: the case of travel agents in Hong Kong”. Parasuraman. 1. (1978). A. G. Bergen. (2000). 6. International Journal of Service Industry Management.C.IJHCQA 21. 20 No. V. “Service quality in hospitals: more favorable than you might think”. 68. Lysonski. S. 3. 524-33. Harvard Business Review.
W. Harper Collins College Publishers. Karandagoda. and Leunis. Y. (2001). and Fidell. O. 208-12. “A performance improvement programme at a public hospital in Sri Lanka: an introduction”. Tomes. 74 No. P. pp. pp. Review of Marketing. 2. S. Health Policy. Y. 1. Vandamme.R. Journal of Health Organization and Management. Using Multivariate Statistics. International Journal of Services Industry Management.Y. Withanachchi. K.T. and Handa. 10 No. pp. Vol.arasli@emu. 25-33.A. and Simpson. J. pp.J. Karnaki. B. Vol.P. “Measurement in a cross-cultural environment: survey translation issues”. 4 No. IL. 188-216. America Marketing Association.. Qualitative Market Research: an International Journal. Washington. 8 No. NY. Journal of Nursing Care Quality. DC. Vol. 3. A. “The ‘unexpected’ growth of the private health sector in Greece”. (2005). 3 No. “Inpatient satisfaction with nursing care at a university hospital in Turkey”. Vol. M. Y. World Development Indicators Indicators in CD Database. S.. 3.emeraldinsight. “Development of a multiple-item scale for measuring hospital service quality”. “International service variants: airline passenger expectations and perceptions of service quality”. Vol. pp. 3.com Or visit our web site for further details: www.Sultan. (2000).). 3rd ed. V. Journal of Services Marketing. in Zeithaml. L.. Uzun.edu. New York. pp. Pavi. and Souliotis. T. (2000). World Bank Publications.C. World Development Indicators (2003).com/reprints . Tabachnick. 167-80.G. Corresponding author Huseyin Arasli can be contacted at: huseyin. pp. “Service quality in hospital care: the development of an in-inpatient questionnaire”. (1995). Vol. N.S. M. “A critical review of consumer satisfaction”.tr Service quality in public and private hospitals 23 To purchase reprints of this article please e-mail: reprints@emeraldinsight. E. pp. Chicago. and Crowe. pp. Vol. 5. 2. 68-123. R. International Journal of Health Care Quality Assurance. 4. (1996). 30-49. 16 No. Vol. 18 No. (2004). “Achieving hospital operating objectives in the light of inpatient preferences”.E. Further reading McGorry. Yi. 14 No. F. Vol. Tountas. 5. and Ng. 74-81. International Journal of Health Care Quality Assurance. Valdivia. (Ed. (1993). (1990). 361-9. 24-33.. (1997).
It draws on the disconﬁrmation paradigm from the psychology and consumer behavior literature and the Gap Model (Parasuraman et al.1108/09526860810841138 Introduction The operations management and marketing literature focus on measuring service quality as the gap between expectations and perceptions. 21 No. Chin University of Houston. 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. Customer services quality. 24-38 q Emerald Group Publishing Limited 0952-6862 DOI 10. The service quality Gap Model is operationalized by the SERVQUAL instrument (Parasuraman et al. 2008 pp. Rhode Island. see Carman. The Gap Model operationalized by SERVQUAL is widely used to measure service quality. 1988). 1990).. Wicks Bryant University. Shelton. Although SERVQUAL is a good base for measuring service quality and . 1988. Bitner. a form of structural equation modeling. Reidenbach and Sandifer-Smallwood. Texas.com/0952-6862. United States of America. Patient satisfaction criteria speciﬁc to hospital selection are not included in this study. process.The current issue and full text archive of this journal is available at www. Smithﬁeld. 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.. Originality/value – This study is the ﬁrst to evaluate patient satisfaction with all three process segments. an approach widely used in service operations (Spreng and Page. 1990.emeraldinsight. 1985. 1996. However. 1990. the SERVQUAL instrument only measures expectations (resulting from the pre-process segment of the service experience) and perceptions (resulting from the post-process segment). Keywords Patients. Design/methodology/approach – A partial least squares (PLS) approach. Findings – Results indicate that each process stage mediates subsequent stages. All three segments should be measured.. USA. Houston. Outpatients Paper type Research paper International Journal of Health Care Quality Assurance Vol. Practical implications – Results indicate what is important to patients in each service process segment that focus where ambulatory surgery centers should allocate resources. 1991. 2000). is used to develop a framework to evaluate patient satisfaction in three service process segments: pre-process.htm IJHCQA 21. Research limitations/implications – Only one out-patient surgery center was evaluated. 1.1 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. and Wynne W. Shewchuk et al. The lack of proper segmentation and methodological criticisms in the literature motivated this study. Oliver. 1996) and has been adopted for health care operations as well (for example. and post-process service experiences. Performance levels.
. 1988). customer satisfaction. 1993). 1993). The R 2 values for the perception scores are often higher than the overall gap scores (Cronin and Taylor. Babakus and Boller. 1993). higher than the gap scores (Parasuraman et al. process. Peter et al. 1993.. 1993). service operations. Additionally.. 1992.the possible trade-offs between functional areas. several problems exist owing to the nature of the creation of the gap measurement (for example. 1992. 1994). Overall satisfaction model . poor discriminant validity. our study develops an alternative method for measuring patient satisfaction in a larger retention framework where satisfaction. 1960). marketing. Rosen and Karwan. Peter et al. 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. 1992. 1998. 1990. Teas. not quality. SERVQUAL only measures the pre-process segment (expectations) and the post-process segment (perceptions). 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. Service process measurement should include all three consumption experience segments: pre-process. 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. Singh. see Cronin and Taylor.. 1990).. 1993. An out-patient surgery center was selected for this study. Therefore. Measuring the three process segments 25 Figure 1. psychology and health care operations literature and by a series of focus group discussion. Our framework was developed from operations management. 1993).. spurious correlations and variance restriction problems make gap measure a poor choice as a measure of psychological constructs (Peter et al. or higher than expectations scores (Brown et al. Low reliability. and post-process (Babin and Grifﬁn. Vandamme and Leunis. 1994.
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.IJHCQA 21. The dotted lines leading into and out of overall satisfaction indicate how satisfaction ﬁts within the larger retention framework (Figure 2). The questionnaire was included with the patient’s discharge papers. There were few missing data in the survey results. 1999). six demographic questions. The relevant constructs were determined for each service process segment from the literature and focus groups. That is.1 26 Method Our pilot survey consists of 100 questions related to the survey constructs. Overall Satisfaction in the model leads directly to loyalty and loyalty leads directly to retention. which patients were expected to return to the doctor at a post-operative appointment. However. The same patient satisfaction antecedents were used for each segment except for tangibles. See Witten and Frank (2001) for a detailed discussion of the algorithm’s use. therefore. independent variables) and applying procedures used in multiple regression (Chin and Newsted. Pilot survey data were drawn from 112 usable responses. (2004a. 1988). the patient satisfaction deﬁnition antecedents are listed in Table II (see Wicks et al. the sample size is sufﬁcient for our regression-based PLS analyses. a sample size of 631 far exceeds the minimum required to provide sufﬁcient analytical power (Cohen. The dotted lines indicate where the exogenous variable for cognitive and behavioral antecedents relates to overall satisfaction. 2004b) for a complete discussion of the Figure 2. Therefore. Some doctors did not forward the surveys to the hospital resulting in a lower than expected response rate.e. The sample size requirement in PLS is typically determined by locating the dependent construct in the model with the largest number of predictors (i. A total of 631 usable surveys were completed and returned (17 percent response rate). The Overall Satisfaction Model is presented in Figure 1. The expectations minimization algorithm was used to substitute missing data in both the pilot and ﬁnal surveys. tangibles are not applicable for the post-process segment. The degree of loyalty depends on the patient’s overall satisfaction. These types of processes are primarily phone transactions. Retention model . the post-process transactions primarily relate to errors in insurance submission. The patient satisfaction deﬁnitions for each segment and for overall satisfaction are listed in Table I. Therefore. two insurance questions and one open-ended question. In our study the constraining construct involved twelve predictors.
. equipment. Behavior is deﬁned as the mental process linked to speciﬁc directed action toward the out-patient surgery center.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. 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. Cognition. is deﬁned as the mental process by which knowledge is acquired about the out-patient surgery center. for example. the satisfaction deﬁnitions and the patient satisfaction deﬁnition antecedents used in this study).e. Patient satisfaction antecedents’ deﬁnitions framework’s development. Loyalty is deﬁned as the attitude toward reuse of the 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. 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. and personnel appear neat and clean Table II.
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
895 0.869 0.921 0.872 0.746 0.988 0. indicates strong item convergence towards a highly reliable scale.760 0.885 0. 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 0.965 0.840 0.869 0.891 0.950 0. All the loadings are signiﬁcant at an alpha of 0. The cross-loadings provide similar results. and OA Stage 3).944 0.998 and 0.856 0.923 0.998 0.884.932 0. The item loadings are provided in Table VI also resulting in high composite reliabilities for the three stage constructs of 0.863 0.808 0.843 Stage 2 Stage 3 0.961 0.941 0.841 0.989 Table VI.926 0.802 0.884 0.815 0.867 0.954 0. The composite reliability.969 0.861 0.900 0.778 0.889 0.887 0.824 0.902 0.924 0.846 0.809 0.837 0.836 0.919 0.898 0.859 OA Stage 1 0.773 0.882 0. as required. OA Stage 2.832 0.789 0.842 OA Stage 3 0. “surgery stay experiences” for OAS_1 and OAP_S.852 0.887 0. Table VII presents the correlations among construct scores with the AVE results on the diagonal. Overall satisfaction – Survey: Correlation among construct scores (square root of the AVE extracted in diagonals) .988 respectively.932 0.810 0. we replaced “out-patient surgery” with “pre-admission experiences” for OAPR_1 and OAPR_2.934 0.869 0. Using the same wording for items OAA_1 and OAA_2. Overall satisfaction model – loadings/cross loadings of items Overall Overall Stage 1 Stage 2 Stage 3 0.997 0. The results of both analyses indicate that the model’s psychometric properties are sufﬁciently strong to enable structural model estimate interpretation.809 0.902 0.793 0.902 0. For each of the three process stages (OA Stage 1.988 Table VII.900 0.796 0. 0.787 0.998 0.997 0.875 Stage 1 0.889 0.996 0.831 0.955 0.843 0. two indicators were used.837 0.895 0.998 0.866 0.865 0.900 0.835 0.834 0. all item cross loadings are higher for the construct on which the item should load than on any other construct. and “post-discharge experiences” for OAP_1 and OAP_2. are all larger than the correlations.997.935 0.846 0.01.980.954 0.757 0.837 OA Stage 2 0. The AVE value square roots.812 0.826 0. represent a strong relationship.920 0.892 0.835 0.794 0.0.
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. 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. These results indicate that models based on . 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. Moreover.148 effect on overall satisfaction. Conclusions and recommendations Our study establishes and tests the relationships between three service process segments and overall patient satisfaction. satisfaction towards the out-patient stay (i. indicating a small effect for both segments on overall patient satisfaction. 0. Speciﬁcally. using the cross-validated redundancy option. The pre-process stage has a signiﬁcantly lower path coefﬁcient of 0. Furthermore. we noted the construct discrimination among the stages as well.1 32 Structural model assessment Bootstrapping results indicate that all path coefﬁcients are signiﬁcant at an 0.e.67.e.7511 for the Stage 3 and 0. The Q2 predictive relevance values. In terms of satisfaction at the start of the process in Stage 1 impact. Stage 2 has a large impact on overall patient satisfaction with an f 2 of 0.790 for overall satisfaction. Stage 2’s impact (path coefﬁcient) on overall satisfaction is 0. The strength of the relationships between patient satisfaction and the three service experience process segments is also tested. the global set of 15 items for overall satisfaction provides an operationally discriminant difference to those used for the three stages.891 from Overall Stage 1 to Overall Stage 2.IJHCQA 21. The f 2 for Stage 1 and Stage 3 are 0.0811 and 0. While this is high for predictive models. with a lower value of 0. Stage 2) has the most impact on overall satisfaction with the pre and post stage satisfactions being much less inﬂuential and approximately equivalent.36 from Stage 1 to Stage 3 and an even lower value of 0. The pre-process segment (Stage 1) has a signiﬁcantly lower impact of 0. In particular.18 and the post-process stage has only a 0. The model is an excellent overall patient satisfaction predictor. what is also important is whether paths estimated are also substantive with high R-squares.788 for Stage 2.18 and the post-process segment (Stage 3) has only a 0.18 from Stage 1 to Overall Satisfaction. whether paths minimally impact or larger). the relative strength of each stage’s impact on overall satisfaction as well as among each other is consistent.973.666. As such. are 0. it should not be surprising to ﬁnd signiﬁcance for all paths owing to the relatively large sample size independent of the effect size (i.148 path coefﬁcient. 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.0676 respectively. Overall satisfaction model results indicate that the patient’s satisfaction with the actual surgical stay.6 percent of the variance in overall patient satisfaction with out-patient surgery experience. we see that the model explains 92. As found when assessing the measurement model. In terms of substantive effects and predictive relevance. as just noted. The highest impact is the path coefﬁcient value of 0.01 alpha and estimates are presented in bold in Figure 3. This implies that the model constructs have high predictive ability. Typical for path analytic/structural equation techniques.
responsiveness. conﬁdentiality. The results of the Process Satisfaction model indicate that convenience has the most impact on the formation of overall process satisfaction. The same 11 antecedents were evaluated for Pre-Process Satisfaction and for Process Satisfaction. Our analysis also found that. The remaining antecedents were ranked as competence. Assurance at this stage can impact how comfortable the patient feels about the surgical process. These results cannot be generalized to all segments since process satisfaction impacts overall satisfaction more than the post-process segment. One possible explanation could be that the process segment convenience aspects act to reduce stress over the actual surgical process. reliability. The greatest impact on overall satisfaction is the actual surgical experience. ranked second in the process segment. security and then convenience. responsiveness. Convenience is closely followed by assurance and courtesy. however.891 from Overall Stage 1 to Overall Stage 2. communication. The remaining antecedents are ranked as conﬁdentiality. empathy. courtesy is most important.180). equivalent to the Stage 1 service experience pre-process segment. Tangibles may be important in this case because of the correlation between cleanliness and a good surgical outcome (i. and empathy. tangibles. competence. For example. empathy. no infection following surgery). the path coefﬁcient for courtesy is almost twice that of the next highest path coefﬁcients: reliability. for this model. Overall Stage 1 has a dramatically lower effect on Stage 3 (0. When the Overall Satisfaction model was evaluated. Assurance. the highest impact is represented by the path coefﬁcient of 0. however. assurance had the highest rankings across all process segments. This indicates that pre-process segment impact. Assurance has the greatest impact on the formation of Post-Process satisfaction. communication. If the health care provider can handle the pre-registration process well then it can probably handle the surgery to a good standard. empathy. have signiﬁcantly less impact on overall satisfaction. assurance and tangibles. 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. but this may be true since process satisfaction had such a large effect on overall satisfaction. reliability. patients pay attention to the facility’s neatness and cleanliness. closely followed by courtesy. diminishes as the patient moves away from the pre-process segment. 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. conﬁdentiality. The tangibles antecedent was not included for Post-Process Satisfaction. and security. Our research establishes and tests the relationships between patient satisfaction antecedents and overall satisfaction for each service process stage. or expectations. courtesy. The results of the Pre-Process Satisfaction model indicate that courtesy has the most impact on customer satisfaction for this segment. competence. communication. For this service process segment. responsiveness. However. each process stage mediates subsequent stages.expectations. Measuring the three process segments 33 . each process stage inﬂuences the development of overall patient satisfaction and all three stages should be included in the model. security. The remaining antecedents are ranked in order of impact on pre-process satisfaction as follows: reliability. in fact. The number one ranking for convenience in the process satisfaction segment was unexpected.e.
IJHCQA 21. convenience for the process segment. 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 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. staff should design parking facilities and procedures to be as convenient as possible by providing adequate signage. assurance for the post-process segment and for overall satisfaction. Conﬁdentiality and convenience had the lowest impact. The low ranking for empathy may have occurred because approachability and sense of security were omitted from the newly-developed deﬁnition. Empathy ranked ninth out of ten antecedents consistently evaluated in all three process-segment models and ranked last in the process segment. The organization should focus on making the center easy to ﬁnd by providing good directions and appropriate signage for example. The health care literature stresses the importance of communication in evaluating patient satisfaction (Shelton. competence. responsiveness. When the patient is discharged. However. 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. so tangibles were not included in the rankings. empathy. The most important pre-process segment antecedent for the patient was courtesy. communication was eighth in the overall rankings. communication. Directional assistance should be available so patients can easily arrive at the proper location within the facility. 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. Conﬁdentiality ranked low in all aspects of the out-patient surgery experience. 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. which may have occurred since a communication aspect was included in the assurance deﬁnition. speciﬁc entry and departure areas for the patients and perhaps valet parking. Patients are pre-registered for out-patient surgery. How well the patient feels that the surgery will be performed may be much more important. so paperwork should be in place when he or she arrives at the surgery center. The results of some rankings were unexpected. Tangibles were not evaluated in the Post-Process Satisfaction model. reliability. but the organization should focus on these aspects during the registration process to alleviate anxiety about the impending surgery. 2000). 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. The remaining surgical procedures should be designed to be as stress-free as possible.1 34 followed closely by courtesy. Designing the out-patient surgery process to be convenient for the patient on the day of surgery can have the greatest . and security. The results of the different satisfaction models indicate the antecedents have differing impacts on satisfaction depending on where the antecedent is measured. 2000). assistance could be in the form of clear and adequate directions possibly from an information desk at the out-patient entry. Patients may consider assurance more important in the out-patient surgical setting than how empathetic the health care providers appear to be.
the major determination would need to be about selecting satisfaction antecedents for industry-speciﬁc applications in the service sector. The Measuring the three process segments 35 . 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. 1988. Kristensen et al. 1978. Barsky (1995). Our study only evaluated patient satisfaction antecedents for an out-patient surgery center located in a large USA city. Bolton and Lemon (1999). 1993. 2001).. Assurance needs to be the focus in any post-process interactions with the patient. Shi and Singh. The model also appears generalizable.impact on evaluating overall satisfaction. 2000. He or she needs to feel that any billing or insurance problems are going to be taken care of appropriately. 1993. Shi and Singh. 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. Naumann and Giel (1995) and Rust et al. The generalized model could also be applied to public service and not-for-proﬁt service areas. The assumption was made that the health care provider and the extent of health care coverage had already been determined. The generalized model could be easily modiﬁed for supply chain applications. Access has been included in numerous health care studies as a construct for determining health care quality and/or patient satisfaction (Ware et al. however. The model should be modiﬁed for public services by determining satisfaction antecedents and the importance of each antecedent in not-for-proﬁt organizations. Sale. 1993) and the satisfaction model might prove valuable in this area as well. (2001). 1995) included value in their studies. Waldbridge and Delene (1993) determined that image was an important health care quality determinant. 2000. The literature reviews and focus groups determined general patient satisfaction antecedents. Naumann and Giel (1995) and John (1992) found image an important quality determinant. and focuses on an insurance-based healthcare system. image and value as satisfaction antecedents. Archer and Wesolowsky (1994). value and image should be included as well. Satisfaction antecedents developed for this study should be modiﬁed and applied to on-line services. Technology has had an enormous impact on how organizations do business (Harvey et al. Shi and Singh. A more generalized model should be developed to evaluate satisfaction in other types of services. image and value should be included in the generalized model. Supply chain management is a particularly rich area where retailer satisfaction. Shelton. 2001). this study does not include access. more work is needed to determine if satisfaction antecedents vary in impact among service industries. the distributor and other entities along the supply chain is extremely important (Preis. Access. 1995. Good results were obtained from these models in an out-patient surgical setting. Therefore. 2001). These factors have been included in quality studies in non-health-care services (see Anton. 2003). (1994. while access. Service models have been applied to service segments within manufacturing organizations (O’Hara and Frodey. 2000) for a review of access). Value has been determined to be important in health care (Donabedian. Barsky. Training programs for administrative personnel in billing and insurance to properly address these issues can also have a great impact on post-process satisfaction. Patients also need to feel that any ﬁnancial information will be kept strictly conﬁdential. Waldbridge and Delene.
Journal of Business Research. (1999). pp. pp. version 3. Journal of Retailing. “The nature of satisfaction: an updated examination and analysis”. 1782-9. pp.. Vol. and Grifﬁn.. (1992). Chin. 481-96. 3. 1. 56. 2. Babakus. Babin. “Quality assessment and assurance: unity of purpose. Journal of Marketing Research. (1998). Bitner. N. M. Again. pp. NJ. “Evaluating service encounters: the effects of physical surroundings and employee responses”.). J. E. and Newsted. 2. pp. Technovation. “PLS-Graph user’s guide.W. K. “The partial least squares approach for structural equation modeling”. Vol. “Research note: improving the measurement of service quality”. “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”. W. 4. 2. “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. (1988). Lawrence Erlbaum Associates. 14 No. Statistical Power Analysis for the Behavioral Sciences.. Archives of Internal Medicine. J. Information Systems Research. European Journal of Operational Research. 2nd ed. Inquiry. pp. References Anton. (Ed. NJ. pp. Chin. (1999). and Taylor. W.0”. Cronin. 120-30. diversity of means”. Barsky. Hillsdale. R. Archer.W. in Marcoulides. Lawrence Erlbaum Associates. pp. Sage Publications. 355-66. Journal of Retailing. pp. J. unpublished manuscript. 41. and Lemon.W. Brown. and Peter. 295-336. Statistical Strategies for Small Sample Research. “Technology and the creation of value in services: a conceptual model”. S. 36 No. determining applicable satisfaction antecedents is vitally important. (1998). B. 33-55. J. “The past. W. 189-217. “Structural equation modeling analysis with small samples using partial least squares”. (1992). and Newsted. (1988). in Hoyle. 25 No. 127-36. present. Lefebvre. Vol. however. Vol. P. P. 66 No. 127-39. Chin. CA. and Lefebvre. pp. 5. 24 No. “Measuring service quality: a reexamination and extension”. “The clinical course of palpitations in medical out-patients”. 155 No. and Boller.R. Journal of Business Research.). Vol. (1990). G.P. Vol. pp. P. Vol. 13 No. (1993). 307-41. 69 No. Vol. Carman. Journal of Marketing. 54 No. pp. 55-68. 2. pp.W. Bolton. (Ed. Journal of Marketing. 1. and future of customer access centers”. J. Marcolin. A. T. E. 253-68. (2000). G. L. (1994). 69-82. “An empirical assessment of the SERVQUAL scale”. Vol. Churchill. 18. Donabedian.. M. (2003). 78 No.1 model should also be applicable to manufacturing organizations that include signiﬁcant service segments. the model provides a foundation upon which to build industry-speciﬁc models. B. (1995). “A dynamic service quality cost model with word-of-mouth advertising”. J. 171-87. Modern Methods for Business Research. (1993). Vol. 16. Thousand Oaks.O. (2001). W. pp. Chin. 36 . Jr. Harvey. G. (1990). and Wesolowsky. 11 No. Vol. “A dynamic model of customers’ usage of services: Usage as an antecedent and consequence of satisfaction”. Cohen. Vol. pp. 173-92. Vol. G.IJHCQA 21. International Journal of Service Industry Management.A. Mahwah. R.
Marketing Research. Gaithersberg. “Caution in the use of differenced scores in consumer research”. “Prioritizing the dimensions of service quality: an empirical investigation and strategic assessment”. R. 8. 18-27. pp. R.. “A service quality model for manufacturing”. 39 No. pp. and Morrison. T. Journal of Retailing. “Exploring perceptions of hospital operations by a modiﬁed SERVQUAL approach”. (1995). A. 12 Nos 7-8. Management Decision. (1990). (1992). (1994). 195-204. Measuring and Improving Patient Satisfaction. J. M. (1996). Vol. Parasuraman. 51-61. Reidenbach. M. V. Churchill. Vol. pp. T. pp. M. 24-34. CT. and Keiningham. Vol. A. 11 No. “Return on quality (ROQ): making service quality ﬁnancially accountable”. Vol. J. Preis. Ryan. Decision Sciences. Total Quality Management. (2000). pp. P. pp. pp. (2001). Vol.. Quality Assurance: A Pathway to Excellence. 478-500. Oliver. Sale. C. “The impact of interpersonal satisfaction in repurchase decisions”. Journal of Supply Chain Management. 12. Boston. and behavioral components of attitudes”. Journal of Health Care Marketing. 11 No. L. 10 No. “Consumer satisfaction and perceived quality of out-patient health services”.. Yale University Press.. P. Peyrot. International Journal of Service Industry Management. 4. and Berry. 5 No. Irwin/McGraw-Hill.. “A conceptual model of service quality and its implications for future research”. M. IL. V. “Diagnosing customer loyalty drivers”. L. D. A. Rosenberg. (1993). 20. and Sandifer-Smallwood. “Improving quality through patient-provider communication”. Journal of Health Care Marketing. A. D. Zahorik. K. Vol. Journal of Marketing. R. Zahorik. and Keiningham.J. P. pp. “Use of partial least squares (PLS) in strategic management research: a review of four recent studies”. (2000). 2. Vol.Hulland. Parasuraman. Probus Publishing Company. A. C. T. 19 No. B. 31 No. M. Aspen Publishers. Rosen. Naumann. Igbaria. (1988). Chicago.. (2003). 39-52. pp. and Greenhaus. Return on Quality: Measuring the Financial Impact of Your Company’s Quest for Quality. pp. Customer Satisfaction Measurement and Management. (1999). R. Journal of Consumer Research. Basingstoke. G. 1. Quality Press. Milwaukee. 2. Rust. C. M. and Giel. O’Hara. J. and Zeithaml. 46-51. (Eds). 58-70. “Cognitive. (1994). Measuring the three process segments 37 . New Haven. 12-40.I. 2. John. and Rosenberg. 49 No. Berry. (1993). “SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality”. (1993). Strategic Management Journal. J. and Frodey. 890-7. K. Juhl. and Hovland. 2. Journal of Marketing. L. Macmillan Press. MA. R. Journal of Health Care Marketing. Vol. 13 No. H.T. 4. and Brown. Vol. Satisfaction: A Behavioral Perspective on the Consumer. and Schnapf. Kristensen. Attitude Organization and Change: An Analysis of Consistency Among Attitude Components. K. 64 No. (1960). 655-62. WI. Vol. 30-8. Vol. (1992). Rayner. pp. (1985). (1995). 41-50. 47-55. pp. 59 No. in Hovland. affective. Zeithaml. pp. 4. “Customer satisfaction: some results for European retailing”. Vol. J. E. Cooper. Rust. and Karwan.. Shelton. Vol. 3. 3. “The career advancement prospects of managers and professionals: are MIS employees unique?”. and Ostergaard. (1999). Vol. Peter. 23 No. pp. MD..
