ISSN 0952-6862

Volume 21 Number 1 2008

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

International Journal of

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

ISSN 0952-6862 Volume 21 Number 1 2008

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

3 4 5



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


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


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The role of understanding customer expectations in aged care
Leib Leventhal _________________________________________________


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


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


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


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


CENTRE SECTION News and views __________________________________________ Recent publications ______________________________________

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

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

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

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

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

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

which has examined the service quality differences by collecting data from users of both types of hospital within a specified time period. kitchen and service sections (Kibris Newspaper. The majority (626 beds. For example. Gulle. Anderson. Caluda. The contribution of this study to the relevant literature. Second. 2005. Withanachchi et al. 2004. 2004). highlighted additional problems such as institutions’ financial incapability..9 percent) belong to public hospitals (Arikan. 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. First. no empirical research exists to our knowledge on service quality. disinterested staff and limited opportunities for patients to choose the doctors they want (Kibris Newspaper. Whilst pinpointing service-quality problems. long waiting lists. 67. that several ongoing quality problems exist in Northern Cyprus healthcare. 1993). The current Minister of Health and Social Affairs. In a recent study. Poor service quality has been identified as a problem for many years. the health care challenges. Study context Healthcare services are carried out by both public and private institutions in Northern Cyprus. claimed that the sector’s quality and standard are suffering from a lack of structure as well as from employing poorly qualified. with which to develop some future strategies for the promotion of a quality health care service. both are still suffering from a degree of low quality equipment. The present study’s findings may also provide hospital managers and government authorities with useful guidelines. for the first time. Just one year later. therefore. less is known about service quality differences between public and private hospitals (Jabnoun and Chaker. then. the Doctors’ Coalition Minister. and inpatient complaints. 2005). In other words. the Public Personnel Association Head. 2005). is two fold. The authors primarily stated that both the public and private hospital administrations have little or no concept of systematic data collection about inpatient needs. 2004.1 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. 2005). lack of medical equipment and instruments. Furthermore. Franck et al. The remaining institutions are also controlled by the government. complained about the inadequate number of personnel in the hospitals’ cleaning. 1995. He also stated that changing circumstances require an urgent major change. Arasli and Ahmadeva. This introductory section provides a brief description of the service. there are nine public and 52 private hospitals. is to assess and compare service quality in the Northern Cyprus public and private hospital sector. unprofessional personnel. The foremost aim of this study. Arabacioglu. poor service quality and of low priority given to the inpatients’ needs. 2003. Cyprus hospitals’ service quality using a public opinion survey. the former Minister of Health and Social Affairs. Camilleri and O’Callaghan. their proposed model also provided indicators for overcoming these problems by employing a total quality management (TQM) approach. 2002). service quality. medicine and facilities.IJHCQA 21. we can conclude from our personal observations. 1998. Specifically.. Arasli and Ahmadeva (2004) empirically measured. Celal. They found that. Arasli and Ahmadeva. Jack and Phillips. although private hospitals conditions are better than those of their public counterparts. corroborated by the above statement. 2004. as well as the conceptual relationship between .. predominantly in legislation.

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

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

It is important to note. Responses to all items were elicited on a seven-point Likert scale ranging from 1 ¼ strongly disagree to 7 ¼ strongly agree. 2004. (5) food (six items).6 percent) and professionals (14. 1978).2 percent) were married and although occupations were widely dispersed. however. in the future studies. However.Measures A questionnaire was developed based on the studies of Parasuraman et al. Jabnoun and Chaker (2003). (6) physical environment (nine items). 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). A high alpha value of 0.46 for the private hospitals. if required. which I had asked for was given to me” (mean 3. (1998). and finally. Lim and Tang (2000) and Andaleeb (2000). Approximately 71 percent had either high school or vocational school education. Analysis The SPSS 12. other dimensions may be added and adopted. that these dimensions may not represent all service quality aspects.2 to 5. More than 64 percent of the respondents were between the ages of 38-57 who were almost equally distributed in terms of their gender.1 percent). (2) relationships (nine items). the popular ones were: agriculture/animal related (27. the results of explanatory factor analysis showed that all factor loadings were above the recommended cut-off value of 0.19 to 6. 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. which showed that dimensions like food and the physical environment were often studied. There were six dimensions in the present study: (1) empathy (ten items). The reliability of the scale was tested using Cronbach’s alpha. housewives (15. Moreover. The majority (57. This was individually distributed to 15 families in the Famagusta district. The quantitative survey was produced based on a synthesis of the literature we studied.5 (Nunnally.2).1 percent). Arasli and Ahmadeva.0 for Windows was used to analyze our data. Results Table I demonstrates respondents’ demographic breakdown.914 was achieved indicating a good internal consistency for the forty-eight item scale. The lowest public hospital expectation score was obtained from question 44: “the food. (4) professionalism of staff (five items). (3) giving priority to inpatient’s needs (eight items). Expectation scores The mean expectation scores were high when compared to the perception scores – ranging from 3. This low expectation level may be the result of previous experience or negative word of mouth Service quality in public and private hospitals 13 .32 for the public hospitals and from 4. A survey instrument of 48 components was used in order to measure Famagusta hospital service quality.

1 6.4 100.2 454 260 179 15 454 64 27 45 23 25 5 123 61 71 10 454 % 10.5. Sample demographics communication from family members or friends who.7 28.2 39.7 100.4 49.4 3.6 2.19). Although question 5 has the lowest expectation score.9 5. 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” (4.1 5. this is not significantly lower than other items in the questionnaire. This high .1 27.5 1.8 100.0 14.4 9.1 Factor Age 18-27 28-37 38-47 48-57 58-67 68 and above Total Gender Female Male Total Education Primary school Secondary High school Vocational school Undergraduate Graduate Total Marital status Married Single Other Total Occupation Professional Administration Clerical works Sales works Services Agriculture/animal Manufacturer Student Housewife Others Total F 47 62 129 156 43 17 454 229 225 454 9 63 171 152 49 102.4 15. Inpatients’ families sometimes cook or they purchase food from restaurants for their relatives.0 57.4 13.0 13. had disappointing experiences with the quality of food or the limited choice of food.0 50. perhaps.3 34. The highest public hospital expectation score was statement 12: “doctors were capable of performing tests and procedures on me” (5.0 2.32).4 10.6 100. However.0 14 Table I.9 37.IJHCQA 21. it is slightly above 3. thus it can be evaluated as a high expectation score.1 13.2 100.0 9.5 3.7 33.

Doctors were courteous while speaking with me and my family 26.723 5.68 6.91 3.08 0.81 5.59 0.27 0. the nurses did not pay attention (R) 16.783 4.11 0.04 0.57 0. Nurses talked to me in order to get to know me better in their “spare” time 32.741 0.748 0. I was taken care of as an individual not like a customer 12. I had enough confidence in my doctor to discuss my very personal matters 0.70 5.27 0.75 3.12 3.27 5.43 -0.69 4.09 (continued) 15 Service quality in public and private hospitals Table II.93 4.55 0.92 0.23 4.34 5.11 0.21 4.56 0. I was presented with choices when doctors were deciding about my medical treatment 33.792 5.24 0.79 0.768 5. Doctors worked hard to prevent me from worrying 29.81 5.17 0.776 0.76 3.20 0.32 4.802 3.704 0.12 -0.Statements Variance exp: ¼ 22:0%/a ¼ 0:92 0. In hospital.19 0.82 3.95 3. Doctors spent enough time examining me 28.24 0.89 3.74 0.786 0.00 3.787 3.28 0.769 0.12 0.04 5.790 0. Whenever I asked for help.70 5.752 5.89 3.97 5.17 0.19 0.48 0.08 0.15 0. Doctors discussed after discharge medical issues with me Giving priority to inpatient’s needs 21.17 0.32 5.05 FL Public hospital Exp. expectations. Doctors made me feel comfortable even when they were not really successful in treating me 3.74 0.87 5.06 0.89 5. Doctors spent extra time with me to discuss my fears and concerns 18.819 4.44 0. Factor loadings.12 5.15 5.74 5. In hospital.04 0.26 0.773 4.32 4.95 3.34 5.07 Variance exp: ¼ 21:9%/a ¼ 0:87 0.21 4. My personal concerns were of utmost importance for the hospital 23.70 3.22 0. Per.10 0. Doctors did their best to make me emotionally comfortable 14.11 4.77 3.824 3.77 3.782 5.07 0.708 0.841 4.780 0.795 4.02 0.23 -0.763 0.727 5.13 0.67 4.36 0.08 0.82 0.15 0.08 0.821 4.34 0.05 3. Doctors took care of me as soon as I arrived on the ward 4.17 0. I was treated with respect 19.48 5.73 3.41 0.774 0.33 0.09 0.64 0.762 5.91 4.790 4.737 Variance exp: ¼ 12:0%/a ¼ 0:89 0.92 5. I was involved in the planning of medical treatment 25.21 5. Empathy 15.780 3.74 0.16 4.17 0.700 4.23 5.89 5.77 Variance exp: ¼ 40:7%/a ¼ 0:89 0.727 0.779 0.779 0. Per.14 0.771 5.80 0. Nurses were polite while speaking with me and my family 27. Gap FL Gap Private hospital Exp.40 5.80 0.748 4.21 3.86 4.747 0.809 5. perception and gap scores in public and private hospitals .56 5.16 3.21 0. Doctors were capable of performing tests and procedures on me 24.41 5. I had complete trust in my doctor 30.15 5.