18 No. K. Journal of Retailing. Zeithaml. A. and Chin. (2001). 58 No. A. O’Connor. and Page. and Delene. and Singh. 1. and Gale. “The development and evaluation of a patient satisfaction model for health service organizations”. pp. 420-51. pp. 1 No. (Eds). Davies-Avery. 1. Singh. “Expectations as a comparison standard in measuring service quality: an assessment of a reassessment”.. R.. Wicks. Ware. Bryant University. Corresponding author Angela M. DeSouza. Health Services Management Research. A. 1. (2004a). (1996). V. and Frank. 2-15.. 4 No. Health and Medical Care Services Review. (1991). 10. 8-21. evaluation. Vol. I. pp. R. Quality Progress. and consumers’ perceptions of quality”. (1982). Vol. Prediction. Wicks can be contacted at: awicks@bryant.. “In search of service quality measures: some questions regarding psychometric properties”. (2001). (1985). J. San Diego. RI. pp. Vol. (1993). Academic Press. pp. and Leunis. “A multifacet typology of patient satisfaction with hospital stay”. J.. Data Mining – Practical Machine Learning Tools and Techniques with Java Implementations. pp. S.com/reprints . H. pp. Vandamme. 132-9. Journal of Health Care Marketing. Thompson. L. Vol. R.IJHCQA 21. H. “Measuring physician attitudes of service quality”. pp. 3. performance. L. Part 2. in Joreskog. A. “Soft modeling: the basic design and some extensions”. Journal of Health Care Marketing.. R. P. 18 No. Vol. “The measurement of meaning of patient satisfaction”. Delivering Health Care in America: A Systems Approach. W. CA. Vol. Psychology and Marketing.G. pp. and Berry. pp. Shi. Structure. Journal of Marketing.1 38 Shewchuk. 4. Aspen Publishers Inc. MD. W. D. and Stewart. “A reexamination of the determinants of consumer satisfaction”. Witten. 6.edu To purchase reprints of this article please e-mail: reprints@emeraldinsight. Spreng. Teas. Wold. 20-6. Walbridge. Gaithersburg. “Expectations. “Deﬁnitions of the antecedents of patient satisfaction for an ambulatory surgery center”. and Chin.com Or visit our web site for further details: www. 19 No. 12. (1993). A. Fletcher. Teas. (1978). Vol. Vol. pp. 6-16. Bryant University. 67 No. Systems under Indirect Observations: Causality. “Reﬁnement and reassessment of the SERVQUAL scale”. “Development of a multiple-item scale for measuring hospital service quality”. Fletcher. (1990). Smithﬁeld. Vol. 18 No. working paper. 1-54. working paper. RI. (1994). G. (2004b). J. 11.. A. E. (1991). Wicks. L. S. International Journal of Service Industry Management. and White. 30-49. and Wold. B. T. 1187-205. 4 No. J. Smithﬁeld. R. Vol. 13 No. 1. Further reading Parasuraman. Journal of Marketing. 18-34. S. (1993). 65-75.emeraldinsight. “The strategic management of service quality”.
Personality. The Medical Outcomes Study (MOS) evaluated patient satisfaction based on practice type and payment method (Rubin et al. Minnesota. 59 percent rated overall care by their physicians as excellent. Mayo Clinic. Originality/value – Pessimistic or hostile patients were signiﬁcantly less likely to rate their overall care as excellent than optimistic or non-hostile patients. 57 percent rated their overall care by physicians as excellent. Dierkhising and Kenneth P. Patient satisfaction has been widely studied. but little has been written about the association between patients’ personality characteristics and their satisfaction ratings. Mayo Clinic. nor how polished the physician’s interpersonal skills. United States of America. Colligan Department of Psychiatry and Psychology. 39-49 q Emerald Group Publishing Limited 0952-6862 DOI 10. Offord Division of Biostatistics. inconsolable and personally challenging. no matter how comprehensive. USA. Rochester. Satisfaction determinants range from structurally-based ones such as the type of health care delivery system. Many patient and health care provider demographic characteristics have been related to patient satisfaction with a health care encounter. Minnesota. Rochester. Costello. rather than in multi-specialty groups or health maintenance organizations. International Journal of Health Care Quality Assurance Vol.htm Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients Brian A. including interactional style and the physician’s age (Kirsner and Federman. Findings – Among patients who scored high on the pessimism scale. Keywords Patients. 1. The MOS included more than 17. 1993). while 66 percent of the least hostile patients rated it as excellent (p ¼ 0:002). Richard Locke III Division of General Internal Medicine. to physician characteristics. while 72 percent with scores in the optimistic range rated it as excellent (p ¼ 0:003).com/0952-6862. 1. Thomas G. and Robert C. USA Pessimism and hostility scores 39 Received 6 May 2006 Revised 13 September 2006 Accepted 23 September 2006 Ross A.259 had previously completed a Minnesota Multiphasic Personality Inventory (MMPI). Design/methodology/approach – An eight-item patient satisfaction survey was completed by 11.000 patients who had ﬁlled out a nine-item questionnaire after an out-patient visit. 1997). Mayo Clinic. Health services Paper type Research paper Introduction Practicing clinicians know that certain patients are difﬁcult to satisfy. were most likely to rate the overall visit as excellent. Of these. Among the hostile patients. McLeod and G.636 randomly selected medical out-patients two to three months after their episode of care.emeraldinsight.. 2008 pp. Patients seen in a solo or single-specialty practice. 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. Minnesota. Rochester. 21 No.1108/09526860810841147 .The current issue and full text archive of this journal is available at www. efﬁcient and expert their care. The association of pessimism and hostility scores with patient satisfaction ratings was assessed.
For example. and who lived locally (Locke. particularly patient waiting time. and physician-speciﬁc factors related to patient satisfaction. The second data set comprised scores from approximately 335.259 out-patients formed the basis for our study. 1997). Robbins et al. personality traits of pessimism and hostility. This study investigated the personality characteristics of pessimism and hostility as they relate to patient satisfaction ratings.. 1980. including the patients’ personality characteristics. Methods Two archival data sets were abstracted. personal communication. Therefore. who were employees of the center. 1993). 1997). 1984. 1993). structural. lower satisfaction ratings were reported by patients who were young..R.1 40 Physician age and gender have also been correlated with patient satisfaction. as expected.. Conversely. female physicians (Hall et al. patients with depression or anxiety disorders are more likely to express dissatisfaction from unmet expectations (Kroenke et al. is important.IJHCQA 21. such as performing a physical examination. an MMPI.. general satisfaction with the visit and willingness to recommend our center to others. 1994). 1. We hypothesized that pessimistic or hostile patients would report less satisfaction with their care. The study was approved by our institutional review board. Although much has been written about organizational. When the two data sets were merged we found that 1. patients who believe their health status is good are more satisﬁed with their care (Probst et al.259 medical out-patients had completed both the patient satisfaction survey and. and all study subjects gave research authorization. surprisingly little has been written about patient characteristics and their relationship to medical care satisfaction ratings. September 2002).636 medical out-patients who completed a patient satisfaction survey for the Department of Internal Medicine from March 1998 through March 1999. Of the MMPI and the patient satisfaction responses. as assessed by the MMPI. patients’ reports of satisfaction with care. Furthermore. and . The topic of the eighth item was the completion of all scheduled tests and consultations (yes/no). Organizational factors. speciﬁcally. We then assessed the degree of association between: . lower satisfaction is reported by patients after seeing younger. 1997). have been studied and. not satisfaction. A ﬁve-point scale was used to rate seven items pertaining to satisfaction with access..000 Minnesota Multiphasic Personality Inventories (MMPIs) archived at our institution since 1959.. longer waiting times result in lower patient satisfaction (Probst et al. interactions with physicians and allied health staff. understanding factors associated with patient satisfaction. Bartlett et al. The survey response rate was 60 percent. An eight-item questionnaire was mailed to randomly selected medical out-patients two to three months after their care episode. G. Effective communication skills and particular physician behaviors. Patient satisfaction is associated with compliance and willingness to continue receiving care from a particular physician (Rubin et al. before that survey was completed. Pessimism and hostility were chosen for study because these . All MMPIs had been obtained before the satisfaction survey. have been associated with higher patient satisfaction ratings (DiMatteo et al... The ﬁrst data set consisted of information from 11. in a study of patient characteristics among out-patients at our center.
Research shows that a pessimistic explanatory style is predictive of an increased likelihood of depression. . being a medical center employee or a dependent of an employee (“employee/dependent”. Finally. these qualities come closest to deﬁning the intangible characteristics that physicians sense in patients who are difﬁcult to satisfy. The MMPI consists of 550 unique true/false items about thoughts. 2000). Furthermore. 1990). . optimistic. High scores on the pessimism (PSM) scale reﬂect a pessimistic explanatory style. stable (rather than transient) and global (rather than speciﬁc) possess a pessimistic personality trait. age.e. responses were coded “1” for “excellent” or “0” for all other response categories to that item.. For six questions.Hostility amounts to chronic hate and anger. These included patient’s residence distance from our medical center. lower levels of achievement and increased use of medical and mental health services (Seligman. . The scale’s developers describe a “hostile person” (i. .. attitudes. The dependent variables were seven patient satisfaction responses from the eight-item survey. 0 ¼ no) and receiving primary care. This procedure for collapsing and dichotomizing the ﬁve-point scale is in keeping with the convention from marketing literature (Jones and Sasser. 1989. which suggests that people who believe that the cause of an adverse event is internal and personal (rather than external). 5-32). 1993. emotional symptoms. 1 ¼ yes. [and] sees people as dishonest. but signiﬁcant. We considered this variable because many of our patients travel long distances to our center for intensive out-patient . relationships that might not otherwise be uncovered in smaller or more highly selected samples. 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). lone who has little conﬁdence in his fellowman. 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. ugly and mean. in our experience.. pp. Hostility was measured by the MMPI hostility (Ho) scale (Cook and Medley. Our large sample size allowed us to detect small. feelings. as assessed by the MMPI. immoral. 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. unsocial.personality traits. 1995).. we also adjusted for previously identiﬁed predictive covariates. . low scores. are considered relatively stable (Maruta et al. physical symptoms. scoring high on the Ho scale) as: . 1954). These are known and important explanatory variables when modeling patient satisfaction at our center. For the question about recommending the medical center to others. . Pessimism and hostility scores 41 The MMPI scales are reported as T-scores. Statistical methods Logistic regression models were used to assess the association between patient satisfaction ratings and the PSM and Ho scores. 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. 1994). from experience with previous internal analyses. Additionally. responses were coded “1” for “deﬁnitely would recommend” or “0” for any other response. and previous life experiences (Swenson et al. Maruta et al. poorer physical health.
. Among these patients: . 617 (49 percent) were 41 to 65 years old. we modeled the interaction of time and the MMPI scale score within the context of two models.1 42 evaluations during a single episode of care. and . The third included both MMPI scales of interest and the adjusting variables already mentioned.259 out-patient participants: . Therefore. The ﬁrst model was done univariately.1 to 10 years after the MMPI. 185 (15 percent) within 1 year after taking the MMPI. and . 1. 632 (50 percent). . and . . The second model included only one of the MMPI scales of interest and the adjusting variables described above. . either PSM or Ho) and the interaction between time and the MMPI scale of interest as explanatory variables.1 to 5 years after the MMPI. . 388 patients (31 percent) lived within 20 miles. 199 (16 percent) lived 121 to 250 miles away. During the visit studied. 515 (41 percent) were 66 years or older.039 patients (83 percent) had their tests and consultations completed (85 [7 percent] had missing data). and complete appointment itinerary could affect ratings of patient satisfaction. more than 10 years after the MMPI. Therefore. One included the MMPI scale of interest (i. we assessed whether the time between completing the MMPI and the patient satisfaction survey affected the associations we intended to study.IJHCQA 21. The survey was completed as follows: . including only the MMPI scale of interest (i.e. Results Patient characteristics At the time the satisfaction survey was completed by the 1. efﬁcient. 286 (23 percent) lived more than 250 miles away. 277 (22 percent) were seeking primary care. 219 (17 percent). . 201 (16 percent) were medical center employees or dependents. 1 had missing time data. the adjusting variables described above and the interaction between time and the MMPI scale as explanatory variables.e. Travel distance varied considerably: . The other model consisted of the MMPI scale of interest. 719 (57 percent) were female. we believed that scheduling a timely. 222 (18 percent) 1. 386 (31 percent) lived 21 to 120 miles away. Three sets of explanatory variables were used in the modeling. 5. and . 27 (10 percent) were 18 to 40 years old. . Wald x2 statistic p values were calculated from these logistic regression models. . Since the MMPI and the patient satisfaction survey were not completed concurrently. either PSM or Ho).
p . 63 percent. Pessimism and hostility scores 43 . However. The exception is the question pertaining to the patient’s willingness to recommend the center. for which the ratings were not associated with these MMPI scale scores. 67 percent. 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). and . This can be explained by the relatively large positive correlation between the PSM and Ho T-scores (r ¼ 0:61. 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). p ¼ 0:003). the PSM scale scores were not associated with willingness to recommend the center (86 percent of pessimists v. 89 percent of optimists. . p ¼ 0:001). p ¼ 0:002). reﬂecting an increasing pessimistic explanatory style. p ¼ 0:008). physicians responding to questions about the patient’s medical condition and treatment (57 percent v. However. 64 percent. 70 percent. 67 percent. respect shown by physicians (57 percent v. p ¼ 0:282). Speciﬁcally. p ¼ 0:002).e. . 63 percent.001). overall care received (55 percent v. overall care received (52 percent v.001). 75 percent. 0. The results from the models were also similar. 72 percent of the optimistic patients rated it excellent (p ¼ 0:003). the percentage of patients giving “excellent” ratings was signiﬁcantly lower. . This is evident in their responses on individual items: . 66 percent. This pattern was fairly consistent for all survey questions. In general. and . willingness of physicians to listen to the patient and family (60 percent v. even after adjusting for completion of tests/consultations and for all the previously identiﬁed predictors of satisfaction. higher Ho T-scores) as for the PSM scale. the odds of a patient giving the center an “excellent” rating were signiﬁcantly lower. respect shown by physicians (64 percent v.001). while 59 percent of the pessimistic patients rated the overall care provided by their physicians as excellent. 65 percent. overall care provided by their physicians (57 percent v. 0. helpfulness of allied health staff (53 percent v. with higher PSM T-scores. Furthermore. The same patterns were present among the “excellent” ratings in relation to patient hostility (i. With higher PSM T-scores. willingness of physicians to listen to patient and family (54 percent v.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. . p ¼ 0:002). p ¼ 0:008). 0. physicians responding to questions about the patient’s medical condition and treatment (53 percent v. p ¼ 0:001). a signiﬁcantly smaller proportion of pessimists than optimists rated other aspects of their care as excellent: . . helpfulness of allied health staff (47 percent v. . p . 71 percent. p . . p ¼ 0:047). the association weakened when adjusting for the Ho T-score. 66 percent. Table II displays the percentage of “excellent” ratings by Ho T-score groupings and the p values from the logistic regression models.
Patients with low scores (#39) were classiﬁed as optimistic.002 0.075 0. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes. * Entries are the percentages of patients rating that aspect of care as excellent.282 0.056 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. 0 ¼ no].219 0.774 0. pessimistic.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.002 0.003 0.003 0. sample sizes are ranges because the number of respondents varied among questions. 0 ¼ no).008 0. distance from the center by center employee/dependent status interaction.002 0.44 IJHCQA 21.843 0. seen in primary care area [1 ¼ yes. center employee/dependent [1 ¼ yes.002 0. 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. Within PSM groupings. Relationship between patient satisfaction rating of “Excellent” and the PSM T-score PSM T-score groups * Subtotals .841 . d Entries are the percentages of patients who “deﬁnitely would recommend” the center Table I. patients with high scores ($60). and patient age by center employee/dependent status interaction).011 0.221 0. and variables previously identiﬁed from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].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) ($60) 59 64 60 57 53 55 86 p1 a p2 b p3 c 0.005 0. a p1 is the p value from the test of the coefﬁcient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent. patient age [in years]. 0 ¼ not excellent) and the independent variables as for p2 but with both the PSM and hostility scale T-scores included in the model.133 0. PSM T-score.047 0. 0 ¼ no]. 0 ¼ not excellent) and the independent variable being the PSM T-score.229 0.002 0.
434 0. sample sizes are ranges because the number of respondents varied among questions.011 0. a p1 is the p value from the test of the coefﬁcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.008 0. center employee/dependent [1 ¼ yes. 0 ¼ no). Ho T-score. c p3 is the p value from the test of the coefﬁcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent. distance from the center by center employee/dependent status interaction.026 0. Within Ho groupings.941 Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend centerd Notes: Ho ¼ hostility scale of the Minnesota Multiphasic Personality Inventory.328 0.001 0. 0 ¼ not excellent) and the independent variables as for p2 but with both the optimism-pessimism scale and Ho T-scale scores included in the model.001 0.947 0.002 0.0. seen in primary care area [1 ¼ yes. patients with high scores ($ 60).0.001 0. 0 ¼ not excellent) and the independent variable being the Ho T-score. 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.046 .403 0. hostile.097 0. patient age [in years].048 0.068 .001 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 being completion of tests and consultations during the initial visit (1 ¼ yes. * Entries are the percentages of patients rating that aspect of care as excellent. and patient age by center employee/dependent status interaction).006 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 . 0 ¼ no]. Relationship between patient satisfaction rating of “Excellent” and the Ho T-score . d Entries are the percentages of patients who “deﬁnitely would recommend” the center Pessimism and hostility scores 45 Table II. Patients with low scores (#39) were classiﬁed as nonhostile. 0 ¼ no].002 0.001 0. and variables previously identiﬁed from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].001 0.
Clearly there are likely to be other patient-related characteristics that affect patient satisfaction ratings. However. our ﬁndings indicate that important data about the factors contributing to patient satisfaction ratings are missing if patient personality characteristics are not considered. 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 odds ratios increased by about 0. depression) at the time of the survey or episode of care.e.g.1 46 Again. before the encounter. Among patients who would deﬁnitely recommend the center. 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. When signiﬁcant associations existed. having a pessimistic explanatory style as theorized by Seligman) or hostile patients (i. This may result from feelings that. Adverse encounters were believed to result from the physician’s characteristics and behaviors or from organizational and structural factors surrounding the care episode. However. 83 percent) and non-hostile patients (Ho T score # 39.02 to 0. the exception to this trend was the question pertaining to a patient’s willingness to recommend the medical center to others. regardless of their opinion about some aspects of their experience during a particular care episode.03 for every 5-year interval increase. The odds ratios were estimated for each of the three models. These occur independently of other factors already known to contribute to variations in ratings of patient satisfaction. these patients would still recommend the center because of other factors such as the center’s reputation. or certain patient expectations.. Additionally. the estimated odds ratios that corresponded to a 10-unit (1 SD) increase in the MMPI T-scores increased with the interval. There was no signiﬁcant difference in the percentages of hostile patients (Ho T score $ 60. these aspects of patient personality were experienced subjectively and understood solely through physician’s intuition and judgment. In general. 88 percent) who reported “deﬁnitely would recommend the center” (p ¼ 0:434). Our results are a ﬁrst step towards understanding that certain aspects of the patient’s personality affect ratings of their satisfaction with care. Previously. patient satisfaction ratings for particular physicians and health care organizations are tacitly assumed to be a reﬂection of physicians or health care system. Our analysis shows that pessimistic patients (i. Now it is evident that some aspects of the patient’s personality affect ratings of satisfaction with care.e. We included all patients who had completed both a patient . our approach to studying the contributions of patient personality has not been previously taken. except for the question about willingness to recommend the center.IJHCQA 21. 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. high scores on the Ho scale) are signiﬁcantly less likely to rate satisfaction with their care as excellent. Table III displays the odds ratios for “excellent” ratings corresponding to 10-unit (1 SD) increases in MMPI scale scores for PSM and Ho. These may include emotional states (e. unknown to the physician. Discussion Patient satisfaction has been studied from various vantage points. It is notable that willingness to recommend our center to family and friends was not associated with hostility or pessimism.
74-1.77-0. and patient age by center employee/dependent status interaction).78-1.85-1.73-0. Ho ¼ MMPI hostility scale.74-0.85 0. PSM or Ho T-score. seen in primary care area [1 ¼ yes.83 0. 0 ¼ not excellent) and the independent variables as in model 2 but including both PSM and Ho T-scores.03) (0. 0 ¼ no].77-0.70-0.80-1. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.92 0.16) 0.06) (0.92 (0. MMPI ¼ Minnesota Multiphasic Personality Inventory.94 (0.94) (0.76-0.02) (0.76-0.86 0.79-1.13) (0.00) (0.21) 0.74-0.83 0.90 0. the OR was not signiﬁcantly different from 1 at the a ¼ 0:05 level. distance from center by center employee/dependent status interaction.99 (0. * * ORs are for the percentage of patients who “deﬁnitely would recommend” the center.75-0.00) (0.08) (0.84-1.80-1.80-1.85 0.94) (0.01) (0.79 0.01) (0.93) (0.80-1.75-0.94) (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.76-0.73-0.94) (0.93 0.96) (0.84 0.91) (0.72-0.81-1.76-0.87 0. and variables previously identiﬁed from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].76-0.95) (0. c Model 3 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent. PSM ¼ MMPI pessimism scale.98 (0.72-0.86 0. In addition.94) (0.81 0.07) 0.84 0.10) (0.80-1.75-1.94 0.88 1.11) 0.85 0.74-0.89) (0. d For example. b Model 2 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.86 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). OR ¼ odds ratio.82 0.00) (0.92 0.96) (0. 0 ¼ no].98 0.05) (0.84 0. for the PSM scale and the overall care by the physician.81 0.83 0.77-0. if the 95 percent CI for the OR contained 1.91) (0.98 (0.28) 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.97) (0.90 0.76-0.75-1. 0 ¼ no).77-0.85 0.01 Ho scale Model 2b Model 3c (0.83 0.Questionnaire item 0.86 0.94) (0.85 0.92 0.95) (0.93) (0.79-1. patient age [in years].76-0.00) (0. 0 ¼ not excellent) and the independent variable being the PSM or Ho T-score. Odds ratios (95 percent CI) for percentage of “Excellent” ratings for a 10-unit (1 SD) increase in the MMPI T-scores * .79-1.80-1.90 0.19) Model 1a PSM scale Model 2b Model 3c Model 1a 0.91) (0.81 0.92) (0.86 0. a Model 1 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.98) (0.73-1.87 0.81-1.97) (0.95) (0.06) (0.87 0.95) (0.83-1.85d 0.74-1.71-0. center employee/dependent [1 ¼ yes.
Friedman.. while contributing little to the practical management of hostile or pessimistic patients.. 18 No.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. Malinchoc. Irish. who had also been asked to complete an MMPI. Vol. R.M.T. L. M.. pp.. Medical Care. Hall. D. 376-87. pp. Golden. (1980). Journal of Clinical Psychology. Vol.. 4. S. “Proposed hostility and pharisaic-virtue scales for the MMPPI”. 71-95. recall.E. Patient satisfaction ratings may be decreased if these patients are also characterized by traits of pessimism or hostility. M. and Medley. Therefore. Taranta. Furthermore. References Bartlett. the possibility exists that physician care or manner may be modiﬁed by patient personality factors. Patient mix may temper an individual doctor’s satisfaction ratings. and Prince.. and adherence”. age of patient. one might speculate that patients coming to a tertiary care medical center for evaluation. H.. and type of care received. since astute physicians are attuned to the personal qualities of their patients. W. Nonetheless. Medical Care. A. 38. pp. (1954).IJHCQA 21. A. (1984).M. Vol.C. Schulman. DiMatteo. L. (1994). Offord.. Such patients are diagnostically and personally challenging for physicians. Grayson. Although these ﬁndings are intriguing.E. “Predicting patient satisfaction from physicians’ nonverbal communication skills”. Time limits were not imposed because we were studying two personality traits that are relatively stable.L. gender.S. 37 Nos 9-10. M. (1994). D. and communication in medical visits”. “CAVEing the MMPI for an optimism-pessimism scale: Seligman’s attributional model and the assessment of explanatory style”. M. Finally. and Seligman. We included these independent variables in the models as adjusting variables.. R. 32 No.H. including status as employee/dependent. Colligan. 1. Barker.R. 755-64. pp. This inﬂuence is independent of physician or practice characteristics. had a combination of medical and psychological issues requiring multidisciplinary investigation.A. pp. Levine. Cook. 1216-31. Patient satisfaction at our center is associated with several variables. 12. J... signiﬁcant differences were noted in satisfaction on the basis of levels of hostility or pessimism. .M. as deﬁned in this article. Ehrlich. and Miller. P. Roter. Vol. Physicians are much less likely to obtain excellent ratings from pessimistic or hostile patients. Journal of Applied Psychology. “Satisfaction. C.M. and Libber. 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. distance traveled for care. D. E. Vol. J. Conclusions and recommendations This research clearly demonstrates that patient personality characteristics play an important role in the results derived from patient satisfaction surveys. Journal of Chronic Diseases. 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. 414-8. K. 50 No. 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. “The effects of physician communications skills on patient satisfaction.W.P..
E. 1427-31. K. Mayo Foundation. T. R.C. W. and Malinchoc. “The inﬂuence of physician practice behaviors on patient satisfaction”. Colligan. (1997). (1989). pp. 25 No. Vol.M.emeraldinsight. A User’s Guide to the Mayo Clinic Computerized Scoring and Interpretative System for the Minnesota Multiphasic Personality Inventory (MMPI). M. pp.E. American Journal of Medicine.P. (1993). D. Mayo Clinic Proceedings. M. Rubin. C. Harvard Business Review. Vol. Brunner/Mazel.E. Archives of Dermatology. Jennings. 103 No.com Or visit our web site for further details: www.L. Vol. Mayo Clinic Proceedings.. 88-99. and Offord.A. 122. J. and Chamberlin. Jr. Azari. L. 418-25...R. W. 68 No. 11. Swenson. Vol. “Why satisﬁed customers defect”. R. A. McKinley. Bertakis.brian@mayo. B. Frye. achievement. D. Colligan. pp.D.C. 75 No. Vol. Gandek.. 2.P.. (1990).C. Hamburgen. 133 No. Corresponding author Brian A.A. “Patients’ ratings of out-patient visits in different practice settings: results from the Medical Outcomes Study”. Osborne.com/reprints .H. and Colligan.. 835-40. “The identiﬁcation and measurement of the psychoneuroses in medical practice”. T.J. “Optimists vs pessimists: survival rate among medical patients over a 30-year period”. 140-3 (“Erratum”. Seligman. 270 No. 7. and Federman..L. D. NY.. Vol.A. Journal of Family Practice.E. (1997). 736.edu Pessimism and hostility scores 49 To purchase reprints of this article please e-mail: reprints@emeraldinsight.P. R.. Maruta. J. 161-7. and Sasser. Jackson. pp. Vol. “Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome”. and Ware. C. 3. J. (1997). Journal of the American Medical Association. Vol. (2000).. Jr.C. in Mayo Clinic Proceedings. K. Costello can be contacted at: costello. S. M. 1. D. (1993).. Journal of the American Medical Association.. pp. W. Helms. Greenhouse. 339-47.. E. (2000).L.G. Brief Therapy Approaches to Treating Anxiety and Depression. 45 No. R. Vol. and Creten. McHorney. J. Offord. pp. Robbins. Probst. “Patient and physician satisfaction with an out-patient care visit”. pp. Rochester. (1993). Rogers. “Keeping hostility in perspective: coronary heart disease and the Hostility Scale on the Minnesota Multiphasic Personality Inventory”.R.. 75 No. Kosinski. p. 318). K. R. 5. Vol. 5... T. and health”. M.J.. R. Malinchoc.W. “Patient satisfaction: quality of care from the patients’ perspective”. 17-20.S. Family Medicine. and Selassie. K. M. New York. (1995).C. and Hathaway..O. (1943).A. J. Kirsner. pp. pp. Callahan. 109-14. J. Kroenke. 2. “Explanatory style: predicting depression.. H.Jones. Maruta. 3rd ed.