Doctors spent extra effort to make sure that I understaood my condition and its treatment Table II. The nurses spent time with me to discuss my concerns about my condition 5.90 5.34 5.90 0.11 0.19 5.775 0.20 0.69 4.94 4.12 0.29 0.810 Relationships 13.01 3.01 3. The ward rules and regulations were explained to me 22. Gap Variance exp: ¼ 15:3%/a ¼ 0:84 5.86 3.09 0.10 6. Per.750 0.66 0.745 0. Doctors gave me medical advise in a simple way that I can understand 11.06 0.65 0. Doctors explained frankly to me the reasons for tests and procedures Variance exp: ¼ 20:7%/a ¼ 0:87 0.815 0.06 3.38 0.58 3.12 0.16 0.818 0.12 5.89 5.07 Variance exp: ¼ 8:2%/a ¼ 0:93 0.48 0.90 4.745 0.02 4.90 5.745 0.11 0.73 3.04 4.12 4.821 4.763 0.22 3.776 0.819 4.24 4.34 -0.39 0. a ¼ 0:91 0.714 0.87 4. Doctors talked to me frankly and politely 8.776 0.13 0.98 5.60 3.17 (continued) IJHCQA 21. The nurses asked my permission before performing any test on me 20. FL Public hospital Exp.767 5.58 5. The nurses were kind.803 5.12 0.02 5.21 5.07 0.774 0.15 0.785 0.1 .94 4.97 0. Doctors carried out my tests completely and carefully 10.28 Professionalism of staff 9.784 0.13 0.23 0.820 0.17 4.819 0.09 6.14 5.02 5.831 0.03 4. gentle and sympathetic at all times 6. The use of each procedure and test was explained to me before they were done 17.824 4.19 0.79 4.98 5.783 0.09 3. I was treated with dignity and had adequate privacy during my treatment 1.82 0.14 5.20 0. Per.13 0.25 5.721 3.841 6.21 4. I had a clear understanding of my condition during my stay in hospital 2.03 0.769 0. Doctors asked my permission before performing any test on me 31.97 5.45 4.83 3.03 0.87 5. My doctor was interested in not only my illness but also me as a person 7.25 0.731 0.16 Statements Variance exp: ¼ 9:3%.71 4.16 -0.19 0. Gap FL Private hospital Exp.99 3.79 4.46 5.71 3.29 0.

824 4. The ward was well ventilated 34.44 0.52 3.34 0.843 3.91 4.41 0.20 0.94 0. The ward was clean at all times 37.51 0.87 4.45 0.98 0.37 0.14 0.49 Variance exp: ¼ 18:8%/a ¼ 0:94 0.861 4.749 6. There was adequate number of bathrooms and toilets in the ward 41.772 6. Gap Food 45.16 3.850 3.21 3. 46.05 0.849 4.01 3.14 0.58 3. 43.69 0.98 0.19 3.77 0.46 6. while medical procedures and examinations were carried out Notes: Each item is measured on a seven point Likert scale.22 4. Outside noises were kept to a minimum 42.15 0. Gap FL Private hospital Exp.20 3.24 0.03 0.13 Variance exp: ¼ 29:4%/a ¼ 0:93 0.32 0.16 3. 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 0.768 5. 47.87 5. pillows and mattresses were comfortable enough 35.818 0.04 5.64 3. The ward was well furnished and decorated 39.45 0.805 3.23 0.18 0.15 0.719 5.14 0.64 3.03 0. Inside the ward. The screens were drawn around my bed.76 0.35 0.22 5.88 5.817 0.72 6.28 0.66 0.856 3.84 0.782 4.788 4.21 0.23 0.82 4.47 3. noises were kept at minimum level during night times 36.09 3.717 5.732 0.52 0.14 FL Public hospital Exp.44 0.10 0.17 0.68 0.869 4.19 0.861 4.Statements Variance exp: ¼ 15:9%/a ¼ 0:90 0.50 0.738 5.08 Physical environment 40.815 5.89 0.64 0.43 6.761 5.02 5. .784 6.12 4.796 6.807 4.09 3.37 0.29 0.831 4. 44.46 0.34 5.37 0.25 3.67 0.61 5. The bathrooms and toilets were always clean and pleasant to use 38.21 0.91 6.712 4. 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. 48.39 4.724 0.25 0. Per.754 4.84 0. The beds.18 0.12 3.17 5.865 4.09 0.33 0.76 4. Per.

which I had asked for was given to me”. which is a tangible quality factor. p.1 18 expectation level may be the result of a lack of trust in the doctors.68) was observed in statement 38: “the beds. food (15. ranging from 3. pillows and mattresses were comfortable enough”. Of course.03 to 5. All these gaps came under the physical environment construct.28) and portion size (0.03) and the lowest expectation score in private hospitals was obtained from the statement 5: “the use of each procedure and test was explained to me before they were done” (4. The lowest perception score in public hospitals was obtained from statement 44: “the food which I had asked for was given to me” (3. Interestingly. The highest private hospital expectation score was related to: “the bathrooms and toilets were always clean and pleasant to users” (6. The empathy dimension had the highest priority in both types of hospitals with 22 percent variance in public hospitals and 40.12). physical environment (29. physical environment (18.66) and bathrooms/toilets (0. This item’s expectation score was again highest in public hospitals. it seems that people are dissatisfied with public hospital doctors’ competency level. showing that public hospitals are suffering from a lack of cleanliness and comfort. and relationship (15. However. Giving priority to patience needs (21. which are the tangible quality factors.24).7 percent variance in the private.34) was observed in statement 44: “the food. The highest perception score in public hospitals was obtained from the statement 12 “doctors were capable of performing tests and procedures on me” (5. still most expectations were not met in private hospitals. Significantly. about the only thing the inpatient can look forward to are meals to break the monotony. 27) explain: “Apart from the visits.9 percent). Table II also shows that although the overall expectation levels were comparatively higher than public hospitals. It was followed by the gaps related to food service (0. the inpatients consider professionalism (20. but vital issue like the number of ward bathrooms and toilets. The hypotheses H1a and H2a. and relationships (9 percent) important in the public hospitals. are rejected.64). Therefore. Tomes and Ng (1995. none was met in public hospitals. Perception scores The mean perception scores were lower compared to the expectation scores.12 for the public hospitals and from 4. When we compared public and private hospital inpatients (Table II).46).IJHCQA 21. giving priority to patient needs (12 percent). Gap scores Table II shows that although overall expectation levels were low.” Like public hospitals all these gaps come under the physical environment construct. The largest gap (0.3 percent). The highest expectation score in private hospitals was obtained from statement 41 “the bathrooms and toilets were always clean and pleasant to use” (6. .7 percent). both the lowest and the highest perceptions occurred in the same question. inpatients put their priorities differently in public hospitals as: food (33. interestingly.4 percent). It seems that respondents are not satisfied with the public hospital food menu since both their expectation and perception mean scores were low.9 percent). Hence food becomes an important factor. in which the lowest and the highest expectations are reported. especially those in the public hospitals.37 for the private hospitals. while H3a is accepted. therefore. This confirms that private hospitals do not meet expectations about food. The largest quality gaps.12). occurred in the food construct statements.12 to 6. private investment encourages high expectations even on a simple. The largest gap (0. It was followed by gaps in ward cleanliness (0.37).1 percent).8 percent). therefore. there are differences between the two types of hospital services.

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

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

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.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. 1. process. Findings – Results indicate that each process stage mediates subsequent stages. 1990. a form of structural equation modeling. Design/methodology/approach – A partial least squares (PLS) approach. The Gap Model operationalized by SERVQUAL is widely used to measure service quality. see Carman. Texas. 2008 pp. It draws on the disconfirmation paradigm from the psychology and consumer behavior literature and the Gap Model (Parasuraman et al.The current issue and full text archive of this journal is available at www. Customer services quality. The service quality Gap Model is operationalized by the SERVQUAL instrument (Parasuraman et al.htm IJHCQA 21. Rhode Island.. Chin University of Houston. 21 No. Reidenbach and Sandifer-Smallwood. Patient satisfaction criteria specific to hospital selection are not included in this study. the SERVQUAL instrument only measures expectations (resulting from the pre-process segment of the service experience) and perceptions (resulting from the post-process segment). Shelton. 1990. 1988). 1988. is used to develop a framework to evaluate patient satisfaction in three service process segments: pre-process. 2000). 1996. 1990).emeraldinsight. Keywords Patients. Originality/value – This study is the first to evaluate patient satisfaction with all three process segments.. USA. 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. and post-process service experiences. 1985. Outpatients Paper type Research paper International Journal of Health Care Quality Assurance Vol. 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. Wicks Bryant University. Oliver. an approach widely used in service operations (Spreng and Page. United States of America. All three segments should be measured. Smithfield. Shewchuk et al. However. and Wynne W. Bitner. Research limitations/implications – Only one out-patient surgery center was evaluated. 1996) and has been adopted for health care operations as well (for example. Performance levels.1108/09526860810841138 Introduction The operations management and marketing literature focus on measuring service quality as the gap between expectations and perceptions. The lack of proper segmentation and methodological criticisms in the literature motivated this study. Houston. Although SERVQUAL is a good base for measuring service quality and . Practical implications – Results indicate what is important to patients in each service process segment that focus where ambulatory surgery centers should allocate resources. 24-38 q Emerald Group Publishing Limited 0952-6862 DOI 10.

customer satisfaction. Therefore. several problems exist owing to the nature of the creation of the gap measurement (for example. process. 1993). 1993). higher than the gap scores (Parasuraman et al. see Cronin and Taylor. 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. 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. 1992. SERVQUAL only measures the pre-process segment (expectations) and the post-process segment (perceptions).the possible trade-offs between functional areas.. 1988). 1993). Vandamme and Leunis. Singh. psychology and health care operations literature and by a series of focus group discussion. The R 2 values for the perception scores are often higher than the overall gap scores (Cronin and Taylor. 1994. or higher than expectations scores (Brown et al.. 1993. 1990). Peter et al. 1992. 1994). marketing. 1998. our study develops an alternative method for measuring patient satisfaction in a larger retention framework where satisfaction. spurious correlations and variance restriction problems make gap measure a poor choice as a measure of psychological constructs (Peter et al. Our framework was developed from operations management. 1993). Rosen and Karwan. Peter et al.. poor discriminant validity. Teas. 1990. 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 operations. An out-patient surgery center was selected for this study. 1960).. and post-process (Babin and Griffin. Low reliability. Babakus and Boller. Overall satisfaction model . 1993. 1993). Measuring the three process segments 25 Figure 1.. Additionally. not quality. 1992.

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

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. equipment. Cognition. for example. Loyalty is defined as the attitude toward reuse of the center. and personnel appear neat and clean Table II. 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. 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. 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. The validity of several other constructs outside the satisfaction portion of the PLS model is logically connected to this study in Figure 2. the satisfaction definitions and the patient satisfaction definition antecedents used in this study). is defined as the mental process by which knowledge is acquired about the out-patient surgery center. Patient satisfaction antecedents’ definitions framework’s development.e. Retention is defined as the actual reuse of the center by the patient. .



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

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

Convergent validity Discriminant validity Table III. Measurement model test criteria

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

Measuring the three process segments 29

Significance testing Predictive relevance

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

Table IV. Structural model test criteria

Figure 3. Overall satisfaction model


Indicator OAA_1 OAA_2

Weights 0.078 0.079

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

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

. . . . .

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

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

are all larger than the correlations.832 0.895 0.846 0.988 Table VII.778 0. All the loadings are significant at an alpha of 0.746 0.866 0. 0.923 0.924 0. two indicators were used.944 0. The cross-loadings provide similar results.794 0.824 0.902 0.941 0.869 0.902 0. Overall satisfaction – Survey: Correlation among construct scores (square root of the AVE extracted in diagonals) .865 0. 0.831 0.884.988 respectively.809 0.773 0.859 OA Stage 1 0.837 OA Stage 2 0.895 0. The AVE value square roots.900 0.932 0.872 0.01.842 OA Stage 3 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 0.926 0.980.998 and 0.996 0. Using the same wording for items OAA_1 and OAA_2.789 0.954 0.793 0. For each of the three process stages (OA Stage 1.889 0.863 0.841 0.997 0.997 0.891 0.867 0.889 0.809 0.934 0.810 0.757 0. as required.884 0.932 0.808 0.846 0.961 0.802 0. represent a strong relationship. The composite reliability.950 0. OA Stage 2.760 0.885 0.815 0.969 0. Table VII presents the correlations among construct scores with the AVE results on the diagonal.902 0.856 0. we replaced “out-patient surgery” with “pre-admission experiences” for OAPR_1 and OAPR_2.898 0.840 0.989 Table VI.875 Stage 1 0. all item cross loadings are higher for the construct on which the item should load than on any other construct. The results of both analyses indicate that the model’s psychometric properties are sufficiently strong to enable structural model estimate interpretation. and OA Stage 3).998 0.998 0.997.869 0.826 0.965 0.892 0.835 0.998 0.837 0.812 0.835 0.861 0. and “post-discharge experiences” for OAP_1 and OAP_2. “surgery stay experiences” for OAS_1 and OAP_S.882 0.843 0.836 0.955 0.988 0.869 0. The item loadings are provided in Table VI also resulting in high composite reliabilities for the three stage constructs of 0.954 0.837 0.796 0.935 0.887 0.921 0.887 0.919 0.834 0.0. Overall satisfaction model – loadings/cross loadings of items Overall Overall Stage 1 Stage 2 Stage 3 0.852 0. indicates strong item convergence towards a highly reliable scale.787 0.843 Stage 2 Stage 3 0.900 0.920 0.900 0.

891 from Overall Stage 1 to Overall Stage 2.973.e. indicating a small effect for both segments on overall patient satisfaction.1 32 Structural model assessment Bootstrapping results indicate that all path coefficients are significant at an 0.IJHCQA 21. In terms of satisfaction at the start of the process in Stage 1 impact.67. The Q2 predictive relevance values. In terms of substantive effects and predictive relevance. 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. This implies that the model constructs have high predictive ability. Typical for path analytic/structural equation techniques. we see that the model explains 92. The pre-process stage has a significantly lower path coefficient of 0. These results indicate that models based on .36 from Stage 1 to Stage 3 and an even lower value of 0. While this is high for predictive models. Stage 2’s impact (path coefficient) on overall satisfaction is 0.18 and the post-process segment (Stage 3) has only a 0. Moreover. As such.666.0811 and 0.18 from Stage 1 to Overall Satisfaction.788 for Stage 2. Conclusions and recommendations Our study establishes and tests the relationships between three service process segments and overall patient satisfaction. the relative strength of each stage’s impact on overall satisfaction as well as among each other is consistent. The highest impact is the path coefficient value of 0.e.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. it should not be surprising to find significance for all paths owing to the relatively large sample size independent of the effect size (i.0676 respectively. 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. satisfaction towards the out-patient stay (i.01 alpha and estimates are presented in bold in Figure 3. with a lower value of 0. 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. as just noted. whether paths minimally impact or larger). Overall satisfaction model results indicate that the patient’s satisfaction with the actual surgical stay. The f 2 for Stage 1 and Stage 3 are 0. the global set of 15 items for overall satisfaction provides an operationally discriminant difference to those used for the three stages.6 percent of the variance in overall patient satisfaction with out-patient surgery experience. using the cross-validated redundancy option. The pre-process segment (Stage 1) has a significantly lower impact of 0. 0. Stage 2 has a large impact on overall patient satisfaction with an f 2 of 0. what is also important is whether paths estimated are also substantive with high R-squares. The strength of the relationships between patient satisfaction and the three service experience process segments is also tested.18 and the post-process stage has only a 0. we noted the construct discrimination among the stages as well.7511 for the Stage 3 and 0. As found when assessing the measurement model. The model is an excellent overall patient satisfaction predictor. Stage 2) has the most impact on overall satisfaction with the pre and post stage satisfactions being much less influential and approximately equivalent.790 for overall satisfaction. are 0. Furthermore. In particular. Specifically.148 effect on overall satisfaction.

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

but the organization should focus on these aspects during the registration process to alleviate anxiety about the impending surgery. 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. 2000). empathy. responsiveness. which may have occurred since a communication aspect was included in the assurance definition. 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. transportation to the facility exit should be ready and waiting so the patient can easily leave the facility. competence. Empathy ranked ninth out of ten antecedents consistently evaluated in all three process-segment models and ranked last in the process segment. so paperwork should be in place when he or she arrives at the surgery center. staff should design parking facilities and procedures to be as convenient as possible by providing adequate signage. The results of some rankings were unexpected. Confidentiality and convenience had the lowest impact. specific entry and departure areas for the patients and perhaps valet parking. However. The most important pre-process segment antecedent for the patient was courtesy. convenience for the process segment. assurance for the post-process segment and for overall satisfaction. 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. Confidentiality ranked low in all aspects of the out-patient surgery experience. The remaining surgical procedures should be designed to be as stress-free as possible. Directional assistance should be available so patients can easily arrive at the proper location within the facility. The low ranking for empathy may have occurred because approachability and sense of security were omitted from the newly-developed definition. assistance could be in the form of clear and adequate directions possibly from an information desk at the out-patient entry. so tangibles were not included in the rankings. The results of the different satisfaction models indicate the antecedents have differing impacts on satisfaction depending on where the antecedent is measured. reliability. Tangibles were not evaluated in the Post-Process Satisfaction model. 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. 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. 2000). The empathy definition developed for this study limits the measurement to the degree to which the health care provider attempts to understand patients’ feelings and concerns. communication.1 34 followed closely by courtesy. Patients are pre-registered for out-patient surgery. and security.IJHCQA 21. Designing the out-patient surgery process to be convenient for the patient on the day of surgery can have the greatest . How well the patient feels that the surgery will be performed may be much more important. 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. communication was eighth in the overall rankings. Patients may consider assurance more important in the out-patient surgical setting than how empathetic the health care providers appear to be. When the patient is discharged.