The current issue and full text archive of this journal is available at www. developing and implementing effective complaints handling systems to assist the industry as it grows in demand. Originality/value – Exploring patient and relative expectation and satisfaction in different theoretical contexts. 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. Design/method/approach – The author ﬁrst explores expectation theory and how it links to customer behaviour and then discusses conﬁrmation/disconﬁrmation theory. . 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. Caulﬁeld North. 21 No.htm IJHCQA 21. 2008 pp. 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 three continues to build the argument by further differentiating between customer expectations in intangible services and then health care services.emeraldinsight. It begins by differentiating between customer expectations in tangible products and intangible services. 1. School of Law. with the onset of the baby-boomer generation entering into aged care. Section four outlines how the role of expectations in aged care differs from those in health care. Additionally. Section two builds the argument that aged care services involve a unique and complex form of customer expectations.com/0952-6862.1 The role of understanding customer expectations in aged care Leib Leventhal Conﬂict Management Systems Designer. 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.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. both owing to the ageing population and to the social nature of baby boomers to complain when their expectations are not met. 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. Australia. Understanding the role of expectations in aged care is important because it can increase customer satisfaction. Keywords Elder care. Findings – The author builds an argument that aged care service providers must understand consumer needs and expectations so that customer satisfaction is generated. is critical. Additionally. Patients. 50-59 q Emerald Group Publishing Limited 0952-6862 DOI 10.
word of mouth or customer needs. while “should expectations” are those that the consumer thinks should happen in the next encounter. In the ﬁnal section. and . 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. They have also been identiﬁed as being fuzzy or focused. strategies for understanding customer expectations and implications for the aged care sector in the wake of its baby-boomer growth stage are discussed. (2) expected needs – those which customers are able to articulate when asked about what they want. (1992. events. implicit or explicit. Over time. services and the like. customers “expected needs” can become “must be needs”. . As Gilbert et al. A review of customer expectation theory Customer expectations are related to complaints through post-purchase affective states that cause affective behaviour such as complaining. increasing in intensity as more dissatisfaction is felt (Santos and Boote.staff must adopt unique approaches to understanding customer expectations. which therefore. a relationship standard based on the overall experience a customer has had in the past with a particular product or service. 2001). an ideal standard or subjective norm. unrealistic or realistic (Ojasalo. an industry standard or objective norm relating to the marketplace. 2003). and (3) exciting requirements – those unexpected needs that produce great satisfaction. Expectations can be based on market communication. Understanding customer expectations 51 How expectations form What forms the basis of expectations has been discussed extensively in the literature. Predictive or “will expectations” are those that the consumer thinks will happen in the next service encounter. Expectations have also been described as standards: . products. p. places responsibility on the provider of goods or services to continually improve . Additionally. satisfaction and dissatisfaction – all relative to the original customer expectation. but will only be missed if not provided for. along with organisational and structural attributes. 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. image. customer pre-attitudes or even the traditional marketing mix can inﬂuence what the consumer will expect from a product or service. Affective behaviours stemming from satisfaction and delight are compliments. Those emerging from dissatisfaction are complaints. These post-purchase affective states range from delight. Prior experiences with organisations also form the basis of consumer expectations. 47) put it: Expectations provide the yardstick people use to evaluate the attractiveness and desirability of outcomes. people.
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. Interpersonal elements that inﬂuence health care customer impressions include: . In summary. sensitivity (open ended questioning). a plethora of other stakeholders often become involved with service delivery. Understanding customer expectations 55 Quality of care impacts on the patient’s intention to return to the health care provider. becomes that kind of care. p. 2001). 1995). Consequently. In short. if patients’ quality of care expectations have been exceeded. Like other products and services. 1995. Loyalty comes from satisfaction. after one has taken into account the balance of gains and losses that attend the process of care in all its parts (Donabedian. quality of care: . 1999. [is] fully meeting the needs of those who need the service most. 1992 as cited by Lim et al. . An important health industry feature is that meeting customer expectations is not enough to guarantee customer loyalty and retention. 424). in a majority of cases. they will be satisﬁed and the health care service provider will retain customers (Bendall and Powers. 424). 1999. ﬁve common interpersonal expectations in health care – important to patients’ wellbeing – are staff attitudes (sincerity and trust). . . 1980. which make it harder to understand customer expectations in general services. if expectations are negatively disconﬁrmed. 50). 2001). each with his or her own set of interests and concerns (ACAA. non-verbal gestures. at the lowest cost to the organisation within limits and directives set by higher authority and purchasers (Ovretveit. p. . which turns into customers’ intention to return to the service provider. privacy (advocating for patient privacy) and appearance (all tangible aspects of care) (Perucca.and courtesy and warmth received).. responsiveness (recognising needs and responding). aged care services have additional layers of customer expectations that make providing these services far more complex than general health care. unlike health care services. Of course. aged care residential services are permanent residential arrangements and with that comes more extreme intimate issues such as . in addition to intangible and process elements of service quality. cited by Lim et al. are unable to articulate their concerns because of a lack of self conﬁdence and fear of retribution (ACAA. 2005). . which is expected to maximise an inclusive measure of patient welfare. Customer expectations in aged care services In addition to the interpersonal skills and caring attitudes needed to meet customer expectations in health care. eye contact. Aside from involving care recipients’ physical wellbeing. . body language and facial expressions (Perucca. and ability to break preoccupations. customer dissatisfaction will occur and the possibility of complaints opens (Bendall and Powers. attitude. 2005). deﬁned as: A process by which health care providers inﬂuence loyalty and maintain existing patients.. In addition. and . 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. aged care service customers are frail and elderly who. being able to tune out the world and tune in the patient. p. .
the importance of process delivery and the necessity of having a quality caring environment. fears. To assist in meeting the aged care residents’ and their families’ expectations. The daughter and mother had lived together all their lives. walking. including immediate family members. feeding. customer expectations in aged care will broaden to include updated information technology processes. security and emotional support (Thomas. when her mother began to suffer dementia. The daughter cared for her mother from 1994. 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. dressing and bathing. Moreover. when. However. This way. Finally. In summary. concerns. 2006). The mother’s dementia worsened to the point of not knowing her daughter by face most of the time. Case study This case study is the basis of a complaint lodged against a nursing home. The case solely represents the views of the complainant. the Aged Care Act 1997. aged care services have the additional complexities of understanding and meeting the expectations of other stakeholders aside from the direct customer. she was expert at administering medication. the mother asked her daughter to swear to her that she would never put her into a hospital or nursing home. hearing and anxiety. in addition to the intangible nature of services. wants. likes and dislikes. In no means is the following case meant to be treated as a judgement of the circumstances that surrounded the complaint. all of which the daughter expected to be done in the same manner in the aged-care facility. the mother was independently able to go to . other stakeholders. until 2003. It also involves deeply personal issues such as customer residency and security and family guilt. During the course of their lifelong companionship. 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. The daughter agreed to this oath and was faithfully fulﬁlling her carer’s role until 2003. Additionally. 2006). 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. when she could no longer bear the burden of being a full-time carer. these rules and principles may not be made clear to residents’ relatives. 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. Different family fragments give an additional complexity as multiple sets of expectations are involved. owing to the intangibility of the nature of service and lack of communication that exists within aged care facilities. 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. she became an expert at knowing every aspect of her mother’s needs. Quality of Care Principles 1997 and User Rights Principles 1997 deﬁne what aged care service customers should expect from their service and service provider. During the nine and a half years of care that the daughter experienced.1 56 home. it would be the best thing to place her mother in the hands of professional carers. A good example of this scenario is illustrated in the following case study. at the age of 92. Upon admission to the home. was placed in the care of a nursing home. The daughter wrote a full list of expectations and instructions (care plan) for the home staff to follow.IJHCQA 21.
Strategies for positively disconﬁrming customer expectations in aged care The onset of the baby boomer generation entering aged care is increasing demand for services. they were the expectations that were listed on the care plan that the care recipient’s daughter handed to the nursing home. those that must be delivered no matter what. The daughter naturally then lodged a complaint via the external complaints resolution scheme and is still pursuing a satisfactory settlement. over the next few weeks. As stated above. Now. wash herself after toileting. One basic strategy already in place in many aged care facilities is to understand customer expectations through resident and family meetings or discussions. Hence. as deﬁned above. (1999) discussed a method of increasing customer satisfaction called quality deployment function. according to the daughter. converse. this service was at the level of the “worst imaginable”. In this case. 2006). hearing aid not being attended to. the daughter communicated these expectations and expected and them to be fulﬁlled.the toilet at night time. 2001) or “minimum tolerable” (Santos and Boote. 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”. issuing medication without authority and with misleading information. these expectations refer to quality of care standards and principles set out in the Aged Care Act 1997. Unfortunately. This model goes through phases: Understanding customer expectations 57 . medicated to the point of being unconscious. according to the daughter. understanding the future customers’ needs and expectations will minimise the amount of time and money spent on complaints handling. feed herself with minimal assistance and walk with a walking frame. In aged care. not taken to the toilet at night. Her mother died ten weeks after entering the home. These included. She felt that her mother’s life was taken away from her owing to what she witnessed and described as horriﬁc care conditions. according to the daughter. This case can be divided into two components for analysis of expectations. allegedly owing to illnesses that were not detected because her mother was. 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. As a mismatch of customer expectations and experiences are the beginning of the complaints process (Thomas. 2003) expectations. 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. At this stage. 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. are those that the customer can articulate when asked about what he or she wants. These expectations. One-to-one interviewing could be used as an additional method for strengthening customer satisfaction and managing customer expectations (Halliday and Hogarth-Scott. not walked. In line with the Santos and Boote (2003) model of positive/negative disconﬁrmation. 2006). These expectations are deﬁned as “must be needs” (Ojasalo. not fed according to her visual impairment needs. 2001) or “desired” (Santos and Boote. 2003) expectations. providers need to create cultures for better practices in complaints handling (Thomas. having kidney failure and pneumonia. which led to the affective state of dissatisfaction. 2000). This case illustrates that both levels of expectations were not met. The ﬁrst group of expectations that were not met were those deﬁned above as “expected” (Ojasalo. Lim et al. the mother not being warmly dressed.
pp. “New customers to be managed: pregnant women’s views as consumers of healthcare”. Halliday. (1999). Journal of Health Care Management. (1964). “Handling complaints in Australia’s residential aged care facilities – a report”. Managing Service Quality. 3. Gilbert. H. it is vital to understand all stakeholders’ quality aged care expectations.R. and Dant.. N. Journal of Health Care Marketing. Listening Post. Gordon. pp. resulting in the daughter taking action through the external complaint resolution scheme. S. D. (1995). Adaptation Level Theory. and Powers. Vol. T.H. P. P. pp. Vol. “Cultivating loyal patients”. Vol. 1. 9 No. F. pp.IJHCQA 21. and that to avoid complaints to the external complaint resolution scheme. S. 15 No. Harper & Row. in aged care. Conclusion This article discussed expectation theory and how meeting customer expectations can lead to either conﬁrmation or positive/negative disconﬁrmation. As a result of not going through this process. the events described above occurred. 9 No. “An innovative framework for health care performance measurement”.V. 3.M. Vol. Managing Services Quality. 46-55.L. providers should do pre-admission assessments to determine whether a potential resident is suited to that facility (Phillips. 200-12. 11 No.1 58 (1) understanding who the customer is (in aged care. J. 6. or given the daughter the choice of seeking a different provider that would have better suited her needs. pp. Ojasalo. 55-69. (2) understanding their expectations through interviews. 12 No. 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.W.K. A case study of negative disconﬁrmation in aged care illustrated how it is the expectations of other stakeholders that are critical in understanding. Bendall. 4. government. 2005). Different types of expectations were identiﬁed.C. Lim. concerns and expectations to be met. “Adaptation and customer expectations of health care options”. 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. (2000). (3) ranking customers expectations.. and Jackson. NY. . J. Journal of Applied Management Studies. References ACAA (Aged Care Association of Australia) (2005). there are multiple parties that includes families. Sydney.). “Managing customer expectations in professional services”. New York. Tang. Vol. 50-2. R. Finally. care recipient. Services were highlighted as being distinct from products owing to their intangibility and delivery process requirements. and (4) identifying quality management systems that address meeting those expectations. (1992). Lumpkin. (2001). and Hogarth-Scott. Helson.P. 423-34. 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. etc.
Perucca. pp.L. Vol.com Or visit our web site for further details: www. Journal of Consumer Satisfaction. and Kumar. L. Parasuraman. 32 No. (2001). pp.Olshavsky. 41-50. Phillips.emeraldinsight. Zeithaml. “A theoretical exploration and model of consumer expectations. (2003).. A. 4. 14. (2006). “A conceptual model of service quality and its implications for future research”.A. 9. Corresponding author Leib Leventhal can be contacted at: LeibLeventhal@bigpond.com/reprints . April-May. pp. post-purchase affective states and affective behaviour”. (2001). J. pp. L. Santos. “Complaints: the right culture hears the message”. 24-5. Vol. (2005). Thomas. 2. R. Health and Aged Care Brief. 20-4. (1985).W. 49 No. R. Vol. 142-56. “Customers with options”. Dissatisfaction and Complaining Behavior. Vol. “One size does not ﬁt all. Nursing Management. pp. 60-73. A. Journal of Consumer Behaviour. Melbourne. Journal of Marketing. Summer. V. S. J. Does your facility ﬁt your residents?”. and Berry. and Boote. Russell Kennedy. National Health Care Journal. “Revealing the actual role of expectations in consumer satisfaction with experience and credence goods”. 3 No.com Understanding customer expectations 59 To purchase reprints of this article please e-mail: reprints@emeraldinsight.
e. We describe three main types of Swedish patient claims and complaints’ data: (1) data generated by Patient Insurance Fund activities. Thomas and Petersen. Measurement. Another issue is the balance between the size of study materials and the timeliness. 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. when diagnosis-speciﬁc analysis requires data pooling over several years in order to reach adequate case numbers.1 Patient claims and complaints data for improving patient safety Pia Maria Jonsson and John Øvretveit Medical Management Centre.com/0952-6862. The National Board of Health and Welfare.. 21 No. It then presents three types of data on patient claims and complaints in Sweden: data generated by the Patient Insurance Fund. 2000.htm IJHCQA 21. It is likely that a variety of data sources will be needed including patient claims databases.The current issue and full text archive of this journal is available at www.g. empirical evidence about the causes of and conditions inﬂuencing adverse events varies according to the investigation method. how they can be used. 2004a). Similarly. but little is known about the data. . Better patient safety depends on better data about incidence and causes. 2000. MMC. 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. This means knowing more about the different systems’ advantages and disadvantages for reporting adverse events and for gathering safety data (Zhan and Miller. 1. e.. 2008 pp. 60-74 q Emerald Group Publishing Limited 0952-6862 DOI 10. 2003). Sweden. Safety. Karolinska Institutet. their strengths and weaknesses.emeraldinsight. Design/methodology/approach – The article ﬁrst describes previous research into patient claims and similar schemes.g. (2) Medical Responsibility Board. both from research studies and from routine monitoring for timely action (Handler et al. data collection method and their limitations as a source of data about the true incidence and prevalence of injuries and safety problems. Patients. data on hospital case-mix. Keywords Quality improvement. 2003.1108/09526860810841165 Introduction Research shows signiﬁcant safety problems in health care in Sweden and abroad (Kohn et al. which makes it difﬁcult to know how much the data correspond to general injury rates and health care patterns. Stockholm. 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. Adjustment for confounders not present in the databases. and (3) Patients’ Advisory Committees respectively. 2004). 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. Findings – The databases’ value is problems related to spontaneous reporting. Phillips et al.. the Medical Responsibility Board and the Patients’ Advisory Committees and considers methodological issues in using the data. Empirical evidence about the number of adverse events for patients varies according to data collection methods.
the hospital admissions with adverse events prevalence was estimated at 9 per cent of admissions and 40. Patients using private providers in the county can also apply for compensation to this publicly funded patient insurance fund. 1996).In Sweden.7 per cent of hospitalisations and that 28 percent of these events were due to negligence (Brennan et al. 1991). The high proportion of patient management errors. The county councils’ Patients Advisory Committees handle all types of patient complaints concerning health services ¨ (Patientnamnden. discuss the value of patient complaints and claims data for research and practical improvement work.). Patients can apply for injury compensation. In Denmark. The committees also host databases with complaints’ information. 58 per cent of all adverse events. therefore. 2001).000 women in the general population were hospitalised owing to care complications in 2002 (The National Board of Health and Welfare. n. The National Board of Health and Welfare (2004 a) estimated that adverse events contribute to Patient claims and complaints data 61 .4 per cent of the adverse events were judged to be preventable (Schioler et al.000 men and 243 per 100. which we describe later. The Harvard Medical Practice Study estimated that adverse events occurred in 3. was regarded to suggest that many of the events would be preventable. present previous and current data analyses. Among these cases. Research into patient claims The frequency of adverse events that occur when patients receive medical care has been reported in a number of studies.5 per cent (Baker et al. events judged to be preventable occurred in 36. The Quality in Australia Health Care Study reported that 16. outline the databases’ development and the information available. n.8 per cent.. 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. 1991). is to: . Complaints’ data are registered in The National Board of Health and Welfare’s RiskDataBase. and holds extensive claims’ data.).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. 1995). statistics compiled by the National Board of Health and Welfare show that approximately 203 per 100.d. The Canadian Adverse Event Study estimated that the incidence of adverse events among hospital patients was 7. In Sweden.. 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. which may have resulted from a healthcare episode without having to ¨ ¨ prove negligence (Patienforsakringen. 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. 2000).d. Based on various databases and studies. This organisation is ﬁnanced from tax revenue raised by the local government counties... all healthcare providers are obliged to have a medical malpractice insurance policy to cover indemnity for patient injuries. 2004).. and .9 per cent and death in 20.. . the Medical Responsibility Board and the Patients’ Advisory Committees? Our purpose. 2004b). Data about these claims are available in an extensive database hosted by the Patient Insurance Fund.
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. 1989). compensation awards can be high. Insurance against claims is also high and medicine is practiced more defensively (Bovbjerg and Sloan. It also may be more likely that health care personnel report “errors” or “near misses”.g.IJHCQA 21. When compared to all claimants. 1998). This was one of the ﬁrst studies showing how these data help to predict and understand adverse events. which allows patients to seek redress from a doctor for perceived negligence (e. UK). Data suggested problem areas for attention that included supervision and foetal heart monitoring. obstetrics and trauma and orthopaedics (Davy et al. where patients do not have to prove negligence in a court of law (although they can use this route). 1990). 1998). 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. Patient claims and complaints systems provide different types of data about health care adverse events. diabetes patients were older and predominantly male. USA... and the total costs to society less. although there is no clear evidence. How has data from both types of malpractice claims systems been used for research. Under a tort system. There are thought to be advantages and disadvantages to each. 1986). Weycker and Jensen.. 2000). 2003).1 62 around 1. 1994).. systematic research into the epidemiology and aetiology of adverse events in the Swedish healthcare system has only just begun. 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. New Zealand and the Nordic countries). Although comparisons are difﬁcult. insurance costs are lower. 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. 2004).800 deaths per year.. This study identiﬁed 906 claims from patients with diabetes where the total indemnity paid was almost $27 million.. seeking compensation may be easier and less expensive.. which found rates associated with both physician performance and specialty (Taragin et al. and (2) a no-fault system.g. which is thought to be important for effective safety reporting systems. which traditionally produce the most claims – accident and emergency. Research also considered whether physician performance and type of speciality is related to malpractice claims.. An unpublished UK study found standardised incidence ratio of error highest in the specialties. Legal redress may act as a deterrent against lower practice standards (Hiatt et al. Under a no-fault system. 2000. The proportion of diabetes claims was highest in . 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.. 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. but can have their claim assessed and compensation awarded through another system. The Physician Insurers Association of America (PIAA) database has been used as a surveillance tool for diabetes-related malpractice claims (Meredith et al. usually administered by a government agency and tax funded (e.
or that health care has not met their expectations. found evidence that malpractice lawsuits could be prevented by quality interventions such as clinical guidelines. one study reported a dramatic rise in the incidence of nurses as defendants in malpractice claims (McDonough and Rioux. 2001. Since the databases were developed at different times and for different purposes.995 22.. 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. 16. Malpractice claims research has been used for ﬁnancial risk management and quality improvement. Goebel and Goebel (1999). Tsai et al.239 18. (2004) reported that medical experts considered that 83 per cent of 371 malpractice cases reviewed could be “improved by quality management”. 1998. The Swedish databases In Sweden the Patient Insurance Scheme.ophthalmology. A greater proportion of diabetes claims.129 8.395 8. Lester and Smith. 1997-2004 . Number of complaints to the Patient Insurance Fund.860 3. 1997).174 8.500 Sources: Statistics from the Patient Insurance Fund. Moles et al.717 8. Persson and Svensson. was associated with the highest level of injury severity. Patient claims and complaints data 63 Year 1997 1998 1999 2000 2001 2002 2003 2004 Patient insurance 8. 2000. Levinson et al.003 9. 2004). Adamson et al. Little research has considered the role of nursing or paramedic professions in patient claims. 1989). Medical Responsibility Board and Patients’ Advisory Committees. 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. as compared to all claims. m. Tsai et al. 1989).227 3.. Table I displays the number of complaints and claims made to each body (1997-2004).938 Medical Responsibility Board 2. for example. 22. they differ in the numbers of complaints as well as in the amount and character of information they contain.070 3. 2005). 1993. The study concluded that the PIAA database can be a useful resource to monitor trends in diabetes-related malpractice. internal medicine. 1996.572 m.. general and family practice..377 3.064 3.871 9... 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. More studies are examining which type of patients ﬁle claims and why (Hickson et al.250 3.552 8. 1994.664 Patients’ Advisory Committees m.119 3. In 1989. Prevention programs designed to reduce liability among high-risk specialties could also lead to improved care quality for patients with diabetes. Claims databases have also been used to assess economic costs (Fenn et al.. Annual reports from the Medical Responsibility Board and The National Board of Health and Welfare Table I.
Under the act. if it was caused by faulty medical or dental equipment or by incorrect diagnosis. both public and private care providers are obliged to have a medical malpractice injury policy that covers patient indemnity. irrespective of fault or negligence. 1975-2004 . .300 in the ﬁrst year of operation in 1975. Indemnity for personal injury can be paid.400 claims in 2003. . 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. 3.000 in 1983. and . Figure 1. if the injury concerned could have been avoided. 7. There is no indemnity in cases where the treatment simply has not led to the desired result or where (predictable) complications arise. In January 1997 the voluntary insurance scheme was replaced by The Patient Injury Act (1996). in the event of accidents in connection with medical or dental care and in connection with incorrect prescribing. Figure 1 shows the annual numbers of both applications for claims and compensated cases from the Patient Insurance Fund (1975-2003).IJHCQA 21.1 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. 9. Indemnity for patient injury could be paid on objective grounds. when a treatment injury as described in the insurance conditions occurred. Claims applications have increased to: .000 in 1993. The conditions in the Act on Injury to Patients largely correspond to the conditions of the previous voluntary scheme. if infection has been transmitted in the course of treatment. 5. Number of claims to the Swedish Patient Insurance Fund.
Specialties with many cases registered in the database include orthopaedics. 2003b). this action is usually an admonition or a warning. 2006). care giver type. Raf and Claes. 1996). care level. since 1998. Ohrn et al. operation for short-sightedness. After 1994. and . after which the Board examines the case and decides. data about possible surgical interventions.Overall 40-45 per cent led to a compensation payment. 1999). 1996. cardiovascular disease. Johansson and Raf. surgery.. Gender-speciﬁc analyses have indicated differences between women’s and men’s injury patterns ¨ (Jonsson and Raf. 1998. Previous studies addressed a range of clinical topics – e. e. to speciﬁc types of medical error or to the use of selected medical technologies ¨ ¨ ¨ (Cronstrom et al. but a generally higher risk of lethal patient injury among men. . The numbers of complaints to the Medical Responsibility Board and the numbers of disciplinary Patient claims and complaints data 65 . .. Regarding such injuries.. cases solely concerning services a patient has received are referred to the Patients’ Advisory Committees. . Certain cases are examined by the chairman alone. injury cause and effect. there is a higher risk of women injured by radiological examinations. Anyone who is or has been a patient can ﬁle a complaint to the Medical Responsibility Board.g. . injuries related to certain clinical ﬁelds. although a small proportion of cases involve withdrawing registration following notiﬁcation from the National Board of Health and Welfare. breast implant etc. and . . The complaints are reviewed by medical experts. Diagnosis and operation codes are used to analyse injuries to patient groups (diabetes..g. injury year. Over the years about 60 per cent of cases have concerned female patients (Pukk et al. data can be analysed by: . patient consequences. Consequently.) or patients undergoing a particular treatment (hip joint replacement. 1997. When taken. data include: .). the complaint may be submitted by a close relative. . which investigates complaints against all registered health care professionals to examine whether there is cause for disciplinary action (Instruction to The Medical Responsibility Board. cataract etc. 1997). . county council. gynaecology and ¨ ˚ obstetrics (Jonsson and Wahlberg. medical specialty. injury effects. basic diagnosis. there were previously also complaints about poor service or care quality. injury cause. If the patient him/herself is incapable. Medical responsibility board The Medical Responsibility Board is an independent national authority. Apart from complaints about errors in medical treatment.
. but was most prominent in dental care and general medicine. e.521 2. 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. 2002).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. They give advice to patients and provide a quasi-independent body for investigating dissatisfaction and mediating disputes Complaints n 2. Number of complaints received and disciplinary actions taken by the Medical Responsibility Board. Hence. The study identiﬁed second-hand information as an aggravating circumstance when assessing the urgency of care needs.659 2. Another study analysed all available complaints about stroke management made to the Medical Responsibility Board over a ﬁve-year period (Johansson et al. Data from the Medical Responsibility Board have been used in regional comparisons (The National Board of Health and Welfare. in contrast to sparsely populated area rates. Uppsala.IJHCQA 21. which shows that a steady increase in the number of cases appears to be levelling off. have few direct sanctions and do not have disciplinary powers. 2003). Kalmar and Kronoberg counties.250 3. 1998). The Patients’ Advisory Committees do not make medical judgements. Claims rates were ¨ appreciably higher in Stockholm.860 3. Nearly all disciplinary actions against physicians concerned misdiagnoses (subarachnoid haemorrhage in particular).1 66 actions in 1995-2004 are presented in Table II.064 3. Cases from the Medical Responsibility Board have been presented in the Swedish Medical Association Journal. 1995-2004 Source: Annual reports from The Medical Responsibility Board . In January 1999.119 3. The Stockholm region also showed the highest number of disciplinary actions per inhabitant. The most common reason for a nurse receiving a warning or an admonition was negligent handling of drugs.227 3. but there have been few scientiﬁc analyses of the material. Analysis showed large differences in Sweden between counties in number of claims per inhabitant in 1999/2000.g.. 2004). Patients’ advisory committees The ﬁrst Swedish law about the Patients’ Advisory Committees was created in 1980. the survey identiﬁed two areas that educational programs could improve patient safety. The high claims rate in the Stockholm region applied to all types of activity. an exploratory study analysed factors and circumstances related to complaints in emergency medical dispatching. a new law came into force. Recently.070 3. partly based on complaints to the Medical Responsibility Board (Wahlberg et al. Goteborg and Bohus counties.377 3.
The Committee’s aim is to solve problems quickly and in a non-bureaucratic way. Results showed that. they feel they may suffer in the future as a result. It is also their task to refer patients to other agencies.. The conclusion was that dissatisfaction about lack of information and patient participation was more likely to be detected by surveys. Distribution of complaints to the Stockholm County Patients’ Advisory Committee.743 % 32 12 45 11 100 n 967 431 1. calculated per 100.000 complaints were ﬁled in 2002 (The National Board of Health and Welfare. Table III shows the complaints’ distribution by one county’s Patients’ Advisory Committee about different issues (Stockholm County Patients’ Advisory Committee.951 Women % 33 15 43 10 100 Table III. hospitals. 24 per cent primary health care and 8 per cent mental health services. This analysis and the studies noted earlier show how each database provides a different picture. the importance of knowing the strengths and weaknesses of each and often the need to use multiple data sources. 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. because. 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. In 2001. Reports to the National Board of Health and Welfare show that more than 22. were compared with corresponding rates for the Medical Responsibility Board and the Patient Insurance Scheme. According to Committee representatives. The previously mentioned study on emergency medical patching (Wahlberg et al. Annual Report 2005 . by gender. Analysis also considered data from patient questionnaires in the same hospitals. public health care districts and other involved authorities. for example. it is problems patients do not want to raise directly with personnel. 2003). 53 per cent concerned inpatient care. The rates per specialty. to ﬁle a malpractice claim. 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. Of these. communication. for example in the ﬁelds of neurology and geriatrics. Sometimes. information Organisation. 2002). Complaints are often questions or criticisms that patients or relatives have tried to take up with healthcare personnel.000 discharges.between patients and health services or personnel. Patient claims and complaints data 67 Men Type of complaint Medical treatment Interaction. 2005 Source: Stockholm County Patients’ Advisory Board. for example. an analysis was made linking data about complaints to the Stockholm County Patients’ Advisory Committee with data from National Patient Register (Arnetz and Arnetz. 2006). while applications and claims in specialities such as obstetrics and gynaecology were higher. the reverse was true. 2003) drew some data from one of the committees. Little research has used data from the Patients’ Advisory Committees.255 298 2.
encouraging and assisting the complaints process. the Patient Insurance etc. have been the basis for the production of this kind of statistic from the National Patient Register (The National Board of Health and Welfare. While this is possible for hospital inpatient care through links to the National Patient Register. 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. but there were variations regarding complaints per 1. Regarding Patient Insurance. it may be advisable to relate the numbers of claims to the healthcare utilization rates. Increased healthcare utilisation is likely to increase the magnitude of harm.000 inhabitants. but there may be cut-off points where the beneﬁt-harm ratio gets too low and the level of healthcare utilisation should be questioned. 1993). 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. Cases are registered in order to assess liability and damages or to solve patients’ problems. used in Sweden since 1998. in comparative studies. researchers and quality improvement practitioners should use these data with caution and awareness of their limitations. different age groups and between women and men. The tendency in various patient groups to report shortcomings in service and treatment to The Medical Responsibility Board. number of complaints per 1. and by healthcare providers’ attitudes and approach to informing.IJHCQA 21. It was noted that neither reporting nor compensation rates were constant. Hence. However. is important. 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. 2004b).1 68 Methodological concerns As the complaints and claims’ databases are so voluminous and the information in them relatively detailed. e. they seem to have a potential to help both quantitative and qualitative quality and safety of care analyses. A critical question is how far matters reported to different instances correspond to general dissatisfaction or injury patterns. trafﬁc safety.000 hospital discharges and number of injuries for which compensation was paid in relation to number of complaints. Similar differences may exist between various clinical specialities. 1992). there are great difﬁculties in calculating rates in outpatient care owing to the lack of outpatient services national registrations. Most patients experiencing problems do not complain. insurance practice over the years also affects material composition. In 1992. and only give a partial picture. The data might not be collected consistently over time.g. One way of dealing with problems related to spontaneous reporting is to follow long-term . Analysing patient injury rates in the general population also permits comparisons of the safety problem magnitude across different society sectors. not for the purpose of assessing quality and its determinants. county councils were compared regarding claims’ numbers and ´ compensated cases from the Patient Insurance Scheme (Rosen and Jonsson.. The ICD 10 classiﬁcation Y-codes. The problem of spontaneous reporting One special methodological problem analysing and interpreting data from the databases is that they are based on spontaneous reporting. Some may make false claims. let alone make a claim (Øvretveit. This may interest researchers when societal resources are allocated to prevent accidents.