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

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Vol. International Journal of Service Industry Management. 8-21. A. pp. Health and Medical Care Services Review. pp. Further reading Parasuraman. R. Structure. and consumers’ perceptions of quality”. (1990). (1991). (Eds). Journal of Retailing. and Page.1 38 Shewchuk. “The development and evaluation of a patient satisfaction model for health service organizations”. (1993). Fletcher. Thompson. (1985). pp. S. Quality Progress. and Chin..emeraldinsight. pp. and Leunis. Health Services Management Research. Wold. 58 No. 1187-205. V. Spreng. 1. S. RI. pp. performance. Ware. and Singh. (1996).edu To purchase reprints of this article please e-mail: reprints@emeraldinsight. J. A. Vol. S. 18 No. evaluation. 19 No.G. A. DeSouza. (2001). A. W. Witten. Prediction. 3. (1993). 1 No. in Joreskog. and Gale. (1978). (1991). 20-6. Smithfield. 67 No. J.IJHCQA Or visit our web site for further details: www. (2004b). R. Systems under Indirect Observations: Causality. “A multifacet typology of patient satisfaction with hospital stay”. “The strategic management of service quality”. 18 No. Vol. P. 2-15. (1982). and Stewart. Gaithersburg. Psychology and Marketing. Bryant University. I. D. and Frank. 12. Smithfield. pp. (1994). and Chin. Shi. 1-54. Bryant University. K. Davies-Avery. 420-51. pp. MD. and Delene. T. Vol. L. and Wold. Vol. “Refinement and reassessment of the SERVQUAL scale”. H. and White. 4 No. Teas. Aspen Publishers Inc. Vol. H. (2001). . “In search of service quality measures: some questions regarding psychometric properties”.. L. Walbridge. Wicks. A. (2004a). RI. Teas. A. Wicks can be contacted at: awicks@bryant. 6-16. CA.. 65-75. 13 No. “Soft modeling: the basic design and some extensions”. R. “Measuring physician attitudes of service quality”. “Development of a multiple-item scale for measuring hospital service quality”. working paper. 18-34.. Vandamme. Vol. 1. 18 No. “Definitions of the antecedents of patient satisfaction for an ambulatory surgery center”. Singh. 30-49. pp. R. Journal of Health Care Marketing.. O’Connor. 10. Journal of Marketing. “Expectations. Journal of Health Care Marketing. 6. 4 No. E. 1. 1.. J. Vol. Vol. Vol. 132-9. and Berry. Academic Press. Delivering Health Care in America: A Systems Approach. “The measurement of meaning of patient satisfaction”. pp. Part 2. Data Mining – Practical Machine Learning Tools and Techniques with Java Implementations. Journal of Marketing. pp. “Expectations as a comparison standard in measuring service quality: an assessment of a reassessment”. W. (1993). B. pp. R. 11. L. J. G. 4. Zeithaml. Wicks.. San Diego. working paper. Corresponding author Angela M. “A reexamination of the determinants of consumer satisfaction”.

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

259 out-patients formed the basis for our study. Bartlett et al. 1997). interactions with physicians and allied health staff. patients’ reports of satisfaction with care..636 medical out-patients who completed a patient satisfaction survey for the Department of Internal Medicine from March 1998 through March 1999. and who lived locally (Locke. Therefore. Pessimism and hostility were chosen for study because these .000 Minnesota Multiphasic Personality Inventories (MMPIs) archived at our institution since 1959. female physicians (Hall et al. 1984. such as performing a physical examination. 1997).. 1993). patients who believe their health status is good are more satisfied with their care (Probst et al. Of the MMPI and the patient satisfaction responses.. When the two data sets were merged we found that 1. 1993). An eight-item questionnaire was mailed to randomly selected medical out-patients two to three months after their care episode. Robbins et al.. including the patients’ personality characteristics.259 medical out-patients had completed both the patient satisfaction survey and. not satisfaction.... The second data set comprised scores from approximately 335. and . understanding factors associated with patient satisfaction. Methods Two archival data sets were abstracted. have been studied and.R. have been associated with higher patient satisfaction ratings (DiMatteo et al. personality traits of pessimism and hostility. before that survey was completed. structural. general satisfaction with the visit and willingness to recommend our center to others. 1980. in a study of patient characteristics among out-patients at our center. and physician-specific factors related to patient satisfaction. 1994). an MMPI. patients with depression or anxiety disorders are more likely to express dissatisfaction from unmet expectations (Kroenke et al. The topic of the eighth item was the completion of all scheduled tests and consultations (yes/no). lower satisfaction ratings were reported by patients who were young. Effective communication skills and particular physician behaviors. We hypothesized that pessimistic or hostile patients would report less satisfaction with their care.. For example. as assessed by the MMPI. The study was approved by our institutional review board. and all study subjects gave research authorization. is important. specifically. personal communication. 1. The first data set consisted of information from 11. Furthermore. as expected. particularly patient waiting time. lower satisfaction is reported by patients after seeing younger. who were employees of the center. surprisingly little has been written about patient characteristics and their relationship to medical care satisfaction ratings.1 40 Physician age and gender have also been correlated with patient satisfaction. Patient satisfaction is associated with compliance and willingness to continue receiving care from a particular physician (Rubin et al. Although much has been written about organizational. 1997). G. A five-point scale was used to rate seven items pertaining to satisfaction with access. We then assessed the degree of association between: . Conversely. All MMPIs had been obtained before the satisfaction survey. The survey response rate was 60 percent.IJHCQA 21. Organizational factors. This study investigated the personality characteristics of pessimism and hostility as they relate to patient satisfaction ratings. longer waiting times result in lower patient satisfaction (Probst et al. September 2002).

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

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

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

003 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. and patient age by center employee/dependent status interaction). 0 ¼ no].075 0.229 0.002 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. * Entries are the percentages of patients rating that aspect of care as excellent.002 0.841 .219 0.282 0.002 0. 0 ¼ not excellent) and the independent variable being the PSM T-score.843 0. 0 ¼ no). Patients with low scores (#39) were classified as optimistic.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. distance from the center by center employee/dependent status interaction.047 0.30 30-39 40-49 50-59 60-69 $ 70 Optimistic Pessimistic (n ¼ 6) (n ¼ 92-95) (n ¼ 307-311) (n ¼ 393-401) (n ¼ 323-329) (n ¼ 102-106) (#39) ($60) 59 64 60 57 53 55 86 p1 a p2 b p3 c 0. Within PSM groupings.003 0.056 0.44 IJHCQA 21. sample sizes are ranges because the number of respondents varied among questions. seen in primary care area [1 ¼ yes. d Entries are the percentages of patients who “definitely would recommend” the center Table I. PSM T-score.002 0.005 0. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.221 0.002 0. 0 ¼ no]. pessimistic. 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. patients with high scores ($60).133 0. 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.008 0.774 0. and variables previously identified from the analysis of the patient satisfaction survey (distance of residence from the center [in miles]. center employee/dependent [1 ¼ yes. Relationship between patient satisfaction rating of “Excellent” and the PSM T-score PSM T-score groups * Subtotals .011 0.

Ho T-score. 0 ¼ no]. 0 ¼ no]. 0 ¼ no).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 .001 0.001 0.002 0.002 0.0.068 . 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.011 0.048 0. patients with high scores ($ 60). 0 ¼ not excellent) and the independent variable being the Ho T-score.001 0.001 0. and variables previously identified from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].006 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 0.941 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. patient age [in years]. and patient age by center employee/dependent status interaction). Patients with low scores (#39) were classified as nonhostile.0.026 0. d Entries are the percentages of patients who “definitely would recommend” the center Pessimism and hostility scores 45 Table II.001 0.434 0. Within Ho groupings.046 .947 0. center employee/dependent [1 ¼ yes. 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.403 0. distance from the center by center employee/dependent status interaction. sample sizes are ranges because the number of respondents varied among questions. hostile. * Entries are the percentages of patients rating that aspect of care as excellent. Relationship between patient satisfaction rating of “Excellent” and the Ho T-score . 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. 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 0.001 0.328 0.097 0. seen in primary care area [1 ¼ yes. 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.

the estimated odds ratios that corresponded to a 10-unit (1 SD) increase in the MMPI T-scores increased with the interval. 88 percent) who reported “definitely would recommend the center” (p ¼ 0:434). our approach to studying the contributions of patient personality has not been previously taken. Our analysis shows that pessimistic patients (i. 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. regardless of their opinion about some aspects of their experience during a particular care episode. In general.g. these aspects of patient personality were experienced subjectively and understood solely through physician’s intuition and judgment. Clearly there are likely to be other patient-related characteristics that affect patient satisfaction ratings. These may include emotional states (e. However. Discussion Patient satisfaction has been studied from various vantage points. Previously. Now it is evident that some aspects of the patient’s personality affect ratings of satisfaction with care.1 46 Again. our findings indicate that important data about the factors contributing to patient satisfaction ratings are missing if patient personality characteristics are not considered.IJHCQA 21.. having a pessimistic explanatory style as theorized by Seligman) or hostile patients (i. unknown to the physician. depression) at the time of the survey or episode of care. except for the question about willingness to recommend the center. high scores on the Ho scale) are significantly less likely to rate satisfaction with their care as excellent. 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. When significant associations existed. This may result from feelings that. Our results are a first step towards understanding that certain aspects of the patient’s personality affect ratings of their satisfaction with care. patient satisfaction ratings for particular physicians and health care organizations are tacitly assumed to be a reflection of physicians or health care system. Additionally. These occur independently of other factors already known to contribute to variations in ratings of patient satisfaction. However. or certain patient expectations.e. 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 patients would still recommend the center because of other factors such as the center’s reputation.03 for every 5-year interval increase. There was no significant difference in the percentages of hostile patients (Ho T score $ 60. before the encounter.02 to 0. Adverse encounters were believed to result from the physician’s characteristics and behaviors or from organizational and structural factors surrounding the care episode. the exception to this trend was the question pertaining to a patient’s willingness to recommend the medical center to others. It is notable that willingness to recommend our center to family and friends was not associated with hostility or pessimism. 83 percent) and non-hostile patients (Ho T score # 39.e. Table III displays the odds ratios for “excellent” ratings corresponding to 10-unit (1 SD) increases in MMPI scale scores for PSM and Ho. We included all patients who had completed both a patient . The odds ratios were estimated for each of the three models. Among patients who would definitely recommend the center. these odds ratios increased by about 0.

75-1.16) 0.Questionnaire item 0.19) Model 1a PSM scale Model 2b Model 3c Model 1a 0.92 0.79 0.86 0.78-1.13) (0.76-0.71-0.81 0. 0 ¼ not excellent) and the independent variable being the PSM or Ho T-score. * See Tables I and II for the p values of the ORs that were significantly different from 1 (associated coefficient was different from 0).91) (0.93 0.21) 0.77-0. c Model 3 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.85 0. PSM or Ho T-score.95) (0. seen in primary care area [1 ¼ yes.88 1.06) (0.76-0.76-0.96) (0.91) (0.74-1.94 0.74-1.92 0.76-0.80-1.85 0.73-0.79-1.83 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. OR ¼ odds ratio. a Model 1 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent. and variables previously identified from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].00) (0.03) (0. 0 ¼ no].94) (0.84 0.94) (0.80-1.99 (0.83 0.01) (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.83 0. the OR was not significantly different from 1 at the a ¼ 0:05 level.94 (0.92) (0. * * ORs are for the percentage of patients who “definitely would recommend” the center.90 0.85-1.87 0. In addition.98 (0.74-0.92 0.05) (0.91) (0.86 0. distance from center by center employee/dependent status interaction.75-0.97) (0.77-0. b Model 2 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.94) (0.85 0.82 0.07) 0.72-0. center employee/dependent [1 ¼ yes.95) (0.87 0.85 0.70-0. Ho ¼ MMPI hostility scale.85d 0.85 0. and patient age by center employee/dependent status interaction).81-1. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.06) (0.76-0.00) (0.93) (0.72-0.81-1.79-1.11) 0. patient age [in years].73-1.80-1.01) (0.08) (0.98) (0.97) (0.86 0.94) (0.76-0.80-1.86 0. if the 95 percent CI for the OR contained 1.94) (0.94) (0.80-1. Odds ratios (95 percent CI) for percentage of “Excellent” ratings for a 10-unit (1 SD) increase in the MMPI T-scores * .98 0.74-0.87 0.74-0.83-1. for the PSM scale and the overall care by the physician.83 0. d For example. 0 ¼ no).84 0.98 (0.10) (0.76-0.86 0. PSM ¼ MMPI pessimism scale.90 0.00) (0.77-0.81 0.96) (0.95) (0.89) (0.79-1.02) (0.95) (0. MMPI ¼ Minnesota Multiphasic Personality Inventory.73-0.75-0. 0 ¼ not excellent) and the independent variables as in model 2 but including both PSM and Ho T-scores.84 0.81 0.84-1. 0 ¼ no].80-1.90 0.93) (0.75-1.92 (0.01 Ho scale Model 2b Model 3c (0.00) (0.77-0.

D. Vol. Offord. “Proposed hostility and pharisaic-virtue scales for the MMPPI”. Conclusions and recommendations This research clearly demonstrates that patient personality characteristics play an important role in the results derived from patient satisfaction surveys. Roter. Therefore. Journal of Applied Psychology. and Seligman. 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. gender. 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. Schulman..R. “Satisfaction. 12. 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. 38. 50 No. had a combination of medical and psychological issues requiring multidisciplinary investigation. significant differences were noted in satisfaction on the basis of levels of hostility or pessimism. Taranta. and communication in medical visits”. L. L. J. J. 414-8. Colligan. Journal of Chronic Diseases. and Prince. . “CAVEing the MMPI for an optimism-pessimism scale: Seligman’s attributional model and the assessment of explanatory style”. 4. and Medley. “The effects of physician communications skills on patient satisfaction. Time limits were not imposed because we were studying two personality traits that are relatively stable. pp.S. 755-64. (1994). Physicians are much less likely to obtain excellent ratings from pessimistic or hostile patients. and type of care received. and adherence”. Finally. A. Cook.M. age of patient.. R. 376-87. (1954). 37 Nos 9-10. Patient mix may temper an individual doctor’s satisfaction ratings. E.E. M. pp. Golden.. Vol.T. recall. Levine. M. M.P. Patient satisfaction at our center is associated with several variables. as defined in this article. P. We included these independent variables in the models as adjusting variables. Patient satisfaction ratings may be decreased if these patients are also characterized by traits of pessimism or hostility. DiMatteo. References Bartlett.. pp. R.A. including status as employee/dependent. D. Such patients are diagnostically and personally challenging for physicians. Malinchoc. A. “Predicting patient satisfaction from physicians’ nonverbal communication skills”. 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It begins by differentiating between customer expectations in tangible products and intangible services. Understanding the role of expectations in aged care is important because it can increase customer satisfaction. Keywords Elder care.htm IJHCQA 21. developing and implementing effective complaints handling systems to assist the industry as it grows in demand. 50-59 q Emerald Group Publishing Limited 0952-6862 DOI 10. 2008 pp. Findings – The author builds an argument that aged care service providers must understand consumer needs and expectations so that customer satisfaction is generated.The current issue and full text archive of this journal is available at www. is critical. Section three continues to build the argument by further differentiating between customer expectations in intangible services and then health care services. Patients. Design/method/approach – The author first explores expectation theory and how it links to customer behaviour and then discusses confirmation/disconfirmation theory. . 21 No.1 The role of understanding customer expectations in aged care Leib Leventhal Conflict Management Systems Designer.emeraldinsight.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. 1. 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. both owing to the ageing population and to the social nature of baby boomers to complain when their expectations are not met. Caulfield North. School of Law. 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. 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. Section four outlines how the role of expectations in aged care differs from those in health care. Section two builds the argument that aged care services involve a unique and complex form of customer expectations. Additionally. Originality/value – Exploring patient and relative expectation and satisfaction in different theoretical contexts. Australia. understanding customer expectations at the outset of providing services can reduce the incidence of complaints that may occur after the services have been rendered. 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. with the onset of the baby-boomer generation entering into aged care.

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



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

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

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

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

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

and Berry.Olshavsky. 60-73. pp. 142-56. A. 2. 49 No. J. “Customers with options”. pp.A. “Revealing the actual role of expectations in consumer satisfaction with experience and credence goods”.com/reprints . Russell Kennedy. Health and Aged Care Brief. Thomas. 4. pp. Vol. 3 No. (1985). (2003). V. Corresponding author Leib Leventhal can be contacted at: LeibLeventhal@bigpond. Phillips. 14. 20-4. Vol. Does your facility fit your residents?”.. Journal of Consumer Behaviour. (2001). “One size does not fit all. Parasuraman. J.emeraldinsight. R. (2006). 24-5. “A conceptual model of service quality and its implications for future research”. pp. Melbourne. National Health Care Journal. Zeithaml. R. 41-50. Summer. 32 No. Vol. Understanding customer expectations 59 To purchase reprints of this article please e-mail: reprints@emeraldinsight. “A theoretical exploration and model of consumer expectations. L. Santos. April-May. Perucca. Dissatisfaction and Complaining Behavior. Or visit our web site for further details: www. and Kumar. 9. and Boote. Journal of Consumer Satisfaction. L. (2005). (2001). post-purchase affective states and affective behaviour”. A.W. Nursing Management. Journal of Marketing. pp. “Complaints: the right culture hears the message”.L.