The Patients’ Advisory Committees data. may be additionally aggravated by differences in reporting tendency. 2003a).g. 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.. 2003). A solution may be to pool data over several years to attain enough observations. different specialties or patient groups.g. Adjustment for confounders Special difﬁculties arise when the purpose of the analysis is to compare complaints or claims rates between hospitals or healthcare units. this procedure does not deal with the differences in reporting tendency that may exist between men and women and different age groups. lack of information and patient participation. sex and severity of illness is important when comparing clinical outcomes. it is difﬁcult to know how much of a change is happening in different ﬁelds over time.trends that reveal themselves in the proportions of total materials represented by. there seems to be a weak case for comparing hypothetical standard populations instead of real-life patient ones. orthopaedics and general surgery were compared with hospital managers perceptions care quality in their departments (Pukk et al. Unfortunately. gynaecology/obstetrics. could also be used in qualitative analysis of problems that patients experience in health care. however. needs to be balanced against the rapidity of change in medical practice. Here.g. owing to organisational factors. selection by diagnosis and type of medical or surgical intervention easily reduces the volume of study materials. While adjustment for confounders such as age. we cannot exclude that results may be somewhat biased by lack of adjustment for confounders when comparing the claims rates from different departments. 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. Hence. This. 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. In the claims data.. owing to few previous studies on risks and safety. regardless of patient population composition. High patient satisfaction should be one care target at all healthcare units. however. No correlation was found between managers’ adverse events’ perceptions and the actual claims frequency from patients’ associated with the department. However. the practice of medicine and safety of care may be different today compared to the early 1990s. Responsiveness inherently means that service is adjusted to patients’ needs and expectations. e. Size becomes even more critical if analysis is to deal with several confounders. claims rates from departments of general medicine. Although the study gives an indication of an important phenomenon that should be analysed further. Patient claims and complaints data 69 . The size of the study material is mainly a problem in quantitative research. Size of materials and timeliness of study Although three databases contain large numbers of complaints regarding different medical specialties. the variations between hospital case-mix that occur. the same logic does not necessarily apply to complaints about. In a recent study involving data from the Patient Insurance Scheme. e. e. Owing to medical and technological development.
the healthcare professionals’ reporting tendency has not been subjected to study. are relatively few. e. Canada.400 cases. Following analysis.g. “Lex Maria” (named after an incident at Maria Hospital in Stockholm in the 1930s. .IJHCQA 21.500 cases in 2002). approximately 9.. or that not all complications lead to injury entitled to compensation. under certain circumstances.1 70 Relationship to other sources of safety information As illustrated earlier the National Patient Register includes information about all hospital discharges in Sweden. the annual numbers of Lex Maria cases have not changed much since the mid 1990s. Canadian Institute for Health Information. It should. This and other studies show the value of data on claims and complaints for providing information for researchers and practitioners.000. however. McLoughlin et al. The Swedish Patient Register is in many ways comparable to hospital data sources in other countries. Patient Insurance Fund claims. 2004b). Changes are also possible to these databases and collection systems to make them even more valuable for quality improvement. while the Patient Register only covers hospital inpatient care. Correspondingly. In comparison. but knowledge of risks gives care providers more opportunities for improving quality and helps care consumers choose care and treatment. often the senior physician or the nurse with medical responsibility. In 2002. patient safety indicators constructed from administrative data and developed in. Hence. Analysis of existing data at a local and national level can provide valuable insights for quality interventions as well as for research. Serious injuries. which is related to quality and is driven by patient and user perceptions. the risk of serious patient injury has not changed over time. 1.000 cases were reported according to Lex Maria. Tentatively. 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. is not possible to judge today. As opposed to patient claims and complaints. To what extent this is due to patients underreporting problems. e. Australia and UK (Danzon. The obligation to report rests upon the person nominated by the health care principal. in practice. 2006. at what type of institution and in what medical service an injury or an incident occurred. which contains information on cases since January 1992. and what consequences repeated events can have for the patients affected. 2006). Such analyses could also shed light on the extent patients’ claims and complaints reﬂect safety problems grasped by purely medical-technical safety indicators. the material can show. diseases and risks in health care must. 2006. be reported to the National Board of Health and Welfare – according to a special law. There is a case.g. Statistics regarding “Lex Maria cases” are collected in the Board’s RiskDataBase. 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.200 claims in 2002 – can be compared to the numbers of injuries coded as mishaps (approximately 3. including ICD 10 codes for medical and surgical treatment complications (The National Board of Health and Welfare. when a number of patients died owing to malpractice). be noted that claims data include all levels of care. the numbers of claims to the Medical Responsibility Board – 3. Conclusions The risk of adverse medical events and medical errors can never be entirely eliminated. However. 1990). The number of registered complications in 2002 was approximately 22. therefore.
pp.. pp... A.O. P. Laird. 11.A. pp. 67. pp. Blais. Sheps. Law. 18-55. available at: http://secure. 187-95. and Scott. 324 No. 251-6. F. Norton. (2003). “Malpractice occurrence in emergency medicine: does residency training make a difference?”. Ennis.A. Davy. G. Baker.H. (2002). Hebert.C. V. Canada. Vol. 150 No. 3. S. Tschann. and Fenn. N. 53-123. T. Briant.. “Obstetric accidents: a review of 64 cases”. Agency for Health Care Research and Quality. Each system has its biases. Lay-Yee.L. H. A.htm ¨ ˚ Appelros. Gullion. Localio. Vol. pp. J. Patient claims and complaints data 71 . R. G. (1998). B. pp. N. A. Hebert.therefore. Esmail. Majumdar. R. “Physician communication skills and malpractice claims. pp. Owall. Leape. 1678-86. Medicine and Health Care.. Hogeras.. available at: www.J. 18 Nos 1-2. pp.P. “Case ascertainment in stroke studies: the risk of selection bias”. CIHI (2006). (1989). and Arnetz. (2003). B.. AHRQ (2006). pp. 2. P.E.A.. R. 330-8. the United Kingdom and Australia”. Arnetz.. Results of the Harvard Medical Practice Study I”. Patient Safety Indicators Overview.. A.jsp?cw_page ¼ patient_safety_e ¨ ¨ Cronstrom.R. A complex relationship”. W. 107 No. and Terent. Danzon.gov/psi_overview. P. C. International Dental Journal. P. 6. Cox. Branney. Reid. N. 145-9.. J. Markovchick. Beckman. S..G. Vol.... Manchester Health Services Centre.M. but using a combination can provide a more objective picture.. R. 99-105. and Hiatt. (1996). V. 300. Acta Neurologica Scandinavica. Ghali.S. Analysing Malpractice in the Hospital Setting.M. J. “Treatment injuries in dentistry – cases from one year in the Swedish Patient Insurance Scheme”. Thousand Oaks. and Sloan.. for using data from a number of sources to provide different perspectives on the rate and causes of safety and quality problems. Etchells.R.. “The ‘crisis’ in medical malpractice: trends in the United States. 19 No. “No-fault for medical injury: theory and evidence”. Vol. and Vincent.. Vol. Newhouse. P. Flintoft.. cihi. Vol. Canadian Medical Association Journal. 48 No. Weiler.. Canadian Institute for Health Information. New England Journal of Medicine. 370-6. T. O’Beirne. L.A. CA. and Rene.. Sweden’s Health Care Report 2001. Quality and Safety in Health Care. Stockholm. Pons. (1991). Lawthers. pp. P.. The Western Journal of Medicine. 356-60.R. and Thomasson. References Adamson. 48-58.ahrq. Davis. (2004). Vol. A.R. P. The National Board of Health and Welfare. Brown. and Oppenberg. M. (1990). (1998). R. S.. A. 3.M.. J. pp. British Medical Journal. 12 No. 170 No.. (2000)..A. Vol. J.qualityindicators. R. 1365-7. Vol. “Preventable in-hospital medical injury under the no fault system in New Zealand”.. (1990). Patient Safety.G. P. R. M. Bovbjerg. L. Palacios-Derﬂingher. “Nursing negligence”. C. University of Cincinnati Law Review. Brennan. D. pp.ca/cihiweb/dispPage. and Tamblyn. Manchester. “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada”. 4. A. The Journal of Emergency Medicine. “Patients’ views of the health services – what do complaints to the patients’ advisory committee tell us?”. L. (2004). “Patient safety: lessons from litigation. 2. Sage Publications. E. “Incidence of adverse events and negligence in hospitalized patients. Vol. The epidemiology of error: an analysis of databases of clinical negligence litigation”.. unpublished report to the UK National Patient Safety Authority and Department of Health.
Levinson. M. N.. Barnes. English summary available). N. Kohn. Localio.. identifying. K. and Asplund.A. (1997a). New England Journal of Medicine. Laird. Leape. Entman. and measuring error in emergency medicine”..S. R. 1567-71. “A study of medical injury and medical malpractice: an overview”. Cerebrovascular Diseases. Brennan. “A compilation of ‘diagnostic errors’ in Swedish health care. G.M.S. L. Leape. A. Osteotomy & Continence Nursing. 4. 321 No. C.hsan. Lawthers.1 72 Fenn.R. . Vol. Hebert. Washington. L. Brennan.L. Norstedts.se ˚ Johansson.G. 1583-7.. and Raf. K. available at: www. 7. 324 No. W.. and Raf. Gray. A. (1993).. 865-68 (in Swedish). Miller. Instruction to The Medical Responsibility Board. 10 No. 247-70 (in Swedish.. Barnes. and Corrigan. (2000)..B. pp. ˚ Jonsson. pp. Gillam. and Sloan. “Mishaps in the management of stroke: a review of 214 complaints to a medical responsibility board”.M. (1989). 43. Vol. 7 No. “Deﬁning. Vol. (2000). Weiler. L. Lester. (1989). (1997b). 272 No. R.. Law of the Patients’ Advisory Committees (1998). Mullooly. “Increasing number of nurses named as sole defendants in malpractice suits”. Gender Equality in Health Care. M. Vol.M.S. and Frankel. Peterson.A... 377-84. M. 3848-50. B. C. 94 No. P.B. pp. P. A. “Physician-patient communication.H. Dull..M.. pp.. E. To Err Is Human. Academic Emergency Medicine.C.L. “Reported shortcomings and problems in health care from a gender perspective”.A. Lakartidningen. Localio. L. J. L.. (2004). British Medical Journal. M.. pp.P.A.B. (1996).IJHCQA 21.T. S. Vol. 16-21. Hodges.A.och Sjukvardens Ansvarsnamnd” (“Who can you turn to if you are dissatisﬁed with the care you receive?”). Goebel. Sanders. S. Handler. 158 No. H. A remedy for malpractice suits”. J. Laird. L..M. (1991). 320.. A. 1183-8. H. The relationship with malpractice claims among primary care physicians and surgeons”..P. Journal of Wound. Roter. pp. 480-4. and Wahlberg. 1996: 571. 3. P. P. A. McDonough.. F. Vol. and Goebel. Results of the Harvard Medical Practice Study II”. Vol. 94 No. and Thorpe. “The nature of adverse events in hospitalized patients. 26 No. (Eds) (2000). Journal of the American Medical Association.. Vol. Vol. and Rioux. 4-12. pp.. R. Whetten-Goldstein.. 1. D. 7. J. “Current cost of medical negligence in NHS hospitals: analysis of claims database”. G. P. and Klasco.H. Forum.R. K. L. T. 277 No. 20. pp. Newhouse. (1997). H. ¨ Jonsson.P. “Is quality of health care for women worse than for men? Two ¨ out of three insurance claims concern women”. 175-84. K. W. and Hiatt.G. “Listening and talking to patients. “Halso..L. pp. Githens. J. pp. S. pp. New England Journal of Medicine. V.. (1999). Newhouse. Vol. 10. Clayton. Stockholm (SOU 1996:133). Donaldson. R. “Obstetricians’ prior malpractice experience and patients’ satisfaction with care”. pp. J. The Western Journal of Medicine. ¨ ˚ ¨ HSAN (1996). 6. The Swedish National Committee on Gender Disparities in Patient Care. T. Diacon. Law of the Patients’ Advisory Committees (1998:1656). 1. B..W. Lakartidningen. Hiatt. “Clinical practice guidelines for pressure ulcer prevention can prevent malpractice lawsuits in older patients”.. (1994).B.. and Smith. Vol. 11. Lagerstedt. 268-72. A. A..A. ¨ Johansson. National Academy Press. N. Hickson.E. and Rickman.. Building a Safer Health System. Vol. DC.H. 18 No. ¨ Missed diagnosis is most often a fracture” (in Swedish). Journal of the American Medical Association. pp. Lawthers.T. 553-9..
Patient Safety and Safety Improvement – An Overview.. R. G. K.J.V. 4. (2006) Vol. J. D. (2005).A. 232-9. Miyoshi. R. 225-31. (The) National Board of Health and Welfare (2004b). “Use of the Physician Insurers Association of America database as a surveillance tool for diabetes-related malpractice claims in the US”. Supp. 96 No. Scheer. 7. Injuries reported to the Patient Insurance Scheme as a Basis for Injury Prevention. G. (2006). Phillips. pp.. (1998). Vol.se ¨ Patientnamnden – The Patients’ Advisory Committee (n. (2003b). V. Pukk.M. 18. ¨ ¨ Patientforsakringen (n. and Svensson. and Claes. “Do health care managers know the comparative quality of their care?”. Aylesbury. Vol. “Prolonged national economic effects following patient injuries in Swedish health care. 14-20. and Gaffney. 534-9 (in Swedish). T. Quality Management in Health Care. The National Board of Health and Welfare. (1993). pp. shows data from the Patient Insurance. and Bates. M. Hospitalisation due to injuries and poisoning in Sweden 1998-2002. pp. Horn. M. Rutberg.. D. Monitoring and Evaluation of the Health Services. (The) National Board of Health and Welfare (2002). Mattke.. J. Stockholm (in Swedish)..E. “Dental negligence: a study of cases assessed at one specialised advisory practice”. Moles. J. Vol. J. (1998). P. Simper.. J. (1999). 1096-100. 121-6. The Patient Injury Act (1996:799). ¨ Raf. Øvretveit. Patient claims and complaints data 73 . The Patients’ Advisory Committee. Patients should be informed about the risks”. (The) Patient Injury Act (1996).d. Project Report. Vol. Quality Management in Health Care. (The) National Board of Health and Welfare (2003).A. 184 No. Quality and Safety in Health Care. Diabetes Care.. I. 69-90. Vol.patientforsakring. pp. The single injury is expensive. A.D. pp. Franca. The National Board of Health and Welfare. pp. Tropp.cs Persson. M. V.). A.M. Stockholm (in Swedish). 103 No. pp. 8. Somekh. The Swedish Institute for Health Services Development. B. L. Fryer.L. 130-3. Technical Communications Publications Ltd. S. U. Dovey. (2003a). 18. Vol. 102 No. 8.. 12 No. ´ Rosen.. Millar. (1992)..A. 2001. Bartholomew. (2004). International Journal for Quality in Health Care.. R.d.). Stockholm (in Swedish). L. H. and Elfstrom. and Bedi. 13 No. A. 12 No. Lundberg. 2. Jonsson. Sweden’s Health Care Report 2001.. B..B.. Lakartidningen. pp.. and Green. pp.. J. Cook. (Statistics – Health and Diseases 2004:2). C. “Orthopaedic surgery the most common cause of patient injury”. and Olsson. Gaffney. 930-32 (in Swedish). Vol.M. ¨ Lakartidningen. R.. D. 42. Stockholm (in Swedish). K. Lakartidningen. Brommels. Pukk. S. Measuring Service Quality. Meredith. Vol.. Vol.. available at: www. Lundberg. H. 21 No. J.McLoughlin. Patient Insurance. ¨ ¨ Ohrn. F.sll. but the total number of ¨ injuries is relatively low”. and Penman. L. available at: www. Patients’ Advisory Committees’ reports to the National Board of Health and Welfare. pp. P. se/w_ptn/19010. 3020-5 (in Swedish). adverse events in primary care in the United States”. and Jonsson.R. “Complications are frequent after surgery for excessive hand ¨ sweating. British Dental Journal. “Selecting indicators for patient safety at the health system level in OECD countries”. “Do women simply complain more? National patient injury claims data show gender and age differences”. 4.. Vol. Jr.. Peneloza-Pesantes. “Learning from malpractice claims about negligent. Penaloza-Pesantes. R. (The) National Board of Health and Welfare (2004a). Spri. 3.
S. Vol. Vol. Gibberd. M. Tsai. 49 No... Svenning.T.A. pp. 163 No. R.. “Information on malpractice: a review of empirical research on major policy issues”. ii58-ii63. Stockholm County Patients’ Advisory Committee (2006). (2004). pp.se To purchase reprints of this article please e-mail: reprints@emeraldinsight. A. 12.emeraldinsight. F.R. Y. Lipczak.. Bech. Annual Report 2005. (1986).com/reprints .S. S. (2003).T. Wilson.1 74 Schioler. A.M.. P. Supp. Law & Contemporary Problems. L. G. “Incidence of adverse events in hospitals. Gibberd. A retrospective study of medical records”.maria. 322. 4.R. Vol.IJHCQA 21.R. “Relationship between malpractice claims and medical care quality”. and Bovbjerg.B. 269-77. pp. 458-71. 18 No. 39.. Newby. 2. “Measuring errors and adverse effects in health care”.. 272-8.. European Journal of Emergency Medicine. pp. II. pp. Ugeskrift for Laeger. 5370-78 (in Danish).. and Miller. and Harrison. 320. and Wredling.A. A. A. B. R. (1994). Health Care Management Science. Vol. S. pp. R. pp.. and Hamilton.. J. Trout. Harrison.. Cedersund. “The quality in Australian health care study”. Mogensen. “Factors and circumstances related to complaints in emergency medical dispatching in Sweden: an exploratory study”. R. 61-7. British Medical Journal. W.N.L. pp. Shapiro. (1995). W. Weingart. Vol. 4.R. Koller. 85-111.B. British Medical Journal. Vol.. pp.J. “Does physician performance explain interspecialty differences in malpractice claim rates?”. 17 No. 1. Karns. D. Quality and Safety in Health Care.L. Zhan. R. Runciman.C.. Stockmarr. International Journal of Health Care Quality Assurance.. 3 No. (2001).jonsson@ki. “Administrative data based patient safety research: a critical review”. Vol.. Sonnenberg. B. T.M.. 9. and Petersen. Corresponding author Pia Maria Jonsson can be contacted at: pia. 774-7. (2000). Vincent. W. Vol. C.E.. 7. Taragin.. C. and Frolich. E. 10 No. (2003).D. 7. (2003). M. T. (2001). Stockholm County Patients’ Advisory Committee.. Stockholm (in Swedish). “Epidemiology of medical error”. R. H. J. 163 No.J. Neale. K. Wahlberg. and Carson. pp. and Woloshynowych. Journal of General Internal Medicine. M. E. 32 No. Medical Care. and Chiang. Weycker.A. Zuckerman. Wilson. 517-9. C. and Jensen.W. Vol. Vol.I. “Adverse events in British hospitals: preliminary retrospective record review”. 661-7. 7394-400. M. Medical Journal of Australia. Pedersen. L. pp. Kung. Thomas.C. “Medical malpractice among physicians: who will be sued and who will pay?”. (2000). B. Vol.com Or visit our web site for further details: www. G.
Meinhard Schiller. Clinicians tended to rate their services and offerings higher than referring physicians (p ¼ 0:019). is of growing importance in the rapid changing health care market. Customer services quality. Geographic range was correlated with the frequency of patient commendation (p ¼ 0:005) and the perception of friendliness (p ¼ 0:039). 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. In the German health care system. Munster. Keywords Questionnaires. 1990). Although Germany has a health care system that allows patients direct access to specialized care (Coulter. Originality/value – Survey results should be useful for continuous quality improvement by regular measuring and reporting to executive boards. 2008 pp.htm Evaluating hospital service quality from a physician viewpoint Peter Hensen. Since referring physicians play a strategic role ensuring the survival of institutions providing health care services.The current issue and full text archive of this journal is available at www.com/0952-6862. 1. 1998. 2005). Germany Abstract Purpose – The purpose of this research is to show that referring physicians play a strategic role in health care management. Munster University. This study aims to evaluate the perception of hospital services by referring physicians and clinicians for quality improvement. mutually beneﬁcial International Journal of Health Care Quality Assurance Vol. Hospitals. They inﬂuence the patient’s choice of where to be admitted and organize most of the pre. 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. referring physicians act as de facto gatekeepers to hospitalization. A comparative questionnaire survey was established to identify improvement areas and factors that drive referral rates using descriptive and inferential statistics. Dieter Metze and Thomas Luger Dermatology Department. Rosemann et al. 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..and after-care treatments (Braun and Nissen. The number of referred patients was correlated with medical reports’ informational value (p ¼ 0:042). 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. 75-86 q Emerald Group Publishing Limited 0952-6862 DOI 10. particularly medical reports. 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. Doctors. well established in industrial markets. Signiﬁcant differences between both samples were found with respect to inpatient services and patient commendation. 2006). Hospitals should pay careful attention to their communication tools. 21 No.emeraldinsight.1108/09526860810841174 .
but most remains unexplained (Franks et al. surveying referral physician perspectives is not yet extensively established in the hospital care sector. 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. Method We used a quantitative survey research design. suggesting that referral patterns are related more strongly to the type of community than the supply of specialists (Chan and Austin. 1992) and validated in internal audits among attending physicians. such as disease severity (Chan and Austin. Nevertheless. 1999). 2002).e. Presently. 2003) or individual insurance coverage (Shea et al.. controversial results. the questionnaire size was limited to a one-page-only design and the number of items was restricted to a reasonable quantity.1 76 partnerships between medical professionals in hospital and external physicians are essential and should be sought. Understanding factors that drive referral rates can help identify improvement areas and to anticipate future demands for hospital services. and 6 ¼ “insufﬁcient”. 1999.. and community-speciﬁc characteristics. To increase feasibility and respond-rates. The term “clinician” used in this study encompasses physicians at the clinical department including residents and attendings (i. 2 ¼ “good”. physician-speciﬁc inﬂuences on the referral process were investigated equally. a quality improvement process was initiated that focused on relationships between clinicians and referring physicians. The questionnaire items enabled respondents to rate their perceptions in respect to each speciﬁed quality aspect.. Starﬁeld et al. 2005). Variability in physician referral decisions is observable. 3 ¼ “satisfactory”. A questionnaire study using measurement and feedback was conducted to identify improvement areas from referring physicians’ perspectives. such as socioeconomic status (Carr-Hill et al. A six-point ordinal scale was used: 1 ¼ “very good”. In a large German dermatologic centre providing outpatient and inpatient care at a secondary and tertiary care level.IJHCQA 21. Moreover. Overall. Data collection ¨ We conducted our study at the University of Munster dermatology department. but with a lack of consensus and with. senior and junior doctors). were shown to predetermine referrals from primary care physicians to specialists. 1996) or urban location (Chan and Austin.. 5 ¼ “faulty”. a questionnaire was developed containing 14 items suggested by previous research on physician referrals (Beltramini and Sirsi. 2005). 2003). patient questionnaires and customer complaint systems are widely applied for user orientation in health care systems and hospitals respectively (Castle et al.. . Several patient-speciﬁc characteristics. 4 ¼ “sufﬁcient”. To accomplish our objectives. In contrast. Each item was carefully worded in a clear and precise manner. Our main approach was to compare our results with a corresponding survey regarding the same items from the clinicians’ point of view. to some extent. hospital clinicians should know exactly how the services they provide are perceived by referring physicians. and to reveal associations between quality-related variables and physician-speciﬁc aspects. 2003).
available hospital bed quantity and capacity. . and . Over the years. . such as geographic range or annual number of referred patients. To get an image from hospital medical professionals. outpatient services. Using these data. . commendations from recurring patients. who frequently referred patients to the dermatology department. clinical departments’ perceived reputation. hospital staff friendliness. were continuously stored in a database. . The geographic range between private practice and the hospital were coded using: 1 ¼ city area. names and addresses of miscellaneous specialists and general practitioners. questionnaires were sent by mail to a total number of 304 external physicians in private practice including general practitioners and specialists.. time interval in which medical reports are supplied. and 3 ¼ . Data analysis Statistical analysis was conducted using SPSS. . supplied medical reports’ signiﬁcance and informational value. . . the annual number of referred patients was scaled (Table I) as follows: 1 ¼ 0 2 5 patients. . 2 ¼ regional area. and the rated questionnaire items (Spearman correlation). Referring physicians were asked for their medical specialty. 20-50 km. Equally. No incentives for completion were offered. hospital services and staff accessibility in urgent cases. cooperation with physicians in private practice. and the practice’s postal zip code. was difﬁcult. outpatient consultation availability. 20 patients. . 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. inpatient services. clinicians’ medical expertise. . . respondents were free to use an accompanying stamped and pre-addressed envelope. Our survey was performed anonymously – respondent’s personal data were recorded on the questionnaire. Pearson’s Evaluating hospital service quality 77 . 2 ¼ 6 2 20 patients. CA). 50 km. To avoid personal cost. an unmodiﬁed questionnaire was sent to all dermatology department residents and attending physicians. therefore. education and training for external doctors. San Diego. . release 13. the number of referred patients per year. . . regular newsletter. 20 km.0 (SPSS Inc. A chi-square test (Fisher’s exact test) was used to analyse signiﬁcance differences between deﬁciency frequencies. Factor analysis was used to examine the relationships among the items to identify components that summarize evaluation questions. Reminding non-respondents. and 3 ¼ supra – regional area.Our evaluation questions covered the following quality aspects: . Bivariate correlation analysis was performed to study the association between descriptive variables.