Findings – The databases’ value is problems related to spontaneous reporting. their strengths and weaknesses. empirical evidence about the causes of and conditions influencing adverse events varies according to the investigation method. both from research studies and from routine monitoring for timely action (Handler et al. 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. 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. (2) Medical Responsibility Board.1 Patient claims and complaints data for improving patient safety Pia Maria Jonsson and John Øvretveit Medical Management Centre.1108/09526860810841165 Introduction Research shows significant safety problems in health care in Sweden and abroad (Kohn et al. Sweden. Safety. 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. Keywords Quality improvement. Karolinska Institutet. 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. Measurement. which makes it difficult to know how much the data correspond to general injury rates and health care patterns.. the Medical Responsibility Board and the Patients’ Advisory Committees and considers methodological issues in using the data. 2000. Better patient safety depends on better data about incidence and causes. Thomas and Petersen. Patients. when diagnosis-specific analysis requires data pooling over several years in order to reach adequate case numbers. This means knowing more about the different systems’ advantages and disadvantages for reporting adverse events and for gathering safety data (Zhan and and (3) Patients’ Advisory Committees respectively. Another issue is the balance between the size of study materials and the timeliness. . MMC. 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. Stockholm.g.emeraldinsight. Design/methodology/approach – The article first describes previous research into patient claims and similar schemes.htm IJHCQA 21. 2003). data collection method and their limitations as a source of data about the true incidence and prevalence of injuries and safety problems. The National Board of Health and Welfare. 60-74 q Emerald Group Publishing Limited 0952-6862 DOI 10. 21 No. We describe three main types of Swedish patient claims and complaints’ data: (1) data generated by Patient Insurance Fund activities. e.g. e.. 2004a). Empirical evidence about the number of adverse events for patients varies according to data collection methods. 2008 pp. 1. but little is known about the data. how they can be used. 2004).. data on hospital case-mix. Similarly. 2000. Phillips et al. 2003. Adjustment for confounders not present in the databases. It then presents three types of data on patient claims and complaints in Sweden: data generated by the Patient Insurance Fund.

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

Although comparisons are difficult. UK). 1994). The proportion of diabetes claims was highest in . although there is no clear evidence. 1986). 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). Under a no-fault system. which is thought to be important for effective safety reporting systems. usually administered by a government agency and tax funded (e. 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... When compared to all claimants. This study identified 906 claims from patients with diabetes where the total indemnity paid was almost $27 million. Legal redress may act as a deterrent against lower practice standards (Hiatt et al. How has data from both types of malpractice claims systems been used for research. insurance costs are lower. 2000. An unpublished UK study found standardised incidence ratio of error highest in the specialties. USA. This was one of the first studies showing how these data help to predict and understand adverse events. 1998).g. 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. 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. 2004). compensation awards can be high. New Zealand and the Nordic countries).. 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. and the total costs to society less.IJHCQA 21.. seeking compensation may be easier and less expensive. where patients do not have to prove negligence in a court of law (although they can use this route). 1998). systematic research into the epidemiology and aetiology of adverse events in the Swedish healthcare system has only just begun. obstetrics and trauma and orthopaedics (Davy et al. There are thought to be advantages and disadvantages to each.1 62 around 1. 2000). which allows patients to seek redress from a doctor for perceived negligence (e. which found rates associated with both physician performance and specialty (Taragin et al. diabetes patients were older and predominantly male. Data suggested problem areas for attention that included supervision and foetal heart monitoring. 1990).... which traditionally produce the most claims – accident and emergency. but can have their claim assessed and compensation awarded through another system.800 deaths per year. Insurance against claims is also high and medicine is practiced more defensively (Bovbjerg and Sloan..g. and (2) a no-fault system. 2003). Patient claims and complaints systems provide different types of data about health care adverse events. Weycker and Jensen. Under a tort system. Research also considered whether physician performance and type of speciality is related to malpractice claims. The Physician Insurers Association of America (PIAA) database has been used as a surveillance tool for diabetes-related malpractice claims (Meredith et al. However. 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. It also may be more likely that health care personnel report “errors” or “near misses”.

Table I displays the number of complaints and claims made to each body (1997-2004).227 3.064 3. Little research has considered the role of nursing or paramedic professions in patient claims. Adamson et al. 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. Tsai et al. A greater proportion of diabetes claims. 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.239 18. or that health care has not met their expectations. 2000.. 2001. 22.546 19. 1993... Patient claims and complaints data 63 Year 1997 1998 1999 2000 2001 2002 2003 2004 Patient insurance 8. 1997). 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..572 m. 1994.003 9.ophthalmology. they differ in the numbers of complaints as well as in the amount and character of information they contain. m. Lester and Smith. for example.717 8. Levinson et al. The Swedish databases In Sweden the Patient Insurance Scheme. one study reported a dramatic rise in the incidence of nurses as defendants in malpractice claims (McDonough and Rioux. Malpractice claims research has been used for financial risk management and quality improvement. Since the databases were developed at different times and for different purposes. Annual reports from the Medical Responsibility Board and The National Board of Health and Welfare Table I. In 1989. Moles et al.871 9.995 22. was associated with the highest level of injury severity. 1998. Goebel and Goebel (1999). 16. The study concluded that the PIAA database can be a useful resource to monitor trends in diabetes-related malpractice. general and family practice. 2004). Tsai et al.552 8. 2005).. More studies are examining which type of patients file claims and why (Hickson et al.860 3. 1996..938 Medical Responsibility Board 2.119 3.500 Sources: Statistics from the Patient Insurance Fund.174 8. internal medicine. found evidence that malpractice lawsuits could be prevented by quality interventions such as clinical guidelines. Number of complaints to the Patient Insurance Fund. Medical Responsibility Board and Patients’ Advisory Committees. 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. Persson and Svensson.. as compared to all claims. 1989). 1997-2004 .129 8. 1989).250 3.395 8.377 3.070 3.664 Patients’ Advisory Committees m. (2004) reported that medical experts considered that 83 per cent of 371 malpractice cases reviewed could be “improved by quality management”.

Indemnity for personal injury can be paid. 3. 5.1 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. 1975-2004 . if it was caused by faulty medical or dental equipment or by incorrect diagnosis. Figure 1 shows the annual numbers of both applications for claims and compensated cases from the Patient Insurance Fund (1975-2003). 7. 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. if infection has been transmitted in the course of treatment.000 in 1993. irrespective of fault or negligence. and .400 claims in 2003. Figure 1. The conditions in the Act on Injury to Patients largely correspond to the conditions of the previous voluntary scheme.300 in the first year of operation in 1975. Under the act.IJHCQA 21. in the event of accidents in connection with medical or dental care and in connection with incorrect prescribing. both public and private care providers are obliged to have a medical malpractice injury policy that covers patient indemnity. Claims applications have increased to: . . Number of claims to the Swedish Patient Insurance Fund. . Indemnity for patient injury could be paid on objective grounds. In January 1997 the voluntary insurance scheme was replaced by The Patient Injury Act (1996).000 in 1983. There is no indemnity in cases where the treatment simply has not led to the desired result or where (predictable) complications arise. when a treatment injury as described in the insurance conditions occurred. if the injury concerned could have been avoided. 9.

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

Patients’ advisory committees The first Swedish law about the Patients’ Advisory Committees was created in 1980. 2002). Hence. Goteborg and Bohus counties. have few direct sanctions and do not have disciplinary powers.860 3. 2004). e. but was most prominent in dental care and general medicine. Data from the Medical Responsibility Board have been used in regional comparisons (The National Board of Health and Welfare. In January 1999.659 2. Analysis showed large differences in Sweden between counties in number of claims per inhabitant in 1999/2000. Kalmar and Kronoberg counties. They give advice to patients and provide a quasi-independent body for investigating dissatisfaction and mediating disputes Complaints n 2.664 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..g. Recently. but there have been few scientific analyses of the material.IJHCQA 21. an exploratory study analysed factors and circumstances related to complaints in emergency medical dispatching. Number of complaints received and disciplinary actions taken by the Medical Responsibility Board.250 3.119 3. in contrast to sparsely populated area rates. Claims rates were ¨ appreciably higher in Stockholm. The Patients’ Advisory Committees do not make medical judgements.521 2.227 3. 1995-2004 Source: Annual reports from The Medical Responsibility Board . a new law came into force. Cases from the Medical Responsibility Board have been presented in the Swedish Medical Association Journal. partly based on complaints to the Medical Responsibility Board (Wahlberg et al.1 66 actions in 1995-2004 are presented in Table II. 2003). The high claims rate in the Stockholm region applied to all types of activity. the survey identified two areas that educational programs could improve patient safety. Uppsala. Nearly all disciplinary actions against physicians concerned misdiagnoses (subarachnoid haemorrhage in particular).377 3. 1998).064 3. The most common reason for a nurse receiving a warning or an admonition was negligent handling of drugs.. Another study analysed all available complaints about stroke management made to the Medical Responsibility Board over a five-year period (Johansson et al. The Stockholm region also showed the highest number of disciplinary actions per inhabitant. The study identified second-hand information as an aggravating circumstance when assessing the urgency of care needs.070 3. which shows that a steady increase in the number of cases appears to be levelling off. 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.