The alternative hypothesis would be accepted at a p . representing nearly the complete physician staff in the clinical department. Physician medical expertise was highly ranked by referring specialists. these values were combined to a conjoint deﬁciency variable that represents poorer quality needing action.4 11. the proportions of referring physicians’ ratings of each questionnaire item were displayed (Figure 1). The length of . 50 km) Not speciﬁed Table I.8 17. Regarding the referring dermatologist subgroup. A total of 22 useable questionnaires. were returned from the subsequent internal survey. see Table I) but two respondents did not answer this question. Value 1 “very good” and 2 “good” frequencies were summed to a conjoint variable indicating an acceptable quality level without need for action. 5. The absolute deﬁciency frequencies in our study were used to show areas of improvement. In contrast. Identifying improvement areas Means and standard deviations were calculated to obtain an average rating for items 1-14. Results A total of 53 usable questionnaires were returned by referring physicians (response rate.1 Characteristic Specialist status of respondents Dermatologist Not speciﬁed n 51 2 9 9 32 3 9 6 32 6 % 96. Response rates and the average ratings divided into referring physicians and clinicians along with the comparative statistical results (Table II).4 per cent). a frequency of 60 per cent to 79 per cent is suitable for detecting areas of improvement with lower priority. Absolute frequencies also containing missing values are more predictive for the given population in small samples than relative ones.IJHCQA 21.3 60. 17. 20 km) Regional area (20-50 km) Supra-regional area (. 0.7 17 11. Under the assumption that a potential quality problem is indicated by lower ratings from 3 to 6. a 21 per cent response rate was obtained. In short.20 patients Not speciﬁed Geographic range between clinic and respondents City area (. external physicians’ estimations of patient commendations were low. Data overview and characteristics of referring physicians who responded correlation tested association among questionnaire items.0 60. The overall Cronbach’s alpha for the questionnaire was 0.845. Nearly all respondents declared to be dermatologists (n ¼ 51.2 3. Moreover.0 17. a deﬁciency frequency of 80 per cent and higher can be considered to indicate urgent improvement areas. The calculated deﬁciency frequencies and a ranking of priority are shown in Table III.05 statistical signiﬁcance level.3 78 Number of referred patients per year 0-5 patients 6-20 patients .
11.00 ^ 0.87 2.2 92.10 1.2 77.77 ^ 1.98 ^ 0.42 ^ 0.001 6.9 86.98 2.03 1.41 ^ 1.55 ^ 0.72 ^ 1.032 13.05 ^ 0.64 ^ 0. item response rates. 9. two-tailed Evaluating hospital service quality 79 Table II.9 Variable (item) n Referring physicians n ¼ 53 % Mean (^ SD) n 2.10 Clinicians n ¼ 22 % Mean (^ SD) p-value * 1.23 ^ 0.4 100.05 ^ 0.76 ^ 0.65 1.29 ^ 0.80 ^ 1.84 2.78 3.9 2.1 96.6 96.10 2.73 ^ 0.28 ^ 0.56 2. 8. 7.03 3.0 90.90 2.No.86 2.53 ^ 0. Questionnaire items.65 2.00 ^ 0.73 1. 0.95 ^ 1.60 2. 10.7 96.001 0. 5. mean values.2 2.4 100 100 100 100 100 100 86.8 88.95 ^ 0.002 .69 1.3 96.27 ^ 0. 0. 0.81 2.81 2.15 2.84 2. 48 51 41 90.22 22 22 21 20 100 100 95. 3.49 ^ 0.86 19 22 22 22 22 22 22 86. * Mann-Whitney U test.81 19 22 20 51 49 49 45 46 47 51 96.96 ^ 1. 50 51 52 51 94.2 2.5 92. 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.84 ^ 1.014 0.2 98.46 ^ 0. 2. standard deviation.26 ^ 0. 14.43 ^ 0.93 2.5 84.80 . and comparative statistics .4 3.5 90. 12. 4.77 ^ 0.92 2.63 3.
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. two-tailed Notes: Def. 3.002 .3 45. deﬁciency frequencies. 14. 12. 9. 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. c Fisher’s exact test.5 36. 2.002 0. deﬁciency frequency. b detected by clinicians.9 36.5 40. 10.8 39. 4. frequation . 8. 1. a detected by referring physicians.2 84.0.5 15.5 3 13 2 1 5 6 11 12 14 6 8 4 8 8 50 9.9 66.3 58. and statistical results . Def.8 86.4 18.6 52.6 39.8 45.IJHCQA 21.4 27. 6. Rank of priority.3 95.60 per cent are indicated.6 4.1 80 Figure 1.022 Table III.3 0.1 77.3 27.2 35. Referring physicians’ ratings – proportions of each item No.2 13.001 0. * Areas of improvement with a deﬁciency frequency . Variable * Cooperation Medical expertise Accessibilitya.6 47. 13. 5.1 64.5 27. 7.0 56. b Medical reports: Timea. 11.
001). . Quality features interaction Factor analysis revealed two components that explained nearly 52 per cent of the variability in the original 14 variables. . p ¼ 0:002. Differences were also been found with inpatient resources and inpatient services.61 revealing a statistically signiﬁcant difference (p ¼ 0:019). Moreover. and .001). However. deﬁciency frequency.032. The ﬁrst component. clinicians rated newsletters signiﬁcantly higher than referring specialists ( p . 0. Evaluating hospital service quality 81 Comparative evaluations As seen in Table II and III. Lack of patient commendation had the highest deﬁciency frequency (87 per cent) and the second lowest rating in the referring physicians group. reputation. . An average mean value for all 14 quality items was calculated for each subgroup: . clinical department’s perceived reputation.54. outpatient services. . time interval in which medical reports are supplied. hospital staff friendliness. cooperation. Average rating values and deﬁciency frequencies reveal that clinicians’ ratings were remarkably distinct from those referring physicians scores (mean. 0. clinicians: 2.29. . p .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. medical expertise. . Our ﬁndings suggest these three improvement areas. and . this aspect was supposed to be much higher from the clinicians’ viewpoint ( p . 0. p ¼ 0:002. p . which explains nearly 37 per cent of the variance. and the. . referring physicians: 2. Furthermore.022).69. 0. medical expertise. friendliness. accessibility in urgent cases. . outpatient consultations. Varimax rotation was used to determine what the components represented. is highly correlated with the following variables: . and . there were disagreements between the way referring physicians and the way in which clinicians themselves rated some items. There were signiﬁcant differences concerning average rating values and deﬁciency frequencies. SD: 0. There were no signiﬁcant differences between referring physicians’ ratings and those made by clinical department physicians concerning: . . cooperation. SD: 0. referring physicians criticised staff accessibility in urgent cases (64 per cent).
059 0.1 82 The second component is highly correlated with inpatient bed capacities and inpatient service offerings. 12.539 0. sample of referring physicians 8.594 0.IJHCQA 21. Variable 1.528 0.601 0. 0.001 . 2.0.0. Discussion Our study described and evaluated the way referring physicians and clinicians rated several quality items from their individual perspectives.001 .001 0.465 . Table IV. The ﬁrst component represents a construct with generic attributes that improvement activities cannot inﬂuence directly. particularly when we did not remind respondents or offered an incentive for completion. Table IV shows that most variables were highly correlated with these two items.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. 6. the medical specialty of which the majority of responses were received.067 0.015 0.639 0. and . 10.471 0.514 1 0. 14. 9.001 .301 0.369 0.001 0. equal or even lower response rates have been observed from physician samples (MacDowell and Perry.348 0.001 0. Signiﬁcant negative correlations were found between geographic range and hospital staff friendliness (p ¼ 0:039). Moreover.001 . the number of referred patients was signiﬁcantly negatively correlated to medical reports’ informational value (p ¼ 0:042). This survey is limited to: . sampling referring physicians via the manually maintained databank.595 0. 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 0. such as cooperation and reputation.149 0.006 46 47 51 50 50 49 49 45 46 47 49 48 51 41 0.001 0.008 .647 0. 0. This may be caused by a lack of quality management sense. 0.001 . However. 4.0. 1992).428 . Beltramini and Sirsi.054 0. were calculated. .594 0. 11.0. 3.342 0.0.0. 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 .615 0. 1990.001 .034 .532 0.002 No.251 0. An equally important ﬁnding is that inpatient capacities and service offerings were not correlated. Correlation analysis of generic quality perceptions represented by reputation and cooperation with other quality items.505 0. 13.364 0.001 . one geographical region. 5.015 0. It may be speculated that there is a lack of motivation and incentive for private practice physicians to participate.013 . 7. Although the study response is low. we considered the response rate acceptable. 0. 0. and the frequency of patient commendations (p ¼ 0:005).547 0.001 0. Correlating quality items representing a generic quality perception.000 0.001 . in former studies dealing similar questions.
and those variables.161 20. such as medical reports and newsletter articles. 5. 11. hospital administrators and clinicians should pay careful attention to communication tools.253 20.120 20. accessibility in urgent cases.262 20.320 20.207 0. 10. medications.148 0.032 0. Moreover. Curry et al.001 20.059 20.083 20. . sample of referring physicians Nevertheless. Using this approach.174 20.421 20. 8. Variable 1.. 9.157 20. 6.189 20. 3. For interpretation. The present ﬁndings suggest that timely and signiﬁcant information about: . hospital stay. discharge.079 20. which represents a further tangible communication and cooperation aspect. Not only do patients expect a seamless healthcare system and continuity of .102 20.150 20. such as 80 per cent and more. proposed procedures. our survey questionnaire provides a ready-to-use instrument that identiﬁes crucial improvement areas. are major points for satisfaction and perception of adequate cooperation. . 13. which are less tangible.231 0. 7. such as providing medical reports and newsletters.. it is important to distinguish between variables that can be directly inﬂuenced by management activities.295 20. can be chosen individually for each item and should be monitored over time. 4.007 20. major improvement areas demanding urgent action could be identiﬁed. 12.005 Note: * Two-tailed test of signiﬁcance Table V.075 20. 2005).055 20.037 20. In conclusion. 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. Correlation of geographic range and number of referred patients with quality items. and .042 Evaluating hospital service quality 83 0. Elija and Marja-Leena. The high importance attached to timely and adequate communication back to referring physician was previously reported in other studies (Cummins et al. and should address this problem by investing in systematic communication improvement programs.029 20.131 48 48 49 48 48 46 46 42 43 44 48 45 48 38 20.183 20. has been found to be improvable. 1980. Critical deﬁciency frequencies indicating relevant areas. such as reputation and cooperation. 2.039 0.No. 14.219 0. 1980.
The long-term strategic challenge lies in building creative and sustainable referral networks that promote professional partnership among physicians. expectations and satisfaction. the frequency of patient commendation was found to be associated with the geographic range.IJHCQA 21. hospitals need to understand stakeholder needs. 93 No. was signiﬁcantly higher. which makes it difﬁcult for referring physicians to give a valid rating. are much more interested in reading and understanding medical reports than physicians who refer a greater number of patients. which is separated into inpatient and outpatient care sectors with spending caps (Altenstetter. Vol. Regular measurement and reporting to hospital staff members and the executive board is mandatory for a quality improvement process. Surveying referral physician perspectives is an essential method for gathering information on health care service perception. pp. estimated by clinicians. Before customer satisfaction can be addressed. (2003). “Insights from health care in Germany”. Referring physicians expect management to be shared with their cooperating medical partners. Working in separate medical realities may diminish understanding for the concerns of others (Kvamme et al. 2001). proposing a strong positive self-image in terms of services they provide. One may speculate that physicians. C. 2003). utilizing survey results. Although we found statistically signiﬁcant disagreements. clinicians tend to rate quality higher than referring physicians. American Journal of Public Health.1 84 care between services but also the physicians who refer patients to higher-level health care institutions. physicians and the public (Scammon and Kennard. comparative analysis allowed us to conclude that the majority of quality problems are perceived in a similar manner by referring physicians and clinicians. References Altenstetter. 1983). Not competition between specialists. 1. but good working relations across all boundaries is required. An assumable cause may lie in a few but important referrals from the viewpoint of the referring physician. therefore.. A second step. This situation is particularly important in the German health care system. If the distance between referring specialists and hospitals is great then patient commendations decline. 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. is equally important. 38-44. Although the validity of this latter item remains doubtful. However.. who refer only a few patients to the clinical department. in general. Health care provider images and satisfaction with those providers vary among consumers. 1993). . This may be subject to rather infrequent contact. Recommendations We cannot have an accurate understanding of how our services are perceived by others without asking them. We note that the frequency of patient commendation. 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. care levels and care sectors (Javalgi et al.
providers and administrators”. R. pp.biomedcentral. Zwanziger. 312. Journal of Health Care Marketing. 288-95. 10 No. 3. 8.D.. L. and Marja-Leena. and Nissen. and Austin. 500-11. Vol. 67-74. Vol.K. Jr. J.W.. Vol. Vol.A. and Inui. N. 41 No. British Medical Journal. General practitioner-specialist referral process”. P. pp.Beltramini. Vol.. 101-26. Vol.R.T. Olesen. Journal of Health Care Marketing. 34 No. Rosemann. K. Gesundheitsokonomie und Qualitatsmanagement. Vol. 10 No. Vol. “Die Bedeutung der Einweiserzufriedenheit fur Krankenhauser ¨ ¨ und ihre erfolgreiche Messung”. and Lester. 3. physician. pp. M. T. L. Journal of Health Care Marketing. (1999). pp. “Variations in primary care physician referral rates”. and Roland. 1008-12.C. W. pp. Franks. J. Wensing. pp. 10 No.. 3 No. P. A. R. S. 1996-2017. 54-8. Failure of consultants to provide follow-up information”. R. “Informational inﬂuences on physician referrals”. T. Brown.. “Part II. Eija. ¨ ¨ Braun. Mackesy.A. Vol. (2001). Internal Medicine Journal. Vol. 35 No.O. and Kennard.. 4. L. Health Services Research. and Samuelson. Carr-Hill.E. W. and Mulligan. Javalgi. M. (2003). 6 No. “The referral process: a study of one method for improving communication between rural practitioners and consultants”. Journal of Health Care Marketing. Vol. M. 1974-6.B. “Establishing an effective referring physician network”. pp. and Koritsas.. “Managing demand at the interface between primary and secondary care”. pp.. 2. 13 No. G. pp. multi-level modelling approach”.J.G. R. 1. J. (1980). MacDowell. and Perry.A. (1990). 491-6. Vol. R. 19 No. The Journal of Family Practice. 2. A. pp. and Hays. “Patient. W. and Sorbero. Curry. (2005). Rice. (1998). 10 No. G. Kvamme. P. 1. Evaluating hospital service quality 85 .F. 287-91. Chan. (2005). pp. C. and community factors affecting referrals to specialists in Ontario. Mooney. 243 No. M. “Factors inﬂuencing physician choice of an outpatient surgery and testing facility”. Cummins. R. Vol. 6 No. available at: www. 376-84. (2006). BMC Health Services Research. and Sirsi. “How physicians make referrals”. Vol. (1983). B. Coulter. F. Medical Care. “Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP)”. Piterman. 1650-2. patients’ experiences are more positive”.A.M. 6-17. Joseph. (1993). Quality in Health Care. G. 16. pp. (1980). R. Scandinavian Journal of Caring Sciences. “Improving health care strategy planning through assessment of perceptions of consumers. and Szecsenyi. Hepner. (2005). (1996). D. “Home care personnel’s perspectives on successful discharge of elderly clients from hospital to home setting”. Journal of Hospital Marketing. Health Services Research. 5. Vol. 9-17.S. “Communication failure in primary care. “Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices”. com/1472-6963/6/5 Scammon.. Smith. R. J. 40 No. Jr. British Medical Journal. Journal of the American Medical Association. pp. 323-9. 6. and Coggins. Castle. N. Rueter. O. pp. 2. Crandall.B.. 6. Gombeski. pp. R. A. 33-9. “Referrals from general practice to consultants in Germany: if the GP is the initiator. 10 No.J. “Review of the literature on survey instruments used to collect data on hospital patients’ perceptions of care”. (2005). (1990).T. Vol. 2. N. 4.W. Vol.. pp. 316. Canada. A population-based. J.. (1992).
Vasey. P. “Variability in physician referral decisions”.uni-muenster... B. (1999). Forrest. 6.. J. Nutting. and Nag. pp. Vol. pp. C. 1. (2002). 473-80. 15 No.de 86 To purchase reprints of this article please e-mail: reprints@emeraldinsight. Corresponding author Peter Hensen can be contacted at: hensenp@mednet. B. Starﬁeld. 331-48. “Medicare physician referral patterns”.com/reprints .IJHCQA 21. S.com Or visit our web site for further details: www. Vol. Stuart. and von Schrader.emeraldinsight. Health Services Research. D.1 Shea. The Journal of the American Board of Family Practice. 34 No.A. S..B.
Findings also provide a model that includes valid and reliable measures. Originality/value – The research shows empirical evidence about the effect of both patient’s emotions and service quality on satisfaction with healthcare services. which involves diverse phenomena within the cognitive and emotional domain. 21 No.com/0952-6862. Findings – The scales used to evaluate service quality and emotional experience appears valid. 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. 2008 pp. 87-103 q Emerald Group Publishing Limited 0952-6862 DOI 10. although showing good internal consistency. using a revised SERVQUAL scale for service quality evaluation and an adapted DESII scale for assessing patient emotions. Service levels Paper type Research paper Introduction Service quality and customer satisfaction are a major goal in modern organizations. These services have.emeraldinsight. Public services cannot detach from this general concern. mostly because they act on the socio-economic level and serve individuals and organizations that need adequate. Montijo. The results support process complexity that leads to health service satisfaction. Their production.1108/09526860810841183 . Keywords Customer satisfaction. Portugal.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). Practical implications – Patient’s satisfaction mechanisms are important for improving service quality. especially as a service provider. might be enlarged to other typologies in further research – needed to conﬁrm these ﬁndings. heterogeneity and inseparability. Portugal. distribution and consumption are simultaneous processes and they are International Journal of Health Care Quality Assurance Vol. patient’s emotions. revealing that all the predictors have a signiﬁcant effect on satisfaction. timely and effective responses (Vinagre and Neves. Design/methodology/approach – The approach was tested using structural equation modeling. 2002). 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). forces managers and practitioners to address quality and client satisfaction issues as a priority.The current issue and full text archive of this journal is available at www. speciﬁc characteristics. 1. such as intangibility. Research limitations/implications – The emotions inventory. Public Sector importance. with a sample of 317 patients from six Portuguese public healthcare centres. expectations and involvement. Lisboa. however.
several empirical studies revealed that service use has potential to elicit a complex variety of emotional and cognitive responses. equity. Theoretical framework Despite seemingly alike. however. which involves several service dimensions speciﬁc to the service delivered. Having this in mind. Traditionally. Bloemer and Ruyter. the emotions linked to service experience and the complementary effect of expectations and involvement on patient satisfaction. We may need separate criteria to differentiate services mainly on the basis of the sort of experience users have with a particular service. only cognitive measures were considered such as disconﬁrmation or the perceived service performance (Liljander and Strandvik. price.g. is perceived as a global consumer response in which consumers reﬂect on their pleasure level. we intend to know the service quality dimensions perceived by patients and the relationship between emotion. Satisfaction is based on service delivery predictions/norms that depend on past experiences. Focusing on consumer satisfaction with a public healthcare service (in this study we considered patient as a health service consumer). we assume that we can also ﬁnd differing evaluations of the degree of importance (involvement) attached to the service among the patients. Price et al. regret). 1987). Satisfaction. Quality is believed to be determined more by external cues (e.g. 1997). expectations. service employees and customers (Bitner et al. in order to explain service quality and satisfaction. in which customers participate in the production (Gronroos. 1995). Departing mainly from Westbrook’s (1987) and Westbrook and Oliver’s (1991) work. reputation). From an empirical study in six healthcare centres. the customer perceives a service in all its production processes and not merely as the result of that production.IJHCQA 21. 2000). Considering healthcare services consumers’ differing needs. Transactions can thus be open or closed. 1999. Despite the generalized acknowledgment of these differences among service types. the features of these services make it difﬁcult to adopt service quality and customer satisfaction evaluation criteria. related systems/processes. there is a rather limited body of knowledge on the effects that these different types of services have upon consumer satisfaction. Therefore. Some studies found a signiﬁcant relationship between involvement and the level of emotions concerning service experience (e. the degree of involvement can vary as well as the duration of consumer experience. Surprenant and Solomon. Services can also differ in the degree of technical knowledge and skill required.1 88 not storable. The wide diversity of services constitutes another factor that poses measurement difﬁculties. service experience and involvement. Service experiences are the outcomes of the interactions between organizations.. driven by conceptual cues (e.. 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. They are created in buyer-seller interactions and they are essentially ¨ activities or processes.g. involvement seems a variable to be considered in patient satisfaction and emotional response analysis. he suggests that quality is a judgment or evaluation that concerns performance pattern. Oliver (1997) identiﬁed a few major elements that differentiate service quality and satisfaction.. perceived service quality and consumer satisfaction are distinct constructs that may be deﬁned and evaluated in different ways. 1994.. Consequently.. Customer satisfaction and customer perceptions are therefore often inﬂuenced by those interactions (Bitner et al. we intend to evaluate service quality dimensions.. 1997). Although .
(1991) acknowledged that normative expectations (“what services should be”) lead to unrealistic expectations. 2000. Donnelly. 2004)... Some authors criticise SERVQUAL. In short. assurance. 2000).. we suggest that service quality should be one patient satisfaction antecedent. we consider a contingent approach in which dimension numbers vary according to. 2005. 1991. SERVQUAL is considered a useful and valid instrument to measure service diversity.. they suggest that expectations have a tolerance zone between desired service and adequate or minimal acceptable service level (Berry and Parasuraman. Zeithaml et al..perceived service quality may be updated at each speciﬁc transaction or service experience. 2002. Buttle (1995) synthesized some of these criticisms regarding: disconﬁrmation (disconﬁrmation paradigm rather than an attitudinal paradigm). they redeﬁned expectation in predictive terms “what a client may expect from an excellent service”. 1991). 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. it tends to last longer than satisfaction. researchers dispute the relationship between perceived service quality and satisfaction (Ting. service type (contextualized dimensionality). Service quality studies at the consumer level have a decisive impact on the type of research that has been developed ¨ (Gronroos. Quality is no longer analysed and measured from an internal focus. Parasuraman 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. some studies conﬁrmed service quality dimensional variability (e. Although there is general agreement about the inﬂuence of customer’s expectations in overall service quality and The inﬂuence of service quality 89 . 2005. 1985.g. Cook and Thompson. Zeithaml et al. 2001).g. 1985. Subsequently. 1988) and validated (e. Regarding dimensionality. Parasuraman et al. As an alternative to the universal SERVQUAL ﬁve-factor structure. 1995. 1998). empathy and responsiveness – that consumers are assumed to use in a systematic way to perceive services provided. Service quality Quality has been used to describe diverse phenomena. although it requires an adaptation to the organization under evaluation (Curry. Gabbie and O’Neill. Regarding expectation criticisms. Accordingly. The SERVQUAL model includes ﬁve service quality dimensions – reliability. Among consumer satisfaction theories. which is understood as being transitory and merely reﬂecting a speciﬁc service experience (Martinez-Tur et al. and service quality dimensionality (the universality of the ﬁve dimensions are not always conﬁrmed). Wisniewski and Wisniewski. tangibles. Mostafa. In this study. different authors (Parasuraman et al. 1996).. which implies subsequent reﬁnement of quality dimensions relevant to each service. Vinagre and Neves. 1990) deﬁned service quality as a degree and gap between service perception and consumer expectations.. 1990. the appropriateness or utility of expectations in SERVQUAL (the meaning of expectations. Expectations Consumer expectations are central to satisfaction studies. among others. Nevertheless. the meaning of P-E gaps and the contribution of the expectation scores). Cook and Thompson. 1988. 1999). it is now conceived from the exterior (or consumers’) point of view.
Oliver. which implies that we should consider ´ examining positive and negative emotion effects separately (Babin et al. some emotions experienced in the context of interpersonal relationships may be different from those experienced during a consumption experience. because these are measures developed in other contexts... 2004). When the consumer acknowledges a gap. measured on a ﬁve-point Likert-scale. Within consumer psychology. Oliver and DeSarbo (1988) mention theoretical support for those effects. if the discrepancy is too large then we need to obtain a contrasting perception (Bridges. The DESII instrument is a discrete emotions inventory. Izard’s (1977) Differential Emotions Scale (DES). Several studies found a separate effect of expectations and disconﬁrmation on satisfaction (e. In this latter case. designed to measure basic emotions or combinations of emotions experienced by the individual.1 90 customer satisfaction. High levels of satisfaction may include positive and negative emotions (Arnould and Price. we assume that a patient is involved when the . According to the assimilation theory. However if disconﬁrmation is too strong then the consumer may strengthen his or her negative perception thus widening the gap. Different scales have been used in consumer emotion studies. “contrast effect” occurs. 2005. Although involvement represents a more complex construct (Kim. It is assumed that consumers create expectations prior to their service experience against which performance is evaluated. 2005). 2000. if the discrepancy between the consumer’s expectations and perception is small then perceptual judgment will reduce this difference. 1995). They state that expectations cause an assimilation effect while discrepancy causes a contrast effect. he or she attempts to reduce this space. However. Price et al.IJHCQA 21. originally conceived to measure an individual’s emotional state. DES is a measure of emotional state intensity. the mechanism by which expectations may inﬂuence satisfaction directly (Oliver. Assimilation effect corresponds to a narrowing of the gap (leading to an assimilation of expectations with perceptions) while the contrast effect is the opposite. Dube and Menon. 1991). considerable work remains to be done regarding the exact way this process takes place (Coye.g. self-administered. Emotions and consumer experience Emotions refer to a set of responses occurring especially during consumer experience (Westbrook and Oliver. The role of expectations as an assimilation agent provides. However. 1980). 1993). is used to measure emotional experience or emotional reactions perceived by the individual during a time period. as emotions are context speciﬁc. 2001). Generically. while DESII is a measure of emotional experience frequency at a given period and is often used in consumer-experience research. It comprises ten subscales with three items each representing the frequency with which individuals express each of ten basic emotions. as Richins (1997) highlights. 2000. Andreassen. involvement is viewed as a motivational construct that inﬂuences subsequent consumer behaviour (Dholakia. 1997). Involvement Involvement is linked to studies on consumer satisfaction. therefore. difﬁculties may arise when DESII is used for consumer behavior research. Perception can disconﬁrm expectation (either for “worse” or “better”) or conﬁrm it (“neutral” comparison). individuals tend to respond according to their expectations because they are reluctant to admit wide discrepancies. Consequently. 1993)..
Acknowledging potential expectation effects. Zaichokowsky. H4. we depart from the more restricted conception of involvement: the degree of importance attributed to the service by the patient. In this respect. or that conceive involvement as a mediator of disconﬁrmation (e. H3. calls attention to the important role emotions may play when associated with other cognitive variables that explain these phenomena. perceived service quality can also include dimensions that are mostly relational. an individual may be interested in a service or activity even though that service or activity may not be important to him or her. Positive emotions have a positive effect on patient satisfaction. attachment and/or motivation. The diversity of emotional experiences is explained as a function of emotion-cognition interactions resulting in cognitive-affective structures (Izard.g... it is foreseeable that expectations are related to the frequency with which patients experience positive or negative emotions. Therefore: The inﬂuence of service quality 91 . Despite studies that relate involvement with satisfaction. 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. In our study. However. 1997). 1997).. Usually. 1992). 1998) and emotional aspects. especially at the service level. we hypothesized that: H1. Negative emotions have a negative effect on patient satisfaction. opposing the purely cognitive nature of service quality evaluation. it corresponds to a product’s or service’s perceived importance (Mittal. For example. Bridges. service quality is considered mostly a cognitive construct while satisfaction has been considered a more complex concept that includes cognitive and affective components (Oliver. 1993). Service quality has a positive effect on patient satisfaction.g. Bridges. 1993. Some researchers argue that emotional versus cognitive saliency depends on the type and nature of service transactions. we assume an interrelation between cognitive variables in forming emotions and satisfaction (Westbrook and Oliver. Therefore. these may be considered distinct. In these cases. Consequently. service quality and emotions on satisfaction. Involvement has also been operationalized distinctly (e. 1991). 1985) and despite “involvement” semantic distinctions. considering the interaction between the two in service experience. Expectations have a positive effect on patient satisfaction. 1995). However. involvement is similar to importance. 1985). Satisfaction predictors: theoretical model of analysis Acknowledging that consumer experience is complex. interest. Services with more qualiﬁed or more credential properties imply that a consumer’s capacity and ability to evaluate the service provided is reduced. H2. there should be a greater tendency to evaluate aspects relating to attention received during the interaction established along the service experience (Shemwell et al.service is relevant according to the service’s characteristics and the patient’s needs. Within this context. values and interests (Zaichkowsky. the involvement effect is insufﬁciently explored compared to other satisfaction predictors. these relational dimensions are permeable to a strong emotional inﬂuence.
satisfaction and other predictors such as expectations and emotions. Patient involvement has a positive effect on patient satisfaction. Methodology Sample We used a convenience sample composed of individuals attending targeted healthcare centres during approximately one month in each.IJHCQA 21. Research model .1 H5. H8. Patient involvement has a positive effect on expectations. Patient involvement has a negative effect on negative emotions H10. Patient involvement has a positive effect on positive emotions. The research model and the expected effects are represented in Figure 1. Expectations have a negative effect on negative emotions. We obtained 317 valid responses from patients in six healthcare centres. These variables and measures were adopted: 92 Figure 1. H9. H6. Consequently. 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. 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. These assumptions led us to make the following predictions: H7. We presume that service involvement motivates patients to initiate a more positive service-interaction. Expectations have a positive effect on positive emotions.