24 per cent primary health care and 8 per cent mental health services. In 2001.743 % 32 12 45 11 100 n 967 431 1. for example. The Committee’s aim is to solve problems quickly and in a non-bureaucratic way. feed-back sessions at local hospitals have been a popular way of sharing experience. 2002). Results showed that. Table III shows the complaints’ distribution by one county’s Patients’ Advisory Committee about different issues (Stockholm County Patients’ Advisory Committee. Little research has used data from the Patients’ Advisory Committees. an analysis was made linking data about complaints to the Stockholm County Patients’ Advisory Committee with data from National Patient Register (Arnetz and Arnetz. The rates per specialty. 53 per cent concerned inpatient care. 2003) drew some data from one of the committees.255 298 2. Of these. The conclusion was that dissatisfaction about lack of information and patient participation was more likely to be detected by surveys. information Organisation. It is also their task to refer patients to other agencies.000 complaints were filed in 2002 (The National Board of Health and Welfare. This analysis and the studies noted earlier show how each database provides a different picture. According to Committee representatives. were compared with corresponding rates for the Medical Responsibility Board and the Patient Insurance Scheme. the importance of knowing the strengths and weaknesses of each and often the need to use multiple data sources. it is problems patients do not want to raise directly with personnel. for example in the fields of neurology and geriatrics. Analysis also considered data from patient questionnaires in the same hospitals. Complaints are often questions or criticisms that patients or relatives have tried to take up with healthcare personnel.951 Women % 33 15 43 10 100 Table III. resources Other complaints All n 555 204 787 197 1. because. by gender. the reverse was true. hospitals. 2005 Source: Stockholm County Patients’ Advisory Board. Distribution of complaints to the Stockholm County Patients’ Advisory Committee.. communication. 2006). Patient claims and complaints data 67 Men Type of complaint Medical treatment Interaction. Reports to the National Board of Health and Welfare show that more than 22. but feel they have not been heard or respected.between patients and health services or personnel. 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. calculated per 100. The previously mentioned study on emergency medical patching (Wahlberg et al. whereas complaints about care and treatment were more likely to be registered in the complaints to the Patients’ Advisory Committee. for example. Annual Report 2005 . to file a malpractice claim. 2003). public health care districts and other involved authorities. while applications and claims in specialities such as obstetrics and gynaecology were higher. they feel they may suffer in the future as a result. but the effectiveness of using data in the prevention of patient injuries has not been studied systematically.000 discharges. Sometimes.

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

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

in practice.g. which contains information on cases since January 1992.1 70 Relationship to other sources of safety information As illustrated earlier the National Patient Register includes information about all hospital discharges in Sweden. Tentatively. be reported to the National Board of Health and Welfare – according to a special law. 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. when a number of patients died owing to malpractice). are relatively few. or that not all complications lead to injury entitled to compensation. There is a case.200 claims in 2002 – can be compared to the numbers of injuries coded as mishaps (approximately 3. Canada. be noted that claims data include all levels of care.000 cases were reported according to Lex Maria. diseases and risks in health care must. . the annual numbers of Lex Maria cases have not changed much since the mid 1990s. but knowledge of risks gives care providers more opportunities for improving quality and helps care consumers choose care and treatment. the healthcare professionals’ reporting tendency has not been subjected to study. 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. the numbers of claims to the Medical Responsibility Board – 3. under certain circumstances. As opposed to patient claims and complaints. It should. In comparison. Correspondingly. Analysis of existing data at a local and national level can provide valuable insights for quality interventions as well as for research.400 cases. Patient Insurance Fund claims. while the Patient Register only covers hospital inpatient care. To what extent this is due to patients underreporting problems.000. Hence. often the senior physician or the nurse with medical responsibility. Canadian Institute for Health Information. the material can show. 2004b). 1. which is related to quality and is driven by patient and user perceptions. The number of registered complications in 2002 was approximately 22. Australia and UK (Danzon. “Lex Maria” (named after an incident at Maria Hospital in Stockholm in the 1930s. at what type of institution and in what medical service an injury or an incident occurred.IJHCQA 21. the risk of serious patient injury has not changed over time. McLoughlin et al. therefore.500 cases in 2002). e. Conclusions The risk of adverse medical events and medical errors can never be entirely eliminated.g. The obligation to report rests upon the person nominated by the health care principal. e. Such analyses could also shed light on the extent patients’ claims and complaints reflect safety problems grasped by purely medical-technical safety indicators. 2006. The Swedish Patient Register is in many ways comparable to hospital data sources in other countries. approximately 9. 1990). Serious injuries. Statistics regarding “Lex Maria cases” are collected in the Board’s RiskDataBase. 2006). 2006. However. including ICD 10 codes for medical and surgical treatment complications (The National Board of Health and Welfare. is not possible to judge today. Following analysis.. patient safety indicators constructed from administrative data and developed in. Changes are also possible to these databases and collection systems to make them even more valuable for quality improvement. however. In 2002. and what consequences repeated events can have for the patients affected. This and other studies show the value of data on claims and complaints for providing information for researchers and practitioners.

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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. 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. They influence the patient’s choice of where to be admitted and organize most of the pre.and after-care treatments (Braun and Nissen.htm Evaluating hospital service quality from a physician viewpoint Peter 21 No. particularly medical reports. 2005). Munster. Geographic range was correlated with the frequency of patient commendation (p ¼ 0:005) and the perception of friendliness (p ¼ 0:039). 1998. A comparative questionnaire survey was established to identify improvement areas and factors that drive referral rates using descriptive and inferential statistics. 1. Although Germany has a health care system that allows patients direct access to specialized care (Coulter. 1990). mutually beneficial International Journal of Health Care Quality Assurance Vol. is of growing importance in the rapid changing health care market. Doctors. Dieter Metze and Thomas Luger Dermatology Department. Hospitals should pay careful attention to their communication tools. 75-86 q Emerald Group Publishing Limited 0952-6862 DOI 10. Since referring physicians play a strategic role ensuring the survival of institutions providing health care services. This study aims to evaluate the perception of hospital services by referring physicians and clinicians for quality improvement. Hospitals. Rosemann et al. Munster University. Significant differences between both samples were found with respect to inpatient services and patient commendation. The number of referred patients was correlated with medical reports’ informational value (p ¼ 0:042). 2006).The current issue and full text archive of this journal is available at www.. Clinicians tended to rate their services and offerings higher than referring physicians (p ¼ 0:019). Germany Abstract Purpose – The purpose of this research is to show that referring physicians play a strategic role in health care management. Keywords Questionnaires. well established in industrial markets.emeraldinsight. 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. Meinhard Schiller. 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. referring physicians act as de facto gatekeepers to hospitalization. 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. 2008 pp. In the German health care system.1108/09526860810841174 . Customer services quality. Originality/value – Survey results should be useful for continuous quality improvement by regular measuring and reporting to executive boards.

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

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

In short.4 per cent). representing nearly the complete physician staff in the clinical department.3 78 Number of referred patients per year 0-5 patients 6-20 patients . Identifying improvement areas Means and standard deviations were calculated to obtain an average rating for items 1-14. Regarding the referring dermatologist subgroup.8 17. Nearly all respondents declared to be dermatologists (n ¼ 51.3 60. see Table I) but two respondents did not answer this question.20 patients Not specified Geographic range between clinic and respondents City area (.2 3. 5.IJHCQA 21. a frequency of 60 per cent to 79 per cent is suitable for detecting areas of improvement with lower priority. Value 1 “very good” and 2 “good” frequencies were summed to a conjoint variable indicating an acceptable quality level without need for action. The length of .0 17. Moreover. Data overview and characteristics of referring physicians who responded correlation tested association among questionnaire items. a deficiency frequency of 80 per cent and higher can be considered to indicate urgent improvement areas. A total of 22 useable questionnaires. the proportions of referring physicians’ ratings of each questionnaire item were displayed (Figure 1). The calculated deficiency frequencies and a ranking of priority are shown in Table III. Response rates and the average ratings divided into referring physicians and clinicians along with the comparative statistical results (Table II). external physicians’ estimations of patient commendations were low.1 Characteristic Specialist status of respondents Dermatologist Not specified n 51 2 9 9 32 3 9 6 32 6 % 96. 17. 20 km) Regional area (20-50 km) Supra-regional area (. 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. The overall Cronbach’s alpha for the questionnaire was 0.0 60. Results A total of 53 usable questionnaires were returned by referring physicians (response rate. 50 km) Not specified Table I. were returned from the subsequent internal survey. Absolute frequencies also containing missing values are more predictive for the given population in small samples than relative ones.7 17 11. The alternative hypothesis would be accepted at a p .4 11.845. The absolute deficiency frequencies in our study were used to show areas of improvement. In contrast.05 statistical significance level. 0. Physician medical expertise was highly ranked by referring specialists. these values were combined to a conjoint deficiency variable that represents poorer quality needing action.