(P8) “They provide services at the promised time”.Service quality. (P18) “I feel safe in my relationship with the auxiliary staff”. We used a ﬁve-point Likert scale ranging from “completely disagree” (1) to “completely agree” (5). this scale asked patients how they considered services that were provided. 1992) to measure expectations and perceptions. “Generally I am satisﬁed with the nurses”. taking into account a series of hospital service characteristics. “Generally I am satisﬁed with this healthcare centre”. Consumer satisfaction is the main dependent variable in our study. The inﬂuence of service quality 93 . 1988) for the particular healthcare sector contexts. Kilbourne et al. what they thought – on the basis of their experience – what could be expected from services provided in a healthcare unit. (E21) “My doctor would have a good professional preparation”. (P17) “I feel safe in my relationship with nurses”. (E24) “The doctor would give me personal attention”. Babakus and Mangold. This scale consists of ﬁve items and includes: “Generally I am satisﬁed with my doctor”. 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). “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). Patients were asked. we adapted Izard’s (1977) “Differential Emotions Scale” – DESII – used and validated in consumer studies (e. Examples include (E3) “Staff would have good appearance”. We asked respondents to predict the degree of anticipated satisfaction (“what would you expect from this service”: “to feel satisﬁed with this medical consultation”.g. 1992. (P16) “I feel safe in my relationship with my doctor”. (P26) “My doctor understands my speciﬁc needs” Satisfaction measure. 2004. “Generally I am satisﬁed with the services of support”. we used an adapted SERVQUAL scale (Parasuraman et al. Westbrook. 1987... We considered the existing measures’ diversity in the literature. Service expectations quality scale. Carman. Expectations. 1997) proposal. 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. This instrument includes 28 items for the expectations scale and 28 items for the perceptions scale. (E5) “They would fulﬁl their promised service at the time they promise to do so”. Examples include: (P4) “Materials and documents are clear and visually appealing”. Service perceptions quality scale. Using the same 28 items. before consultation. Following recommendations in the literature (e.. Emotions. (E15) “My doctor instils me with conﬁdence” (E19) “Nurses would be always courteous with me”. 1990. We included positive and negative emotions scales but we excluded the “surprise” item owing to its ambiguity. In order to obtain the users’ emotional reactions to the services provided.g. “Generally I am satisﬁed with the level of services performed”.. we used a satisfaction expectation measure focusing on the service to be provided. Vandamme and Leunis. Following Oliver’s (1981. 1991) but not particularly in healthcare services. 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. Westbrook and Oliver.
the service quality factors (i. applying Varimax Rotation and deleting items not satisfying the following criteria: loadings equal or above 0.e. we adopted the Incremental Fit Index (IFI) type 2 index.g. sample size and selected estimation method. Data analysis Psychometric measure validation followed the recommended procedures: . Once the models were speciﬁed and estimated. Considering Hoyle and Panter’s (1995) recommendations. which is less sensitive to sample size and non-normality and Tucker-Lewis Index (TLI) also a type 2.4 in the remaining factors. In this model.1 Involvement. Liljander and Strandvik. Measures showed a good internal consistency with Cronbach’s alpha around 0. 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.90 for the expectations scale and 0. Internal consistency analysis of the factor structure found. or no normality). suggesting that indices’ characteristics depend on data. Thus deﬁned. the signiﬁcance of the structural model parameters were analysed (path coefﬁcients). The ﬁrst step consisted of verifying the model’s ﬁt to the data through ﬁt-measure analysis. and Verbeke and Bagozzi. with means and intercepts estimate owing to missing data and indication of the saturate and independent model measures of ﬁt. Then. a service is considered to be quality whenever perceptions exceed user’s service expectations. . 1993.97 for the emotions scale. Following Hoyle and Panter’s (1995) recommendation. 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). In a second step.IJHCQA 21. Results Service quality measure According to extant literature. 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. a type 3 index and the Root Mean Square Error of Approximation (RMSEA). the revised questionnaire was pre-tested on a sample of healthcare public service users in order to test its consistency. 1997. sample size. service quality results 94 . Our analysis was done using structural equation modelling (SEM) by means of AMOS 4. adopting theoretical criteria for retaining factors with Eigenvalues higher than 1. it is cautious to use more than a single index when substituting the chi-square.6 in the dominant factor and cross-loadings below 0. Given the controversy regarding the indices that one should use in evaluating the model ﬁt in SEM. positive and negative emotions) are treated as observed components of the respective constructs.0.. Internal consistency analysis (Cronbach’s alpha). . Factorial structure identiﬁcation with an exploratory factor analyses performed on the items for each scale (according with the procedures adopted by Mano and Oliver. 2000). the Comparative Fit Index (CFI). results were analysed.
it integrates all items concerning medical performance.76. With factor loadings ranging from 0. 1992. grouped by valence (positive and negative emotions within the emotional experience).67 for the Physical Elements scale (which also has fewer items) to 0. both concerning speciﬁcally the relation with the service provider.69. Parasuraman et al. Measure of emotions in service experience The DESII scale showed high internal consistency for all 30 items (a ¼ 0:91).77 to 0. we fused Reliability and Response Capacity. comprehending simultaneously in the same factor the Assurance regarding their professional competency and empathy towards the patients. nurses and auxiliary staff.60 are also used in the literature (e. (3) Employee’s assurance. we intended to identify service quality scale structure through Principal Component Analysis (PCA). With factor loadings ranging from 0. Nunnaly (1978) indicated 0. Considering that the scale comprehends differing and opposite valences. (2) Physician’s assurance.95.. the Physical Elements dimension was kept. 2007.72 to 0.84 to 0. The scales showed a good internal consistency. we eliminated 11 items owing to cross-loading. The inﬂuence of service quality 95 . it integrates all items from the Reliability factor plus two more from the Response Capacity factor in the original scale. 2002). 1991). 1).in the gap between user perceptions and respective expectations. 1992. From this point of view. 2002. so alpha could be lower in scales with fewer items.g. Wright.01 per cent of total variance. W So. Cronbach alpha varied from 0. Babakus and Mangold. Vandamme and Leunis. Although with fewer items.97 for Reliability. (4) Tangibles.64. it integrates items from the Assurance factor concerning Nurses and Auxiliary staff. The scale presented a high internal consistency (a ¼ 0:97). Considering the construct’s multidimensional nature.7 to be an acceptable reliability coefﬁcient but lower values as 0.. are disaggregated in two groups corresponding to distinct occupational groups: physicians. The Empathy and Assurance dimensions. With factor loadings above 0. it seems justiﬁable that service quality construct dimensionality is focused on the gap between perceptions and expectations (Vinagre and Neves. By analysing the saturation matrix after Varimax rotation (Table I). we used the SPSS “compute variable” function to calculate 28 new variables representing the result of the numerical expression (perception – expectation) for each item. Regarding the theoretical model. The global service quality scale presented a Cronbach alpha of 0. we checked subscale validity and consistency. The extracted factors are interpretable and allow us to identify four service quality dimensions: (1) Reliability. With factor loadings ranging from 0. it groups two items from the physical elements.. we extracted four components that explained 67.68. 2004. Alpha coefﬁcient is dependent not only on the magnitude of correlations among items but also on the number of items in the scale. In order to identify variables concerning service quality. Aspy et al. Using Kaiser’s criterion (“Eigenvalue” .
34 0.06 18.11 0.14 0.23 0.37 0.87 respectively) and 0.17 0.33 0.22 0.18 0.3 0.19 0.83 for “Interest” and 0.21 0.73 0.88 per cent of total variance.28 0.26 0.37 0.08 0.17 0.27 0.88 0.15 0.1 Statement number code QS5 Text Reliability 0.15 0.68 0.01 0.31 0.82 0.27 0.21 0.56 Tangibles 0.09 0.33 0.84 0.73 0.73 0.69 0.27 0.35 0.23 0.25 0.32 0.73 0.82 0.12 0.7 0.3 0.72 10. 1977 study. 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.76 and 0.25 0.66 0. Negative emotions Our PCA on the seven DESII negative valence subscales revealed four interpretable components (Varimax rotation with Kaiser criterion) explaining cumulatively 78.76 0.28 per .22 0.37 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. The internal consistency analysis showed a Cronbach alpha of 0.95 0.33 0.15 0.67 96 Table I.22 23.77 0.28 0.93 Components Physician’s Employees’ assurance assurance 0.22 0.23 0.27 0.69 67.72 0.12 0.3 0.13 0.35 14.24 0.75 0.77 0.22 0.21 0.90 for “Enjoyment” (in Izard’s.84 for the total scale.64 0. Cronbach alpha for these subscales was 0.IJHCQA 21.76 0.21 0.23 0.
66 17.18 0. we started with the measurement model factorial structure analysis as well as its adjustment to data.37 0.23 Fear 0. By applying the Kaiser criterion we extracted a single factor that accounted for 71. TLI ¼ 0:99. “shame”.29 0. imposing two co-variances has shown to improve the ﬁt indices (x2 ¼ 106:89.21 0. the second item in Guilty).14 0.13 0.30 0.20 0.28 0.89 0.73 0.33 0.81 0.83 0.08 0. Factor “Shame” absorbs one factor item that had disappeared (namely. Factors extracted allowed us to identify four negative emotions: “disgust”. Negative emotion’s factor structure: rotated component matrix (Varimax) . IFI ¼ 0:99. However.86 0.87 0.16 -0.90 0.16 0. All the remaining factors were maintained.60 78.001.92 0.25 15.77 0. Satisfaction measure In order to verify the measure’s one-dimensional character we developed a PCA with ﬁve composing items.88.84 per cent of total variance with a Cronbach alpha of 0.11 0.40 0.24 0.27 0.96 0.72 0.24 0. Components Shame Distress 0. Structural model Following Anderson and Gerbing’s (1988) recommendations regarding Structural Equation Modelling. thus conﬁrming our global satisfaction scale’s one-dimensionality hypothesis.79 0.22 0. good internal consistency with alpha values ranging from 0. In a second phase.23 0.37 0.84 0. the hypothesized model was evaluated.27 0. “distress” and “fear”.39 0.25 0.86 0. in order to validate the latent variables.03 0.cent of total variance.18 0.08 0. Satisfaction expectation scale Three items composing this measure revealed a high Cronbach alpha of 0.22 0.12 0.85 0.85 0.27 0.19 0.90.07 0. Seven items had to be discarded in the rotated matrix owing to unacceptable cross-loading (Table II).34 31. p .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 0.27 0. 0.84 0.19 0. df ¼ 51.16 0. The measurement model was estimated without mistakes or warnings (from the program built in control processes) and presented good ﬁt indices.12 0.21 0.74 0. The subscales we found presented.92 for the total scale. Our results indicated that items composing “Aversion” and “Despise” factorise into a single factor.24 0.09 0.87 to 0.10 0.96 for the subscales and 0.19 13.88 Table II.
df ¼ 54.001. Figure 2. The estimated structural model corroborated our hypotheses. CFI ¼ 0:98 and RMSEA ¼ 0:061). Estimated structural model . p . As the measurement model revealed good ﬁt. TLI ¼ 0:99. 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. IFI ¼ 0:99. Results showed that the structural model has good ﬁt (x2 ¼ 134:46. The perceived service quality. 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. 0. All estimated parameters were signiﬁcant. The predictors we considered had a direct effect on patient satisfaction.1 98 CFI ¼ 0:99 and RMSEA ¼ 0:052). indicating that latent variables were actually depicting different constructs.IJHCQA 21.
001). 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. (1991) acknowledged. Conclusions and recommendations In our initial discussion. responsiveness. These modiﬁcations may have. 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. 2002) and that it is necessary to adopt a contingency approach in which the number of dimensions varies according to. given the healthcare services’ credential. This study provides further support for the idea that service quality construct dimensions vary (Vinagre and Neves. all the remaining measures refer to the human element linked to service performance. 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. As predicted. empathy and tangibles. 1989) statement that patients often are in no position to assess care process technical quality and they are sensitive to interpersonal relationships. 0. Employee’s assurance and Tangibles. The remaining two dimensions seemed to be speciﬁc to this type of service. We departed from the assumption that this multidimensionality was equivalent to ﬁve quality dimensions proposed by Parasuraman et al. considering several studies developed by other researchers. we acknowledged that these dimensions lacked stability as well as the possibility that variations may occur depending on the characteristics of each service. Expectations had a direct effect (b ¼ 0:37. We thus veriﬁed that positive and negative emotions were partially mediating the effect of expectations and involvement on satisfaction.001). so the interaction dimensions gained greater saliency: “assurance and empathy with the physician”. nurses. 0. administrative staff) and consequently.(1988). p . assurance. patients have no “skill” to evaluate exactly the service’s technical reliability. two dimensions were clearly kept: “reliability” and “tangibles”. We believe that this approach is preferable to the idea of the ﬁve-factor universal structure present in the SERVQUAL scale. Regarding the dimensions proposed by Parasuraman et al.001) and an indirect effect (b ¼ 0:12. lowered the likelihood of ﬁnding similar results.the expectation and the emotions (especially the positive ones) all predicted satisfaction.001) and an indirect effect (b ¼ 0:28. This result is also consistent with Donabedian’s (1980. SERVQUAL was minimally altered to guarantee its adaptation to Portuguese public healthcare centres’ context. among others. Service quality measures have shown that with the exception of physical elements. 0. 0. In our study. As Sureshchandar et al. p . somehow constrained the possibility of replicating the study and. the type of the service. p . The inﬂuence of service quality 99 . the interaction/intervention element’s importance has been acknowledged by many researchers. However. a multiplicity of events of service and interactions. The involvement also had a direct effect on satisfaction (b ¼ 0:15. we considered that the service quality construct is multidimensional. p . therefore. (2002) highlighted. Physician’s assurance. “assurance with the nursing and auxiliary staff”. (1988): reliability. auxiliary staff.
g.1 100 The scale used to evaluate the emotional experience appears valid. pp. mainly positive ones. Babakus. 268-76. “Adolescent violence: the protective effects of youth assets”. (1993). 82 No. Therefore. greater or lesser degree of involvement) are also operating within these dynamics. they do not know how to manage those emotions. which involves diverse phenomena within the cognitive and emotional domain. Rodine. (1992). Journal of Counseling and Development. and Mangold. B. 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. (2005). Arnould. Our study highlights the importance of relational and emotional aspects in patient satisfaction. pp. more or less qualiﬁed. Vol. The higher the individual involvement. M. 133-9. is not extended to typologies proposed by other authors. Future research could develop the idea of dimension variability regarding the service quality dimensions and test whether emotions experienced in speciﬁc service contexts (e. 103 No. and Gerbing..B. Results also supported the process complexity that leads to satisfaction with a service. (2000). 26 No. References Anderson. Our study highlighted the effect of emotions. satisfaction levels may be affected if the providers of these services disregard the patient’s emotions and if.. consequently. 3. K..F. 3. the results showed that individuals experience pleasant or unpleasant emotional states following expected levels of satisfaction. Vol. pp. pp. 3. Satisfaction also varied with the involvement seen as the importance level of the service to the patients. Vesely. HSR Health Services Research. L.W. D. “Structural equation modelling in practice: a review and recommended two-step approach”. Psychological Bulletin. (1988). S.C. and Grifﬁn. on the patient’s satisfaction. L. 34 No.. These results support the assimilation effect of expectations. pp. it is necessary to take into account relational aspects between the service provider (physicians. Aspy. 411-23. Some limitations have to be considered in our study. T. 6.G. the less they tend to experience negative emotions. although showing good internal consistency. L. pp.K. operating like a self-fulﬁlling prophecy. Expectations also have a direct effect on emotions: the higher the expected satisfaction the more individuals tend to experience positive emotions and. (2004). E. 767-86. The emotion’s inventory we used. Yong-Ki.. R.IJHCQA 21. The pattern of emotions associated with service experience showed the coexistence of diverse emotions linked to the service experience. E. 156-75. Eun-Ju. Andreassen. higher the tendency to feel satisﬁed with the service provided. nurses and auxiliary) and the patients and the goodness of interpersonal skills in patient patient’s satisfaction (Donabedian. and Price.J. Babin. “Adapting the SERVQUAL scale to hospital services: an empirical investigation”.L. 19 No. J. 24-45. “River magic: extraordinary experience and the extended service encounter”. Vol. Vol.W. . S. one should keep in mind that besides seeking to provide high standards in terms of service quality. European Journal of Marketing. “Antecedents to satisfaction with complaint resolution”. and Marshall. W. Oman. Vol. 1980). Journal of Services Marketing. Vol. 20.. Even when performance is perceived as high quality. K. a more open or closed transaction. 2. McLeroy. “Modelling consumer satisfaction and word-of-mouth: restaurant patronage in Korea”.. Journal of Consumer Research.J. From a management view point. C.
322-38. (1997). “Customer loyalty in high and low involvement service settings: the moderating impact of positive emotions”. ´ Dube. 3. 248-58. Journal of Retailing. Explorations in Quality Assessment and Monitoring: The Deﬁnition of Quality and Approaches to its Assessment. 10. 4. Vol. Bitner. Free Press. O. “Customer evaluation of service employee’s customer orientation: extension and application”. “Customer contributions and roles in service delivery”. (2004). and O’Neill. and Menon. 180-90. 6 No. and Parasuraman. (1998). E. A. 4.J.A. pp. 6. 1. Bloemer. pp. ¨ Gronroos. pp. International Journal of Public Sector Management. 7.D.T. (1999). and Zeithaml. 1. 8 No. pp. Managing Service Quality. Bridges. Vol. Buttle. and Hocutt. MI.J. The inﬂuence of service quality 101 . “Critical service encounters: the employee’s viewpoint”. A.. Vol. 287-304. Dholakia. ¨ Gronroos. 294. 35 No. 25-32. R. A. Vol. A. Donavan. pp. Psychology and Marketing. (1995). Vol. B. 33-55. Donnelly. 1. “Innovation in public service management”. W. 66 No. Health Administration Press. C. and Ruyter. (1990). Marketing Services: Competing through Quality. Vol. U. B. (2000). (1980). Booms. M. 15 No. 13 No. D. L. “Reliability and validity of SERVQUAL scores used to evaluate perceptions of library service quality”. “Is there a role for expectations in SERVQUAL?”. 293-306. “Measuring service quality in local government: the SERVQUAL approach”. “Multiple role of consumption emotions in pot-purchase satisfaction with extended service transactions”. 1..M. pp. NY. (1994). 15 No. “Services attributes: expectations and judgments”. 193. 3. 3-28. (2000). 95-106.A. pp. pp.. 2. and Mohr. International Journal of Service Industry Management. 9 No. “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. 26.H. European Journal of Marketing. John Wiley and Sons Ltd. pp. 54-71. Vol. Bitner. “The deﬁnition of quality: a conceptual exploration”. Hubbert. (1991). “A motivational process model of product involvement and consumer risk perception”. 58 No. M. Vol. Vol. 6 No. Vol. C. Service Management and Marketing: A Customer Relationship Management Approach. Working Paper No. L. 3-11. Curry. M. “Managing customer expectations in the service encounter”. Donabedian. and Thompson. International Journal of Service Industry. 185-97. Vol. J. M. p. Faranda. (1995). A.A. Vol. pp. pp. (2001). Journal of Quality Management. NY. “Marketing services: the case of missing product”. C. 3.A. (1996). K. Ann Arbor. 1340-62. V. University of Manchester. Carman. 11. 4. Journal of Marketing. (1989).L. K. 8 No. Vol. Journal of Business & Industrial Marketing. J. (2001). “Institutional and professional responsibilities in quality assurance”.Berry.R. F. International Journal of Service Industry Management. M. pp. Vol. 15-20. (1999).W. L. New York. 11 No. (2000). Journal of Academic Librarianship. Vol. Journal of Marketing Management. Managing Service Quality. 1 No. Donabedian. (1993). Vol. Cook. “SERVQUAL and the Northern Ireland hotel sector: a comparative analysis – Part 1”. Coye. 315-30. pp. pp. New York. pp.T.M. Manchester. Gabbie. Quality Assurance in Health Care.
4. and Berry. Liljander. (1991). Nunnaly. Yavas. A.A.. ´ Sıntesis. Silla.L. (1997). Journal of Fashion Marketing and Management. (2005). “A conceptual model of service quality and its implications for future research”. Journal of Consumer Research. and Zeithaml. B.IJHCQA 21. Journal of Retailing. MA. V. Kilbourne. “Measurement and evaluation of satisfaction processes in retail settings”. satisfaction and relationship-oriented outcomes”. and emotion-cognition relations”. “Reﬁnement and reassessment of the SERVQUAL scale. C. and Ramos. 14. L. (1988). Mostafa. “Customer-service provider relationships: an empirical test of a model of service quality. 20 No. M.1 102 Hoyle. “Writing about structural equation models”. Price. in Hoyle. U. Zeithaml. D. Madrid. Vol. Parasuraman. McGraw-Hill. R. (2001).L. and Strandvik. 516-32. 7. multiple-item scale for measuring service quality”..L. Irwin/McGraw-Hill. “Basic emotions. Journal of Retailing.L. 64. A. R. (1985). H. Satisfaction – A Behavioural Perspective on the Consumer. 67 No. L. J. A. L.. V.. 8 No. pp.M. pp. 41-50. London. pp. Issues and Application.M. International Journal of Service Industry Management. Journal of Consumer Research. pp. T. “SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality”. Z. “Emotions in service satisfaction”. Mittal. Parasuraman. 2.T. (1998). J. Oliver. Vol. pp. Journal of Consumer Research. and Berry. (1995). Oliver. pp. “Going to extremes: managing service encounters and assessing provider performance”. (1978). H. Journal of Retailing. V. 12 No. and Tierney. Arnould. 2. Vol. Journal of Marketing Research. Vol. 524-33.A. W. 12-37.A. Vol. 4. International Journal of Service Industry Management. Vol. pp.E. Oliver. “Response determinants in satisfaction judgments”. pp.. 83-97. 3. Psychology and Marketing. (2004). Mano. pp. Vol. pp. 3.H. 451-66. R.. feeling and satisfaction”. Duffy.A. 24. Vol. Richins. E. V. 25-48. Berry. 9 No.E. R. . J. (1997). pp. 127-46.S. 99 No. Duffy. pp. (1995).J.. 9 No. 158-76. Vol. P. pp. Structural Equation Modeling – Concepts. 2. L. G.E. Vol. V. Parasuraman.J. Boston. “Assessing the dimensionality and structure of the consumption experience: evaluation. 7. (1981). 420-50. (1993). pp. Kim. J. Plenum. pp. “A comparison of four recent measures of consumer involvement”. M. Psychometric Theory.L. Izard. C. 18 No. 59 No. (1997). “The applicability of SERVQUAL in cross-national measurements of health-care quality”. (2005). Zeithaml. pp. “Consumer proﬁles of apparel product involvement and values”. (Ed. and Oliver. NY. Vol. and DeSarbo. (1977). R. 155-68. relations among emotions. 148-69. Oliver. 460-9. 207-20. and Bilgin. 17. pp. 663-82. 57 No. 3. 561-5.. Human Emotions. (1980). Sage.L. and Panter. Vol. and Giarchi. 4 No.L.L. Shemwell. M.L. International Journal of Health Care Quality Assurance. 2. (1995). Psychological Review.P.). A. New York. “Measuring emotions in the consumption experience”. Vol. Izard. Calidad de servicio y satisfaccion del cliente. Journal of Marketing. W.H.L. Vol. Vol. (1992). 495-507. “An empirical study of patients’ expectations and satisfactions in Egyptian hospitals”. “A cognitive model of the antecedents and consequences of satisfaction decisions”. Vol. R. Journal of Marketing. (1988). R. NY. New York. ´ Martinez-Tur. 18 Nos 6/7.-S. Journal of Services Marketing.
“The dimensionality of consumption emotion patterns and consumer satisfaction”. B. and Anantharaman. 10. 258-70.N. (2007). 86-96. Vol. pp. (1990). D. 92 No. “Determinants of customer-perceived quality: a conﬁrmatory factor analysis approach”. (1985). 4 No. Vinagre. V. M. 67 No. Verbeke. American Journal of Public Health. Vol. Public Administration Review. J. and Bagozzi. Journal of Marketing Research. (1987). Vol. R. 22 No. J.H. pp. in ¸˜ ¸ Colibri (Ed. International Journal of Bank Marketing. (1987). and Berry. (2002). 64 No. Vol. R.S. 3. “Service quality and satisfaction perceptions: curvilinear and interaction effect”.G. Percursos da investigacao em Psicologia Social e Organizacional. pp. 24. Rajendran.A. Corresponding author Maria Helena Vinagre can be contacted at: helenavinagre@gmail.L. “Development of a multiple-items scale for measuring hospital service quality”. R. patient-provider relationship. expectations. and Oliver. G. Vol.com/reprints . 1.A. “Measuring the involvement construct”.L..emeraldinsight. pp. “Sales call anxiety: exploring what it means when fear rules a sales encounter”.. H. Vandamme.L. 1. Westbrook. “Product/consumption-based affective responses and post-purchase processes”. and Neves. International Journal of Health Care Quality Assurance.. Wright. pp. 1662-7. C. Journal of Services Marketing. 51. and Solomon. Vol. Westbrook. C. pp. Journal of Consumer Research. (2004).E.Sureshchandar. 9-34. International Journal of Service Industry Management. Wisniewski. Free Press.F. 88-101. New York. Vol.com Or visit our web site for further details: www. M. 12. R. 18. Vol. 407-20. Zeithaml. Delivering Quality Service: Balancing Customer Perceptions and Expectations. pp.H. W So. Zaichkowsky. 54-64. W. “Public service and motivation: does mission matter?”. and Leunis. (2002). 217-28. (1991). Journal of Marketing. 30-49. “Predictability and personalization in the service encounter”.R. L.A. pp.P. Surprenant. 6. 84-91. “Measuring service quality in a hospital colposcopy clinic”.). NY. and the placebo effect: implications for health promotion”. A. and Wisniewski. (2002). Vol. Vol. (2005). pp. Ting. Parasuraman. 341-52. D. R. M. J. “Acupuncture outcomes. (2000). pp. Journal of Marketing. (1992). Vol. Journal of Consumer Research. ¸˜ Lisboa. 1. Vol. R. “Medicao da qualidade de servicos em autarquias locais”. 16 No. pp. 271-90. 3. 18 Nos 2/3.com The inﬂuence of service quality 103 To purchase reprints of this article please e-mail: reprints@emeraldinsight. pp.
104-124 q Emerald Group Publishing Limited 0952-6862 DOI 10. The “reliability and fair and equitable treatment” factor was found to be the most important healthcare service quality dimension. 21 No. agreeing to pay a price premium. 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. 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. Keywords Health services. Service levels.htm IJHCQA 21.1 The relative importance of service dimensions in a healthcare setting Rooma Roshnee Ramsaran-Fowdar Faculty of Law and Management. preferring the company over others. Reduit. Private hospitals. On the other hand. based on factor and reliability analysis. . 2008 pp. social needs for belongingness and affection and individual needs International Journal of Health Care Quality Assurance Vol. clothing and safety. doing less business or switching to alternative service providers. Human needs are states of felt deprivation such as physical needs for food. customer dissatisfaction may lead to unfavourable behavioral intentions such as negative word-of-mouth. . Retaining customers may be more proﬁtable than attracting new ones. Clancy and Schulman (1994) calculated the cost of attracting new customers to be approximately ﬁve times that of keeping current customers happy. 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.The current issue and full text archive of this journal is available at www. increasing their volume of purchases.1108/09526860810841192 .com/0952-6862. 1. Therefore. Mauritius Abstract Purpose – The paper aims to focus on an augmented SERVQUAL instrument that was used to measure private patients’ service expectations and perceptions. Findings – A new service quality instrument called PRIVHEALTHQUAL emerged from the study. or . 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. University of Mauritius. praising the ﬁrm. Design/method/approach – A questionnaire was administered to 750 and 34 per cent responded. Zeithaml and Bitner (2000) described how customers express such intentions in positive ways: . 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.emeraldinsight.
desired expectations as a comparison against which service performance is assessed. (2) reliability. (3) responsiveness. Speciﬁcally. additional research is necessary to gauge its applicability to healthcare services. Parasuraman et al. Zeithaml et al. The most widely accepted measurement scale for service quality is SERVQUAL (Parasuraman et al. 1993.. Given healthcare’s credence. Wants are the form taken by human needs as they are shaped by culture and individual personality. 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. One of these criticisms is SERVQUAL’s inappropriateness as a generic measure for all service settings. 1993a. Spreng and Singh.. 1989. there is a need to test if SERVQUAL is a comprehensive patient evaluation of healthcare service quality measure or if additional dimensions are needed. 1993b). This model proposes that service expectations can be separated into an adequate standard and a desired standard (Zeithaml et al. 1992. Cronin and Taylor. Although SERVQUAL proved to be a robust service quality measure. Within each dimension there are several items (22 in total) measured on a seven-point scale from strongly agree to strongly disagree. Exactly what are consumers’ needs and wants in a healthcare context? By and large. 1993. 1989). 2000). (4) assurance. 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. and (5) empathy. Teas. Between these two expectation levels lies “tolerance zones” that represent a performance range consumers consider acceptable. relationship between patient and doctors and the punctuality of appointment among others may be medical care quality indicators. 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. 1993). 1990).. These service quality surrogate indicators can be used by patients to assess service provider efﬁcaciousness. Recently. Parasuraman et al. researchers proposed that multi-expectation standard approaches may be more appropriate for service quality models (Boulding et al. which consists of ﬁve essential service quality dimensions: (1) tangibles. Carman. In their popular measuring service quality framework. staff appearance. it has been subject to criticisms conceptually and methodologically (Babakus and Mangold.for knowledge and self-expression. Ofﬁce aesthetics. Since SERVQUAL was generated outside healthcare and has limited examination in the healthcare literature. 1993... research on consumers’ multi-expectations.. Brown et al. 1993. Importance of service dimensions 105 . 1988). (1988) used a single expectation standard. 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). There is research that service quality is contingent upon service type (Babakus and Mangold. However. 1994). 1990.
inability to take initiatives and poor leadership. One reason for this difference in health status may be the relative level of investment in the health services in different countries. The public sector employs over 690 doctors (including about 245 specialists) and around 2. 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 1.716 at the end of 2001. employs over 400 doctors and provides primary and secondary services in 14 private clinics. Private general practitioners (GPs) were selected because they deal with patients on a long-term basis. Given the physician shortage. there were 1. that is. patients have to wait in long queues in the public hospitals. People at the bottom of the socioeconomic ladder obviously cannot access paid services. 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 . The number of doctors registered has declined over the years since these professionals prefer to work overseas where they are better remunerated. one bed for 315 inhabitants or 3. Nevertheless. private medical services were identiﬁed as a suitable study setting to explore professional service quality and its evaluation from the clients’ perspectives.3 per cent in Singapore. Consequently. 8 per cent in New Zealand. poor remuneration. The private sector. low working life quality.089 inhabitants. 2001. which absorbs 32 per cent of the country’s total health expenditure. The private sector has 588 beds of which 283 are single rooms (Ministry of Health and Quality of Life. At the end of 2001.1 tolerance zones. The Mauritius healthcare system The Republic of Mauritius has a total area of 720 square miles and a population of 1. Presently.700 nurses.000 population in Mauritius is signiﬁcantly below that found in countries with better levels of health. All impede patient service delivery in the public sector. MSS and MSA is in the exploratory stage. 5. 9.IJHCQA 21. Consequently.2 beds per 1. new measures are needed to improve its performance to reach the levels achieved by places such as New Zealand. 2003). 8. Healthcare service performance is also relatively low in Mauritius compared to other countries because of stafﬁng differences. Compared to other African countries. Often.2 million residents (Central Statistics Ofﬁce. Furthermore.9 per cent in Belgium.000 live births. representing one doctor for every 1. the government allows public doctors to practise privately as part of its staff retention strategy.8 per cent of its Gross Domestic Product on health compared to 3. Although Mauritius is doing well. 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.8 per cent in France and 13 per cent in the USA (Ministry of Health and Quality of Life. 2002). for instance.000.107 doctors in Mauritius. Mauritius spends about 2. the number of doctors and nurses employed per 100. in comparison to developing countries. Indeed. Mauritius has made remarkable progress addressing citizens’ healthcare needs. The total number of beds in government institutions was 3. Mauritian medical care is freely provided by the state and there is also a well-established private sector.9 per cent in Seychelles. Similarly. Singapore and other developed countries where average life expectancy is above 75 years and infant mortality rates is below seven. there is a serious demoralisation problem among hospital employees resulting from cumbersome workload. 2002). many nurses have migrated.
The study revealed that customers used the same general criteria to arrive at an evaluative judgement regarding service quality.e. we seek to accomplish the following speciﬁc objectives: . service quality characteristics and the criteria used by customers when assessing service quality. Physical quality includes structural aspects associated with services such as the reception area. discussed three kinds of quality: (1) physical. to measure service quality in a private healthcare setting. The researchers also identiﬁed two inter-related service quality dimensions. Along the same line. on the other hand. customers’ expectations) with the seller’s actual service performance (Parasuraman. and (3) corporate. was to conduct empirical research on service quality frameworks. (1985) deﬁned service quality as an overall evaluation. Our purpose. Parasuraman et al. product repair and maintenance). “outcome” quality and “process” quality. doctor’s ofﬁce hours and secretary’s behaviour. which correspond to the ¨ dichotomy proposed by Gronroos (1982) and to the “physical” and “interactive” quality characteristics identiﬁed earlier by Lehtinen and Lehtinen (1982). while (2) functional quality refers to service delivery processes or the way in which the customer receives the service (i. (1985) study was the most extensive research carried out into customer service Importance of service dimensions 107 . This idea was supported by exploratory research conducted by Parasuraman et al. Addressing the major issues discussed above. to identify the most important service quality dimension in a healthcare setting. Consequently.’s. securities brokerage. which refers to the degree and direction of discrepancy between customers’ perceptions and expectations.insurance. 2000). Literature review Different theoretical perspectives on service quality were developed during the 1980 s. what is offered and received). Corporate quality includes image and reputation.e. Topics discussed with focus group members included the meaning of quality in the service’s context. Lehtinen and Lehtinen (1982). Parasuraman et al. credit card. (1985) using twelve consumer focus-groups in four industries (banking. how the service is offered and received). Zeithaml (1988) later deﬁned service quality as the consumer’s assessment of overall excellence or superiority of the service. similar to but not the same as an attitude. Technical quality can relate to the surgeon’s performance. (2) interactive.e. and . Interactive quality involves contact between the customer and service personnel. Olshavasky (1985) also viewed quality as a form of overall service evaluation similar in many ways to attitude. while functional quality may consist of the doctor’s waiting room. From these earlier writings. distinguished two types of service quality: (1) technical quality refers to core service delivery or service outcome (i. examination room and medical equipment. ¨ Groonroos (1982). for example. it can be seen that service quality notions arise from a comparison of what customers feel a seller should offer (i. therefore.
empathy and tangibles. For example. They suggest that environment. (1990). other studies (Carman. 1993) demonstrated that service encounter situational characteristics such as customers’ prior experience. that customers rated all ﬁve SERVQUAL dimensions important. Attempting to capture the essence of various comparison standards. 1994) suggest that multi-expectation standard approaches may be more appropriate in service quality models.’s (1985) ﬁve service quality dimensions.’s (1985) well-known SERVQUAL model.or situation-speciﬁc. On the other hand. Parasuraman et al. 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. physical and corporate quality. In a study of 1936 customers in two banks. replication studies by other investigators failed to support the ﬁve-dimensional factor structure obtained by ¨ Parasuraman et al. repair and maintenance. 1992) and up to nine (Carman. 1990. However.. Lately. Babakus and Mangold (1989) argue that SERVQUAL’s dimensional instability results from the type of service sector under investigation. (1993) and Parasuraman et al. That is. research indicates the possibility of two public utility sector dimensions (Babakus and Boller. desired expectations (what the consumer feels a service provider should offer) was used as a comparison against which service performance was assessed. in their study of credit-card. Turner and Pol (1995) also reported that quality dimensions are not equally important. Mowen et al. (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. The SERVQUAL instrument is described by Parasuraman et al. followed by responsiveness. assurance. the instrument has been criticised conceptually and methodologically. Because some service quality determinants are perceived generically.IJHCQA 21. while others are industry. Zeithaml et al. some researchers such as (Boulding et al. Moreover. deﬁned service quality as three constructs: interactive. (1993) pooled insights from past expectation . This ﬁnding consistently cropped up in other studies such as Zeithaml et al. (1990) reported service reliability as the most critical dimension perceived by customers. In Parasuraman et al. Lehtinen and Lehtinen (1982). contractual performance (outcome) and customer-employee relationships (process). developed by Parasuraman and his colleagues. The 22-item SERVQUAL instrument. motor care tire centre and acute care hospital. (1993. long-distance telephone and retail banking services. Groonroos (1982) conceptualised service quality as a two dimensional construct comprising technical and functional quality. (1988). Zeithaml et al. McDougall and Levesque’s (1994) study also did not support Parasuraman et al. business school placement centre. customer’s physical or emotional status and other non-medical characteristics can inﬂuence customers’ service quality perceptions. They revealed only three underlying elements: tangibles. (1991) as a reliable and valid service quality measure with relatively stable dimensions that apply across many service industries.1 108 quality perceptions. Zeithaml et al. 1990) in a dental school patient clinic. two insurance companies and a long-distance telephone company. One main criticism is the applicability of the ﬁve SERVQUAL dimensions to different service settings. however. which underpin service quality. Respondents considered reliability as the most important and tangibles the least important dimension. a single expectation standard. (1990) reported. included ﬁve service quality dimensions described above. Despite its widespread use.
Separating these two expectation levels is a “tolerance zone” that represents a service performance range a customer would consider satisfactory. most customers are realistic and understand that company staff cannot always deliver the preferred service level. In other words. This service quality framework combines adequate. customers also have an expectation threshold. The latest SERVQUAL modiﬁcation. (1994) found that tolerance zone measures had convergent and predictive validity. Hence. (2) service level adequacy.conceptualisations with ﬁndings from a multi-sector focus-group study to develop an integrative customers’ service expectation model. 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. therefore. the tolerance zone is a service range within which customers do not pay explicit attention to performance. 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). As mentioned earlier. desired and predicted expectations along with perceived performance. 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. Moreover. incorporates this expanded expectation conceptualisation. Convergent validity is the extent to which the scale correlates positively with other measures of the same construct. A performance below the tolerance zone (or below the adequate service level) will engender customer frustration and dissatisfaction and decrease customer loyalty (competitive disadvantage). However. adequate and perceived service ratings using Importance of service dimensions 109 . termed adequate service. On the other hand. (Berry and Parasuraman. 2004). and (3) a speciﬁc company’s perceived service. 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. 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. (1994) modiﬁed SERVQUAL’s structure to capture the MSS and MSA gaps. Parasuraman et al. three values (on a nine-point scale) are measured: (1) customers’ desired service level. 1991). The three-column format (Table I) involved obtaining separate desired. 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. Additionally. For each SERVQUAL attribute. the tolerance zone provides detailed and probably more accurate managerially diagnostic information and thus better strategy decisions (Teas and DeCarlo. The tolerance measures were also less susceptible to response errors compared to single expectation measures. customers will be satisﬁed if performance falls within their tolerance zone (competitive disadvantage). or the minimum level of service customers are willing to accept without dissatisfaction. 2000). If the correlation between two measures is high then the initial measure is said to have predictive validity. Parasuraman et al.
110 IJHCQA 21. . .1 When it comes to. 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 2 3 4 5 6 7 8 9 1 Modern-looking equipment Table I.
three identical. with emotions approaching love for the patient” and an “outcomes” dimension that included “pain relief. life saving. user-friendly forms). The perceived – desired and perceived – adequate differences were used to calculate MSS and MSA respectively. Importance of service dimensions 111 . (2) empathy (e. Additionally. Using principal components analysis and Varimax rotation. research conducted by Haywood-Farmer and Stuart (1988) suggested that SERVQUAL was inappropriate for measuring professional service quality since it excluded “core service”. waiting room. waiting time. On the other hand. age. helpfulness. (3) physical access (e. waiting room facilities. Gabott and Hogg (1994) reported six factors that affect consumer satisfaction: (1) service range (e. Peyrot et al. (5) situational (e. Parasuraman et al. Healthcare sector service quality Previous SERVQUAL tests in health care settings yielded mixed ﬁndings. access to care. bedside manner. sex. decoration). The “caring dimension” implied a “personal. and (3) examination comfort (physical comfort and time in the examination room). reported two major additional dimensions not captured by SERVQUAL: caring and patient outcomes. receptionist’s manner. facilities for disabled). “professional competence” and “communications” as factors signiﬁcant for both physicians and patients in service quality evaluation. ofﬁce visit. “service customisation” and “knowledge of the professional” dimensions. one practical problem with the three-column format is that it calls for three separate ratings that respondents may ﬁnd more time-consuming. However. on the other hand. (1993) separated service attributes into three factors using factor analysis: (1) staff behaviour (friendliness. explanation).g. and personal issues. anger or disappointment with life after medical intervention”. access by public transport. A GP (1) (2) (3) (4) satisfaction study by Drain (2001) yielded four factors: care provider. and (6) responsiveness (time spent with doctor and time spent in waiting room). number of doctors). Babakus and Mangold (1992) found the instrument reliable and valid in hospitals. Brown and Swartz (1989) identiﬁed “professional credibility”.g. human involvement. Bowers et al. (4) doctor speciﬁc (e.g. home visits). (1994). parking. The perception-only ratings (Column 3) were found to have the most predictive power.g. specialists.g. (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.g. side-by-side scales. (2) pre-examination comfort (e. appointment time convenience).
as well as an . . it is hypothesized that: H1. however. 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. which implies that one generic service quality measure is inappropriate for all services.1 112 Dean (1999) identiﬁed four stable dimensions using SERVQUAL to compare service quality dimensions in two different healthcare settings (medical centre. (3) same gender as the patient. Lam (1997) and Taylor (1994a. 1994b) reported that SERVQUAL was a consistent and reliable one-dimensional scale. studies show that SERVQUAL does not cover all healthcare services dimensions that are important to patients. few studies including Babakus and Mangold (1992). (2) tangibles. Loaded together these dimensions accounted for approximately 68 per cent of the variance in both settings. and (5) empowering patients to make decisions. Core outcome is the most important healthcare service quality dimension. research indicates that perceived service quality is contingent upon service type. (4) advising. responsiveness.’s (2004) study also showed that SERVQUAL captures service quality multidimensionality: . Therefore. reliability and empathy.IJHCQA 21. 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. Therefore. (2003) identiﬁed ﬁve main service attributes that explain people’s GP service preferences: (1) communication. (3) empathy. However. tangibles. In short. (2) doctor-patient relationship. . . overall (second order) service quality factor. and (4) reliability and responsiveness. there has been limited recent published work on service quality dimensionality after the mid 1990s. However. using factor analysis. Kilbourne et al. Although Berry and Parasuraman (1991) argued that the SERVQUAL “reliability” dimension is the outcome of service performance representing the core service. maternal and child health centres): (1) assurance. Recently. Morrison et al. A different argument is proposed for consideration in a healthcare environment.
Importance of service dimensions 113 . (2) Appealing materials such as pamphlets.Method We used a cross-sectional quantitative research design. (1994). response format. (2) Section B consisted of a question that measured respondents’ overall service quality evaluation. Respondents were chosen to achieve age. Selected items were reﬁned and paraphrased in both wording and contextual applications as appropriate to suit our research purposes. Respondents circled the appropriate number on a seven-point scale from Low (1) to High (7). education level. responsiveness. The list below summarises the questionnaire’s 47 service quality items. ethnicity. (1994). 1996). All items were phrased positively as suggested by Parasuraman et al. their friends and other associates. question wording and questionnaire sequence into consideration (Kinnear and Taylor. target respondents. residence. adequate and perceived service scales. and their GP service ratings. after carrying out in-depth interviews on healthcare quality with patients. occupation.’s (1994) three-column format was used with three identical desired. each item investigated was checked once again before verbally and structurally being changed to reﬂect our research needs. our questionnaire consisted of three sections: (1) Section A included 47 statements on different aspects of GP services. magazines. gender. Their choice best reﬂected their desired and minimum service level expectations. personal income and marital status diversity. the 47 service quality items measured on a seven-point scale from low to high. Parasuraman et al. These scales add strong diagnostic value and the three-column format possesses comparable reliability and validity to other formats studied. including gender. Detailed notes were taken during interviews and these were eventually compiled into a report. (3) Section C covered respondent demographics. and used the regression purposes. posters and so on. hypothesis. Respondents were subjected to a set of open-ended questions on their quality perceptions of services provided by private GPs. Our questionnaire was designed taking preliminary considerations such as the research questions. monthly household income and private healthcare payment mode. Additionally. newspapers. respondents were asked to rate the overall quality of GP service on a seven-point Likert scale. A convenience sample was used by choosing people working at the Mauritius University. occupational status. 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. empathy and assurance from Parasuraman et al. Our modiﬁed SERVQUAL-type questionnaire for use in the healthcare sector was constructed by retaining some items from the updated SERVQUAL dimensions: tangibles. Service quality questionnaire items (1) Ability to get an appointment at a convenient time to me. marital status. age. Next. This separate question for measuring overall service quality using the average measured gap helped to measure multi co-linearity. Consequently. 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. reliability. address.
Prompt service without an appointment. Physician compliance with hygienic and other precautions. Uniform fees and other charges for all patients. Physician reputation. . Clear display of GP’s qualiﬁcations. Convenient hours of operation. Punctuality of appointment. GP’s willingness to listen carefully to patients. Honesty and integrity of physician. Visually attractive and comfortable physical facilities (e. chairs. Convenient clinic location. Ability of support staff to inspire trust and conﬁdence in patient. Knowledgeable and skilled support staff. Reliability in handling the patient’s problems. GP accessibility by phone. Careful diagnosis of the patient’s problems.IJHCQA 21. GP having patients’ best interest at heart. GP’s emphasis on patient education. Knowledgeable and skilled GP. Courteous and friendly doctor. Professional appearance/dress of the GP. GP’s familiarity with latest advances in medical ﬁeld/products. GP’s readiness to respond to the patient’s questions and worries. GP making patient feel good emotionally and psychologically. Modern medical equipment. GP accessibility at odd hours in case of emergencies. waiting room. GP’s medical qualiﬁcations. Maintaining accurate and neat records of the patient’s medical history. Courteous and friendly support staff. Willingness to help patients. tables and amenities).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. Highly experienced GP.g. Prescription of affordable medicines. Ability of GP to inspire trust and conﬁdence in patient. GP’s emphasis on prevention of health problems. Professional appearance/dress of the support staff.
Respondents must also have visited a private GP during the preceding year and be over 18 years of age. the response rate achieved was Importance of service dimensions 115 . Sommers (1999) reports that for scientiﬁc validity. Questionnaires were also sent to workplaces.e. Response rate From 750 questionnaires distributed over a period of ﬁve months in 2003. (1999) suggest that. A total of 750 questionnaires were distributed and administered in two stages. to refer the patient to a specialist. Second. families and friends. 150 questionnaires were hand-delivered to the receptionists in ﬁve randomly selected private GPs. Basilevsky (1994) and Hair et al. 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. (46) Remembering names and faces of patients. Owing to the relatively large University and other contact commuter base. Thus. Physician’s willingness. there should be at least four or ﬁve times as many observations (sample size) as there are variables. a total of 260 were completed and returned. They were asked to ensure that each was an immediate family member. three were omitted from our data analysis owing to incomplete or missing information – a ﬁnal response rate of 34 per cent. First. 600 questionnaires in batches of two were distributed to Mauritius University undergraduate and postgraduate students. (47) Thoroughness of explanation of medical condition and treatment. 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. schools. We used a convenience sample. if necessary.000 females (Central Statistics Ofﬁce. Positive medical outcome of treatment. Completion instructions were given to each receptionist. Since there is a maximum of 47 items.(39) (40) (41) (42) (43) (44) Maintenance of patient conﬁdentiality. Therefore. pharmacies. laboratories). Completed questionnaires were then collected by the researcher over a period of two months. 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. (45) Reassuring the patient about the recovery. Quality of GP’s referral contacts (i. our 34 per cent response bettered the Mauritian 15-25 per cent national response-rate average. other relative or associate. They were requested to ask visiting patients to ﬁll in the questionnaire when waiting for the doctor’s consultation. contacts with specialists. 2003). Of these. every attempt was made to randomise the data collection process. Personal conduct and manners of the GP. neighbour. Physicians making patients feel safe and relaxed during their visits. Moreover. a sample size of 188 to 235 respondents would have been appropriate. a survey must achieve a rate of response that includes at least 30 per cent of the patients whose opinion was sought. as a rough guideline. hospitals. 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.
MSS scores explained 19. Data analysis We examined dimensionality using factor analysis. Only factors with Eigenvalues greater than one were retained and a decision rule of factor loadings in excess of 0. Results are illustrated in Table III. Cronbach alphas. Nevertheless. the MSS format was found to be superior. . Raw data were initially organised into MSS and MSA. The same conclusion was reached when comparing the Cronbach alphas. eigenvalues. Based on the total variance explained. We can. principal component analysis was used to extract the maximum variance from our data. Although MSS and MSA scores produced fairly low R 2 values.8 per cent. Therefore. According to Table III. it does not mean that these constructs are unrelated to overall service quality. therefore. McDougall and Levesque. Three different regressions were done. Factor rotation maximises the loadings’ variance on each factor thus minimising factor complexity (Tabachnick and Fidell. and . 1992. The Varimax rotation technique.40 was considered. empirically supporting the superior predictive power of this scale compared to the difference-score measures (Babakus and Mangold. 116 .’s (1994) recommendation. MSS scores explained the item loadings in a better and sound conceptual way. Table IV summarises two factor analysis results derived from MSS and MSA scores based on: .3 per cent of the variation in overall service quality and MSA scores 9. Factor structure reliability was tested for internal consistency after items were grouped. while MSS (sum of MSS means of 44 service statements retained from MSS construct divided by 44). A comparison of two possible formats is needed to determine which should be used to decide the factor structure for further analysis. was chosen for our factor analysis second stage. Comparing individual factor Eigenvalues revealed that results were relatively equivalent. Moreover. the total variation explained. with maximum likelihood method. There could be a nonlinear relationship between them that is not captured by R 2. Cronin and Taylor. Both MSS and MSA scores from 47 service quality items were factor analysed using Parasuraman et al. the factors derived from the MSA construct were slightly superior to the MSS score format. 1994). The resulting respondent proﬁle was deemed to be encompassing and fairly well distributed. a regression analysis was performed to assess the questionnaire’s convergent and predictive properties.1 considered adequate for the study. Overall service quality ratings were used as the dependent variable. 1992. Findings and discussion Table III shows that the perceptions-only scale had higher R 2 value than the other two measures. In the initial stage of factor extraction.IJHCQA 21. To test instrument scale validity. Table II provides a summary of the respondents’ demographics. conﬁrm the service quality scale’s convergent and predictive validity. 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. 1989). MSS convergent and predictive validity were superior compared to the MSA format (Table IV) by the higher R 2.
8 1.4 3.9 25.000 Rs 10.8 8.1 16.2 51.0 11.8 72.9 Importance of service dimensions 117 Table II. 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 10.2 51.001-40.4 12.0 0.001-20.1 6.1 3.) Self-employed Others Highest level of education completed CPE (cert.9 14.8 50. doctors.6 3.001-20.2 3.000 Rs 40.1 5.0 17.0 8.000 Rs 10.3 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 % 49.001-50.4 49. etc.9 20.000 Above Rs 50.2 3. Respondents’ demographic proﬁle .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. lawyers.1 34.1 61.2 15.5 7.2 44.000 Rs 30.8 32.0 44 56 40.7 24.1 0.
1 4.092 47. Our study adds to the large body of service quality research.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.72 Table IV. which largely explain the total variance: “Core Medical Services/Professionalism/Skill/Competence” and “Information Dissemination”. of items 19 5 15 MSA format 65.76 4 5 2 2 4.000 0.193 0.2 6.95 0.72 No. we named our new service quality instrument PRIVHEALTHQUAL. which were obtained using factor and reliability analyses on data from private healthcare settings. there were two additional dimensions with high Eigenvalues and Cronbach alphas.098 Adjusted R 2 0.189 0.337 0.9 0. Comparison between MSS and MSA score formats . Although some dimensions were relatively equivalent.2 1.6 Cronbach Alpha 0. Moreover. One way to test core outcome ` dimension importance (vis-a-vis other service quality dimensions) is to examine its Independent variable used Table III.87 0.97 0.545 df 1 1 1 Sig. which demonstrates that SERVQUAL is not a service quality generic measure for all industries.5 0. “Fairness and treatment equity” was also associated to the “reliability” dimension.000 0.340 0.2 4 7. therefore. of items 13 8 9 4 Eigenvalues 6.IJHCQA 21. managers should not continue to ignore consumer expectations. 0.6 3. Consequently. We also show a need to examine current tools that measure service standards in the professional services domain.4 3.91 0.75 0.9 4 Cronbach Alpha 0. Clearly.8 1. From our comparisons it can be said that an augmented and modiﬁed SERVQUAL instrument can be used in a private healthcare context.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.8 0.94 0.294 21.000 MSS format 63.094 F 102.’s (1988) SERVQUAL dimensions.81 2 0.4% Eigenvalues 9. our study provides evidence that expectations drive service quality diagnostic evaluations by consumers and. an understanding of both adequate and desired expectations is necessary to avoid service shortfalls and achieve better resource allocations. Proportion of variance in overall service quality (dependent variable) Perceptions-only (overall) MSS (overall) MSA (overall) R2 0.
2 Reliability – ability to perform the expected service dependably and accurately 3. Here. 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. caring. technical expertise. 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. . effectiveness and beneﬁt to the patient.SERVQUAL dimensions 1. accurately. Assurance – courtesy and knowledge of staff and their ability to inspire trust and conﬁdence 5. individualised attention provided to patients by physicians Core medical services/ professionalism/skill/ competence – the central medical aspects of the service: appropriateness. Tangibility – physical facilities. equipment and appearance of personnel Service quality dimensions in private healthcare (PRIVHEALTHQUAL) 1. 6. Table V. 4. The square of the correlation gives the proportion of criterion variance that is accounted for by its linear relationship with the predictor. 4. Empathy – caring. we shall use the PRIVHEALTHQUAL scale derived from the MSS scores. Table VI lists the results. The signiﬁcance test of r evaluates whether there is a linear relationship between two variables in the population. individualised attention provided to customers 5. 7. image and appearance of GP Reliability/fair and equitable treatment – ability to perform the service dependably. Tangibility/image – physical facilities. Responsiveness – willingness to help customers and provide prompt service 3. The Pearson product-moment correlation coefﬁcient (r) indicates the degree that quantitative variables are linearly related in a sample. knowledge. SERVQUAL Dimensions versus service quality dimensions generated from factor and reliability analyses correlation with a global measure of service quality and satisfaction.
the dimension “Reliability/Fair and Equitable Treatment” is the most important.005 255 0. a new dimension “Fair and Equitable Treatment”.1 MEDETAN Pearson correlation Sig. ‘GP’s medical qualiﬁcations’. is not supported – consistent with many studies including Zeithaml et al.100 0.119 255 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.’s (2003) studies. In fact. (two-tailed) n Pearson correlation Sig.097 0.000 255 0.IJHCQA 21.’s (2002) and Hellier et al. our research adds to the large body of previous research on service quality. “assurance/empathy” and “equipment and records” dimensions. Berry and Parasuraman (1991).113 255 120 MEDEREL MEDERES MEDEASS MEDECORE MEDEEQUI Table VI. we suggest that seven service quality dimensions are applicable to private healthcare. (two-tailed) n Pearson correlation Sig. However. (two-tailed) n Pearson correlation Sig. Thus.175 * 0.247 * 0.213 * 0. (two-tailed) n Pearson correlation Sig. was associated with the “Reliability” dimension. Our study supports Carman’s (1990) argument – that SERVQUAL scale items/dimensions need to be modiﬁed to suit particular industry settings.098 0. Consequently.01 level (two-tailed) From Table VI. overall service quality evaluation and satisfaction MEDEINFO Note: * Correlation is signiﬁcant at the 0. “Reliability” includes “careful diagnosis of the patients’ problems”. Correlations between service quality dimensions. consistent with Sureshchandar et al. Hypothesis H1 given earlier.001 255 0. This reﬂected patients’ views that everyone should be treated alike by their GP. (two-tailed) n What is your evaluation of the overall service quality you receive from your GP? 0. therefore. (two-tailed) n Pearson correlation Sig.001 255 0.122 255 0.210 * 0. we conclude that core outcome is not the most important dimension in health care service quality. (1990). followed by the “core outcome”. This new dimension included items such as “uniform fees and other charges for all patients”. and physician’s willingness to refer patients to a specialist if necessary”. (two-tailed) n Pearson correlation Sig. .
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.
Importance of service dimensions 121
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.
Importance of service dimensions 123
Vol. A. V. Journal of the Academy of Marketing Science.L. “The behavioural consequences of service quality”. Further reading Zeithaml. L. 31-46. 60. and Parasuraman. (1993). V. V.1 Zeithaml. A.. Parasuraman.mu 124 To purchase reprints of this article please e-mail: reprints@emeraldinsight. Vol. New York. L. Journal of Marketing. and Berry.com Or visit our web site for further details: www. Berry. (1990).. L.L. and Parasuraman. Berry.L. Corresponding author Rooma Roshnee Ramsaran-Fowdar can be contacted at: rooma@uom. pp.A.com/reprints .A. “The nature and determinants of customer expectations of service”. Zeithaml.IJHCQA 21.ac. 21 No.emeraldinsight.A. 1. Delivering Quality Service: Balancing Customer Perceptions and Expectations.. pp. A. (1996). The Free Press. NY. 1-12.
Assistant Director-General for Health Action in Crises at the World Health Organization. the consortium of USA-based international NGOs.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. a committee that is responsible for world-wide humanitarian policy and consists of heads of relevant UN and other intergovernmental agencies. “These new IASC guidelines are a signiﬁcant step towards providing better care and support to people in disaster. 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 Dr Ala Alwan. While this is increasingly recognised. . “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”. Community healthcare. people’s human rights and development. said Mr Jim Bishop. Red Cross and Red Crescent agencies. which if not adequately addressed can lead to long-term mental health and psychosocial problems. These can threaten peace. They identify useful practices and ﬂag potentially harmful ones.and conﬂict-affected areas worldwide”. Recent conﬂicts and natural disasters in Afghanistan. when communities and services provide protection and support. Vice President for Humanitarian Policy and Practice of InterAction. and clarify how different approaches complement one another. Indonesia. The guidelines address this gap. The guidelines have been published by the IASC. many people involved in emergency response have viewed mental health and psychosocial well-being as the sole responsibility of psychiatrists and psychologists. most individuals have been shown to be remarkably resilient. and NGO consortia. Sri Lanka and Sudan among many others involve substantial psychological and social suffering in the short term. Until now. many actors identiﬁed the need for a coherent. The guidelines have been developed by staff from 27 agencies through a highly participatory process. 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. Yet. systematic approach that can be applied in large emergencies.
Division for International Protection Services at the Ofﬁce of the United Nations High Commissioner of Refugees. The guidelines include attention to protection and care of people with severe mental disorders. Deputy Director. These guidelines give sensible advice on how to achieve that. focusing on the topic of health and migration.int Europe Future oncology healthcare strategy on the agenda of the Portuguese EU council presidency Keywords Healthcare strategy. They focus on strengthening social networks and building on existing ways community members deal with distress in their lives. healers. For further information: www. Dr Bruce Eshaya-Chauvin. acting Coordinator of the International Council of Voluntary Agencies. and women’s groups to promote psychosocial well-being. remarked: “Achieving improved psychosocial support for populations affected by crises requires coordinated action among all government and non-government and humanitarian actors. health workers. 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. Head of the Health and Care Department at the International Federation of Red Cross and Red Crescent Societies.” “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. 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. as well as access to psychological ﬁrst aid for those in acute distress.who. NGOs can play a major role in this regard. including severe trauma-induced disorders. Quality healthcare. ESMO . Coordination of mental health and psychosocial support is difﬁcult in large emergencies involving numerous agencies.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. The guidelines have a clear focus on social interventions and supports. 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. Treating survivors with dignity and enabling them to participate in and organize emergency support is essential.IJHCQA 21. and local contributions to mental health and psychosocial support are easily marginalised or undermined. Affected populations can be overwhelmed by outsiders. where cancer will be an important part of the agenda. They emphasize the importance of building on local resources such as teachers.” said Ms Manisha Thomas.
including a comprehensive overall strategy. cancer remains a huge public health challenge and a tremendous threat.has been invited by Dr Joaquim Gouveia. Director of the ESMO Political Ofﬁce in Brussels. The Round Table session on cancer will be chaired by Dr Joaquim Gouveia. comprehensive cancer control plans consisting of a variety of activities and strategic approaches. health determinants. The meeting will open with a welcome address by Professor Hakan Mellstedt. we will be able to achieve the expected relevant outcome: survival. this Round Table will address crucial issues in terms of the EU health agenda. as well as newcomers”. ESMO President. and . Under the broad theme of creating a “European Health Strategy”. 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.” The common objective of the meeting will be to create capacity building for developing and implementing effective policies and programs. he said. which are built on large coalitions and involve the necessary sectors. Although great scientiﬁc progress has been achieved in oncology and continues to be achieved. for the prevention and control of cancer. “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”. Professor Mellstedt continued. such as facing speciﬁc health problems. Professor Mellstedt said. morbidity and mortality worldwide. “The interactive format of the meeting. ESMO. member of the MAC (Members of the European Parliament Against Cancer). with prominent participation of Dr Marija Seljak. acknowledged Professor Mellstedt. News and views iii . a service that touches the lives of every single EU citizen. “The Portuguese representatives. will stress the following instruments: . said Professor Mellstedt. “Only by sharing expertise and exchanging best practices in Europe. ESMO. . and Mr Alojz Peterle. and by advocating together to get support and the appropriate political commitment. “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”. with a wide expertise. said Pascale Blaes. together with the Portuguese Presidency. to be a key partner in this meeting for aspects related to cancer. Slovenian Public Health Director. “The selection of such topics reﬂects the importance politicians place on assuring best quality healthcare. Cancer is one of the major causes of disease. population-based cancer registries. health services and patient mobility. National Coordinator of Oncological Diseases in Portugal. and its connections with other speciﬁc and global issues under discussion. Appropriate tools will need to be identiﬁed for the proposed policies to be effectively implemented. “It will certainly be complicated but is highly challenging”. screening programs. As a main actor in the ﬁeld. and patient satisfaction”. “The impact of this meeting will inﬂuence the future oncology healthcare strategy throughout the European Union”. better quality of life.
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. Clinicians will be able to see how their own activity compares to the health outcomes reported by patients. . Paul Robinson. . and what patients say about their experience of receiving that care and treatment.medicalnewsblog. said: “There is considerable interest within the health service in the potential of PROMs – patient-reported outcome measures. and judge them against national benchmarks. the EQ5D patient-reported outcome measure compared to a major new normative database. “Patient Driven Quality”. Kay Usher. 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’”. target and evaluate quality improvement initiatives.” The data tools included are: CHKS’ admitted patient care data set. correlate activity performance data with patient health and patient experience. applied to particular clinical specialties.1 iv will guarantee a high value contribution to the global debate on cancer and health in Europe. Hospitals will be able to measure the three sets of indicators.IJHCQA 21.” 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. outcome data and patient experience data gives UK hospitals the ability to: . for the ﬁrst time.info/ UK Quality improvement: patient-reported outcomes and experiences now integrated with clinical data for the ﬁrst time Keywords Patient feedback. said: “This combination will provide a patient-focused picture of the quality and effectiveness of the service provided by a clinical specialty over time. over time. The combination of performance data. For further information: www. the charity which is a leading authority on capturing patient and staff feedback and using it to improve services. and the Picker Institute. the leading independent provider of healthcare information. Quality improvement measures UK hospitals can now combine their clinical data with both patient-reported health outcomes and a measurement of patient experience. business manager at the Picker Institute. The new service. external relationship manager at CHKS. Healthcare standards. is being developed jointly by CHKS. and bespoke patient experience questionnaires developed to national standards by the Picker Institute.
. but we must never forget that most patients . said: “We all hear a lot of negative comment about the NHS.org v Patients give vote of conﬁdence in overall care provided by NHS hospitals in largest national survey Keywords Patient satisfaction. There were 30 trusts where one in ﬁve. . Chief Executive of the Healthcare Commission. Among trusts. patients rated the food as “poor”. few patients rated the food as “poor” – just 2 per cent in one trust. these ﬁgures varied between 2 per cent and 42 per cent. And compared with the Commission’s previous inpatient survey in 2005. Of the patients who indicated that they needed help eating. Performance standards. The results also highlighted considerable variation in the performance of acute trusts on a range of issues relating to dignity in care. Just 2 per cent of patients said the overall care they received in hospital was “poor”. answering calls for help. 84 per cent in this survey compared with 78 per cent in 2005. the biggest test of the experiences of patients in NHS hospitals in England. In autumn 2006. demonstrate efforts to meet standards for better health. or more. coordinated on behalf of the Commission by the Picker Institute. “very good” or “good”. 20 per cent said they did not get enough. There were encouraging signs on cleanliness with 93 per cent of patients saying their room or ward. 80. Looking at planned admissions only and excluding those who stayed in critical care units. News and views For further information: www. This compares with 92 per cent in the 2005 survey. The ﬁndings are from the Commission’s inpatient survey. and assistance with eating.000 patients at 167 acute and specialist trusts responded to the survey. . More patients said they waited six months or less for planned admissions. The survey highlights include: . 11 per cent of patients nationally said they shared a room or bay with a patient of the opposite sex. These include the standard of food. was “very clean” or “fairly clean”..pickereurope. more people responded positively to questions about cleanliness and efforts to control infection through handwashing. 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”. . Anna Walker. There was variation in how trusts scored on single-sex accommodation. But in most other trusts. mixed-sex accommodation. . and benchmark their own performance and reputation against the national data set.
Continuous improvement Under the new community pharmacy contract in England and Wales.uk Patient satisfaction surveys made easy: Department of Health Keywords Clinical governance. evaluation and reporting of results. too many patients still say they wait a long time while being admitted. Completion will therefore be mandatory.org. “The results also suggest that we need a fresh drive to tackle a set of issues related to treating patients with dignity. For further information: www. Staff should remember this as it shows that patients value the good work they do. For example. like offering help with eating and answering calls for assistance. The NPA will have member support ready as soon as the announcement is made. but as yet there is no compulsion to conduct such a survey. Patient experience. The independent watchdog is also preparing a national report on dignity in care for older people. When the requirement is introduced.IJHCQA 21. implement and evaluate the survey yourself. implementation. expertise and resource in-house to cope with a survey. all contractors will be asked to complete an annual patient satisfaction survey. Options (1) and (2) would only be recommended if a contractor had the time. the NHS is performing below standards on segregated accommodation. it has inspected 23 trusts where performance data raised particular questions. (3) Outsource the print. (1) Print. which uses information to target inspections and ultimately leads to an annual performance rating. . There are likely to be two or three options available to contractors.” The Commission will feed the results of the inpatient survey into its annual assessment of NHS trusts. where there are problems it seems as if there are a minority of trusts that are letting the rest down. But. As part of this. Results should be fed in to PCTs by the end of the ﬁnancial year – therefore the ﬁrst set will be due by March 2008. “Looking at waiting times. There may be scope to reduce this by looking at delays in admissions units. “Patients have the right to expect all hospitals to get the basics right. It is also clear that for a signiﬁcant minority of patients. 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. the National Pharmacy Association (NPA) will be offering its members three levels of support to match these options.1 vi have consistently rated the overall quality of their care as good or excellent. which will form one of the Clinical Governance requirements. (2) Print and implement your own survey and outsource the analysis of results and reports. from arrival at A&E to discharge.healthcarecommission.
implement. Healthcare standards. It is aimed at helping patients choose where they want to be treated when they need non-emergency surgery. Results are returned to contractors within the next ﬁve days. However. please contact us on r. The NPA has also commissioned CFEP to produce a resource pack to guide its members through the complex area of patient surveys.” Raina Jordan.firstname.lastname@example.org. NPA Commercial Director. from encouraging patients to complete the questionnaire to the analysis and actions arising from the results. A new web site is being launched in an attempt to strengthen patient choice. 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. 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. This is a practical guide showing how to design. an independent company that specialises in producing patient feedback surveys for healthcare professionals.uk”. pens and a large self-addressed envelope in which to return the completed questionnaires. News and views vii NHS web site aims to boost choice Keywords Patient choice. More than that. A high quality report of the results. The entire survey process.6m NHS Choices web site will include information on issues as varied as waiting times. Simon Ellison. in-store materials to explain the survey to patients. Patient empowerment Patients are being given more choice over where they are treated. hospital ratings and general cleanliness. 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. a ballot box.The STANDpoint system from Customer Research Technologies conducts all the research electronically and provides speedy analysis results. we are conﬁdent that the feedback members will gain from their patients will mean that they gain a high return on their investment. analyse and evaluate the results of the survey. CRT simply delivers the device to the pharmacy and collects it two weeks later. (CFEP) UK Surveys. Ministers also hope it will lead to detailed data on clinical outcomes being published – to date only heart surgeons reveal performance statistics. The service includes the supply of an appropriate number of questionnaires. . sealable envelopes to ensure patient conﬁdentiality. says: “A resource pack will be available to members free of charge. available in various languages. 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. including benchmarked data and patient comments will then be produced. provides pharmacy contractors with a validated questionnaire which focuses on the ﬁve domains of patient experience as deﬁned by the Department of Health. will be validated. The £3. The completed questionnaires will be analysed and the results fed back to the contractor.
And that will be extended to all specialities by April next year. 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. it highlights a clear need for better signposting as patients are often unable to determine . Later in the year people needing hip and knee operations will be able to choose from any hospital. . It has detailed information on 40 of the most common diseases and also uses data compiled by the Healthcare Commission on hospital performance. Health Secretary Patricia Hewitt said: “We know patients and the public are thirsty about getting information on health. The RCGP plan recognises the pivotal role of GPs and includes across-the-board recommendations for the Department of Health. One of the problems with the internet is that some of the information about health is top quality and some of it is rubbish.with the internet age resisting progress is fruitless.nhs. “What NHS Choices will do is give the public access to the best information about health.1 viii Patients have been given a choice of where they can go to be treated for non-emergency treatment since last year. 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.” For further information: www. The health secretary said: “We now have to do this with other procedures. of highly variable quality and that urgent action is needed to restore conﬁdence in out-of-hours services. The web site includes death rate data from individual heart units. fragmented. Primary Care Trusts (PCTs). .IJHCQA 21.” Ms Hewitt is also hoping the web site will push doctors into releasing information about the results of treatment. which was already available via a Healthcare Commission web site. While the RCGP recognises that good quality urgent care exists in some areas. 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. GP practices and health organisations to improve urgent care services for patients.uk 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. The multi-media web site has sections giving advice on healthy lifestyles and also allows users to carry out an online health check. including ratings and MRSA rates. At the moment. The Royal College of General Practitioners says that services are confusing. patients are given a choice of at least four local hospitals and the top-performing foundation trusts. Service delivery.
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 action plan calls for: (1) Care to be conﬁgured around the needs of patients with better signposting for access. To address this. which will enable PCTs to monitor clinical outcomes. RCGP Chairman Professor Mayur Lakhani. GPs are still involved in OOH rotas and a large proportion of OOH is still provided by GP co-operatives. the RCGP will shortly launch a national Out of Hours Clinical Audit Toolkit. It has also identiﬁed concerns about variation in quality of out of hours services. (5) Engagement with local GPs and recognition of their key role in leadership. PCTs must make efforts to engage and involve GPs in out of hours care: some PCTs have already managed to do this effectively. walk-in centres and minor injury units to foster integration and co-ordination of care between providers. (4) Quality standards including clinical outcomes to be monitored and enforce. (6) Stronger multidisciplinary urgent care teams whose members have been trained to nationally agreed standards. (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. (2) All GP practices to have a system for responding to and dealing with urgent care during surgery hours. and training opportunities in urgent care for GP Registrars.the most appropriate service to access. and to kickstart action in improving urgent care services.” “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. planning and support for urgent care and out of hours services. (3) PCTs to develop Urgent Care Networks comprising GP practices. (7) The Department of Health to make urgent care a priority and set a clear national strategy. 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. emphasising the necessity for high clinical standards. (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 . a practising GP in Leicester. Athough no longer contractually responsible for out of hours work. (8) Emergency care practitioners to be trained to a deﬁned national standard including an assessment of competence.” 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.
Being ill in the middle of night is frightening experience and patients need to be sure the NHS will be there for them. Any attempt to downgrade the role of GPs will lead to further diminution of quality and put pressure on other parts of the NHS. 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. As the proven experts in providing urgent care. and this plan will go a long way towards demystifying the maze that currently exists. “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. it is important that GPs have a strong inﬂuence on urgent care.medicalnewstoday. Urgent care competencies should also be incorporated within GP appraisal and CPD. Through an increased reliance on management companies who provide environmental services (EVS) to help enhance the patient experience. but we see HCAHPS as an opportunity”. Financial management. Chief Nursing Ofﬁcer and . said: “Patients are very confused and bewildered about which services may be available to them outside GP surgery appointments. “Everyone has struggled with patient satisfaction and the surveys in general. Professor Lakhani said: “A step change in policy is needed.com x Americas Outsourcing improves patient satisfaction Keywords Patient experience.” For further information: www. not the lucky few. Clear signposting to appropriate care is essential.1 GP Registrars. We urge that PCTs be held to account for the quality of their out of hours services. “The majority of care is still provided by GPs. 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.” Ailsa Donnelly. Chair of the RCGP Patient Partnership Group. 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. 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. says Laura Fortin. hospitals can improve survey responses. 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.IJHCQA 21.
by virtue of the fact that they specialise only in healthcare EVS. St Joseph was one hospital who chose this route. McKee is part of the Phoenix. accomplishing gains in EVS often proves elusive. Any hospital that wishes to remain in the running must act now to position itself as a leader among survey respondents. continues Schock. Given such a short timeline. News and views xi . Texas. 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. Colorado. quietness. “Clean areas invoke a sense of conﬁdence and a positive feeling about the people and services. and EVS plays a key role in patient satisfaction. Dirty places tend to trigger a sense of doubt.” Composed of 27 items that encompass critical aspects of the hospital experience – such as the responsiveness of hospital staff. At that point. which encompasses 20 hospitals and other facilities that offer an array of medical services.2 million ft2 St Joseph Medical Center in Houston. so we work really well together”. and how nice the person was who cleaned their room – these are things they can easily quantify on a survey. can transform that facet of hospital operations into a high-scoring asset when surveys get ﬁlled out. Arizona-based Banner Health organization.” The challenge of improving EVS Coupled with the typically low retention rate of EVS employees and hospitals traditionally lacking systematised processes for this department. agrees Marilyn Schock. and cleanliness of the hospitalthe HCAHPS survey provides a standardised instrument and data collection methodology for measuring patients’ perspectives on hospital care. Colorado. uncertainty and a feeling of scepticism about the people and services being provided. and management has to seek out what is best for their operation”. Founded in 1979 and based in Englewood. states St Joseph’s Fortin.Chief Operating Ofﬁcer at the 1. administrators at some hospitals are increasingly turning to management companies and consultants who. “It made sense for us to go with Medi-Dyn because we share a similar vision and value system with them. comments Fortin. 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. Celebrating its 30th birthday. so housekeeping deﬁnitely has a role”. EVS plays a crucial role in meeting the patient’s expectations of excellent patient care. Assistant Administrator at McKee Medical Center in Loveland. In response. “Patients can deﬁnitely assess how clean their room is. many administrators and operating ofﬁcers are opting for quick solutions. and upping the “cleanliness” factor is an effective means of enhancing the perception of competency. “Cleanliness is an important part of the healing and caring environment”. “EVS is an important part of the patient’s experience in the hospital”.USA. Typically. “I believe each facility is unique. “There are studies out there that show a deﬁnite correlation between patient satisfaction and your bottom line.
Other hospitals that chose the same option as St Joseph and McKee include Memorial Hermann Hospital in The Woodlands. really believes in this and understands what we are trying to accomplish within our EVS department. so effective training in meeting patients’ expectations must extend to all levels of the department. “We started a competition between departments: nursing competes against each other on scores each month. That was up from the 70th percentile on courtesy and the 65th percentile on cleanliness when Medi-Dyn began the contract in June 2003. where more than 99 percent of patient responses have ranked EVS services as good or excellent since 2001.” “Medi-Dyn’s expertise combined with our culture of excellence ensures a seamless teamwork approach. In other situations. When EVS “shines”. Natchez Community Hospital in Mississippi. EVS staff represents a tough population for retention. saving over US$350. He is very involved in patient satisfaction. Fortin reiterates. so do HCAHPS surveys Early positive returns on patient surveys from hospitals that rely on EVS management experts prove hard to ignore. both managers and all direct labor staff are employed by the contractor under a full-service option. “We only utilise Medi-Dyn for its management services – the employees are our own but they report directly to the Medi-Dyn manager”.” “In the selection of any vendor. “Typically. “The Medi-Dyn Director here. “and housekeeping has blown all other departments off the map. for example. and. administrative reporting procedures and ﬁnancial accountability. Bill Walles. When you have that. The attainment of such successes hinges on proven quality control systems. you can’t fail”. so they are doing something right”. one particular hospital reduced its full-time-equivalent EVS staff from 72 to 46. Gains in EVS management can even possibly inﬂuence capital outcomes. physician questionnaires. At the same time. department head inspections. says Fortin. as well as ancillary departments”. Texas. Through such feedback mechanisms as: patient interviews.000 per year while improving quality of service. . it is the EVS worker who frequently comes into direct contact with patients. At the McKee Medical Center. the level of quality can consistently improve over time. One of the lesser-known beneﬁts of turning to an EVS management expert to help enhance HCAHPS results. Under the guidance of Medi-Dyn. maintaining EVS as the hospital’s top-scoring department.1 xii In a management-only structure. the contractor provides the on-site management needed to effectively lead daily operations. This allows hospital administration to concentrate on other facets of patient care and improving the facility’s ratings. Press Ganey scores in third quarter of 2006 for “courtesy” and “cleanliness” were in the 99th percentile. where patient satisfaction scores for EVS are consistently above the 95th percentile. Intermediate levels of integration also exist. the key is to get the right management person”. is the fact that it can yield a return on investment that is often superior to managing the department from within. and its managerial staff from eight to four. exposing new hires to our goal of improving the patient experience. notes Schock.IJHCQA 21. is phenomenal.
healthservicetalk. and the ‘face’ that you want to put out there is one of cleanliness”. “Perception is everything. agrees Schock. a Charlotte. recalls Fortin. For further information: www. it improves the possibility a patient will return or recommend your services”. “EVS plays a key role in how your hospital is rated. North Carolina based healthcare services company that owns and operates general acute care hospitals in partnership with leading physicians throughout the USA. does not end with just good ‘H-caps’ scores. As of August 2006.“When our hospital was up for sale. St Joseph’s became a part of Hospital Partners of America. “The cleanliness deﬁnitely affected their overall impression of our facility”. every person that came in that was interested in buying the hospital could not believe how clean it was”.coml News and views xiii . but the customer-service gains you achieve.
D. the focus is usually on “after the event” accounts . McAndrew. Samociuk and S. these are not reviews of titles given. Patient involvement. provision and evaluation. Using patients’ experiences in medical education: ﬁrst steps in inter-professional training?. Collins and S. O’Neill. J. Looking back. . . The person as a life expert: this is not a love song.IJHCQA 21. . . J. . Beyond the tick box: providing a strategic direction to patient involvement in education. Professional education Current health policy places an emphasis on the greater involvement of health service users and carers in all aspects of their care. J. . Quality standards Experience Based Design (EBD) is a new way to bring about improvements in healthcare services by being user-focussed. S. McAndrew. Warne and S. Skidmore. healthcare professionals. xiv Using Patient Experience in Nurse Education Edited by Tony Warne and Susan McAndrew Palgrave Macmillan ISBN 9781403934017 Keywords Healthcare policy. E. when individuals have become consumers of health care services. Kilminster. They are descriptions of the books. Nursing. Warne. McGregor. Horne. carers.e. McAndrew. and meets a growing demand for educational approaches that address the perspectives of patients and carers. A. G. Morris. education and professionalisation in a contemporary context. Healthcare improvement. Ewart. Hepworth.stepping forward. S. Simpson. . Patients as teachers: utilising patients in classroom teaching. Stark and I. ISBN 13 9781846191763 Keywords Patient experience. based on information provided by the publishers. Nursing policy paradoxes and education implications. A long term affair. A. or in the training of health care practitioners. student-centred learning in community and primary care nursing. H. Costello and M. .1 Recent publications Please note that unless expressly stated. Patient-centred. E.i. This book ﬁlls that gap. Bringing User Experience to Healthcare Improvement: The Concepts. F. Stronach . Facilities. However. P. Methods and Practices of Experience-based Design Paul Bate and Glenn Robert Radcliffe Oxford ISBN 10 1 84619 176 9. There is little patient involvement in “before the event” experiences such as planning to meet health care needs. S. Contents include: . Thislethwaite and B. including planning. Canham.
Concepts: a quiet revolution in design. So what’s different? . particularly directors of service improvement in hospitals and directors of nursing. Future directions for experience-based design and user-centred improvement and innovation. 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. Contents include: . It will be of great interest to health and social care management. . .family and friends are all involved in the patient experience and systems and policies need to adapt to take this into consideration. Patient satisfaction In today’s health care environment. Through anecdotes and real-life examples from practicing physicians. methods and practices of EBD. This compelling book illustrates a new approach to redesigning health systems so that they truly meet the needs of patients and staff.). this exciting guide offers a unique approach to healthcare customer satisfaction. it’s need to know! It gives you action steps in all areas of the practice. . the very people who are experiencing them. Experience-based design: tools for diagnosis and intervention. Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty explains why understanding and meeting patient expectations is not only nice to know. The intellectual roots of experience design. This is a must for all health care staff. Patient groups and national organisations. . By exploring the underlying concepts. health and social care policy makers and shapers. Recent publications xv Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty Anne-Marie Nelson Jones & Bartlett ISBN 0834209225 Keywords Healthcare evaluation. Bringing the user experience to health care. . Methods: becoming a disciple of experience. “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. and quality improvement and organisational development specialists in healthcare.” Lynne Maher. It offers recommendations for the future and many interesting points for discussion. . . . Using stories and storytelling to reveal the users’-eye view of the landscape Patterns-based design: the concept of “design principles”. too will ﬁnd the book inspirational. having satisﬁed patients just is not enough you are now being judged by payers and compared to other providers. patient satisfaction is a big part of that evaluation. you will learn . Patient expectations.
. . . Lighting and leading the way. . . Now is the time to create loyal patients and winning practices. . . Making wrongs right. . Contents include: . but patient expectations remain the same. Want compliant patients? Communicate and educate. more compliant patients. Empower your patients with knowledge. Empowerment? It’s just plain old trust! .IJHCQA 21. Set standards for a great ﬁrst and last impression. . Where does clinical quality ﬁt in the picture? . How to earn raves from patients and payers. . Eighteen ways to learn what patients want. . . The telephone connection. How do you rate when you’re face to face with your patient? . Some things change. . For practice administrators and managers only: how to gain physician participation. and practical techniques to increase patient satisfaction in this updated edition. a more productive and committed staff. . . Winning practices for loyal patients. . Create a schedule that satisﬁes everyone! . Success is a team effort. Motivation: it takes more than a paycheck.1 xvi how to develop higher patient satisfaction. The diversity imperative hits health care. Want to communicate better? Listen well.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.