53 ^ 0.63 3.2 98.10 Clinicians n ¼ 22 % Mean (^ SD) p-value * 1. and comparative statistics .77 ^ 0.0 90. two-tailed Evaluating hospital service quality 79 Table II.03 1.No.78 3. 50 51 52 51 94.28 ^ 0. item response rates. 0.001 0.65 2.4 3. * Mann-Whitney U test. 14.80 .41 ^ 1. 2.60 2.5 90.1 96.5 84.7 96.98 ^ 0.49 ^ 0.29 ^ 0. 48 51 41 90. standard deviation. 3. 9.55 ^ 0.84 ^ 1.6 96.90 2.10 2.80 ^ 1.10 1.56 2.032 13.27 ^ 0.87 2.43 ^ 0.72 ^ 1.64 ^ 0.84 2.92 2.2 2.00 ^ 0.05 ^ 0.8 88.9 2. 12.2 2.23 ^ 0. 10.81 2.86 2.46 ^ 0.95 ^ 0.73 ^ 0. 4.95 ^ 1. 0.77 ^ 1.2 77. 8.81 2.9 Variable (item) n Referring physicians n ¼ 53 % Mean (^ SD) n 2. 11.96 ^ 1.5 92.4 100.73 1. mean values.2 92.001 6.42 ^ 0. 0.014 0.9 86.15 2.86 19 22 22 22 22 22 22 86. 5.81 19 22 20 51 49 49 45 46 47 51 96.26 ^ 0.65 1.84 2. 7.002 .05 ^ 0.98 2.69 1.4 100 100 100 100 100 100 86.03 3.22 22 22 21 20 100 100 95. 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.3 96.93 2. Questionnaire items.00 ^ 0.76 ^ 0.

001 0.5 3 13 2 1 5 6 11 12 14 6 8 4 8 8 50 9.3 95. 3. Rank of priority. 10. 9. b Medical reports: Timea. 4.6 39.6 52. 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. Def.3 27.9 36. deficiency frequency. 2.IJHCQA 21.4 27.1 80 Figure 1. 8.8 39.002 0. 14.5 36. 1.9 66. 7.5 40.6 47.6 4.0. c Fisher’s exact test. 5.1 64.8 45. 6. Referring physicians’ ratings – proportions of each item No. frequation . 13.5 15. and statistical results . 12.3 0. Variable * Cooperation Medical expertise Accessibilitya. 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.2 84.3 58.4 18.8 86. deficiency frequencies.3 45. a detected by referring physicians.60 per cent are indicated.2 35. b detected by clinicians.0 56.2 13.1 77.002 .5 27. two-tailed Notes: Def. * Areas of improvement with a deficiency frequency .022 Table III. 11.

An average mean value for all 14 quality items was calculated for each subgroup: . However. hospital staff friendliness. deficiency frequency. outpatient consultations. 0. accessibility in urgent cases. SD: 0. p ¼ 0:002. . p ¼ 0:002. p .61 revealing a statistically significant difference (p ¼ 0:019). SD: 0.032. clinicians: 2. Our findings suggest these three improvement areas. .69. medical expertise. . outpatient services. The first component. cooperation. reputation. Average rating values and deficiency frequencies reveal that clinicians’ ratings were remarkably distinct from those referring physicians scores (mean. and . medical expertise.29. which explains nearly 37 per cent of the variance. referring physicians criticised staff accessibility in urgent cases (64 per cent). Lack of patient commendation had the highest deficiency frequency (87 per cent) and the second lowest rating in the referring physicians group.022). friendliness. . There were no significant differences between referring physicians’ ratings and those made by clinical department physicians concerning: . Moreover. .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. . Furthermore. and the. Quality features interaction Factor analysis revealed two components that explained nearly 52 per cent of the variability in the original 14 variables. . referring physicians: 2.001). clinicians rated newsletters significantly higher than referring specialists ( p . 0. clinical department’s perceived reputation. time interval in which medical reports are supplied. Evaluating hospital service quality 81 Comparative evaluations As seen in Table II and III. p . there were disagreements between the way referring physicians and the way in which clinicians themselves rated some items.54. and . Varimax rotation was used to determine what the components represented. Differences were also been found with inpatient resources and inpatient services.001). . is highly correlated with the following variables: . There were significant differences concerning average rating values and deficiency frequencies. cooperation. and . . 0. this aspect was supposed to be much higher from the clinicians’ viewpoint ( p . 0.

5.001 .595 0.008 . Cooperation Medical expertise Accessibility Medical reports: Time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter Note: * Two-tailed test of significance .001 . 14.0. This may be caused by a lack of quality management sense.001 . the medical specialty of which the majority of responses were received. particularly when we did not remind respondents or offered an incentive for completion. It may be speculated that there is a lack of motivation and incentive for private practice physicians to participate. 4.006 46 47 51 50 50 49 49 45 46 47 49 48 51 41 0.054 0.0.364 0.465 .0.001 . This survey is limited to: .0.369 0.001 0.514 1 0. 0. Significant negative correlations were found between geographic range and hospital staff friendliness (p ¼ 0:039). The first component represents a construct with generic attributes that improvement activities cannot influence directly. 10. and the frequency of patient commendations (p ¼ 0:005). Discussion Our study described and evaluated the way referring physicians and clinicians rated several quality items from their individual perspectives.013 . 6.001 0.001 .015 0. Table IV shows that most variables were highly correlated with these two items. in former studies dealing similar questions. 0.539 0. sampling referring physicians via the manually maintained databank.067 0. 2.342 0.647 0.059 0. and . were calculated. 11. Beltramini and Sirsi.001 0. 7.301 0.001 0. 3. Table IV.1 82 The second component is highly correlated with inpatient bed capacities and inpatient service offerings.547 0. 0.348 0. 1992). Although the study response is low.000 0. Variable 1. A further interesting point was to test for correlation between questionnaire items and both geographic range and annual number of referred patients (Table V). 13. An equally important finding is that inpatient capacities and service offerings were not correlated.615 0.IJHCQA 21. Correlating quality items representing a generic quality perception.532 0.471 0. 9.639 0.001 . 12.0.0. one geographical region. 0.002 No.601 0. equal or even lower response rates have been observed from physician samples (MacDowell and Perry.428 . 0. However.149 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. .034 .001 . sample of referring physicians 8.0. the number of referred patients was significantly negatively correlated to medical reports’ informational value (p ¼ 0:042).251 0. Correlation analysis of generic quality perceptions represented by reputation and cooperation with other quality items.015 0.528 0. such as cooperation and reputation.001 0.594 0.001 .594 0.001 0.505 0. Moreover. 1990. 0. we considered the response rate acceptable.

Moreover.231 0. 9. 1980.005 Note: * Two-tailed test of significance Table V. Critical deficiency frequencies indicating relevant areas. 14. In conclusion. discharge.150 20. can be chosen individually for each item and should be monitored over time.032 0. Not only do patients expect a seamless healthcare system and continuity of . such as medical reports and newsletter articles. 5. 7. Elija and Marja-Leena. and should address this problem by investing in systematic communication improvement programs.219 0.079 20.102 20.075 20.083 20. 6.148 0. major improvement areas demanding urgent action could be identified. and . sample of referring physicians Nevertheless. 11.059 20. 1980.120 20. The high importance attached to timely and adequate communication back to referring physician was previously reported in other studies (Cummins et al. 10.189 20.131 48 48 49 48 48 46 46 42 43 44 48 45 48 38 20.. and those variables. our survey questionnaire provides a ready-to-use instrument that identifies crucial improvement areas. accessibility in urgent cases. 2. which represents a further tangible communication and cooperation aspect. Curry et al.039 0.037 20. Variable 1. has been found to be improvable. 3. Using this approach. are major points for satisfaction and perception of adequate cooperation. 13.029 20.295 20. 2005).007 20.042 Evaluating hospital service quality 83 0. medications. such as reputation and cooperation..253 20. 4.183 20.157 20.161 20.320 20.055 20.001 20. . such as providing medical reports and newsletters. proposed procedures. For interpretation. 12.207 0.421 20. Correlation of geographic range and number of referred patients with quality items. it is important to distinguish between variables that can be directly influenced by management activities. . The present findings suggest that timely and significant information about: .262 20. Cooperation Medical expertise Accessibility Medical reports: time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter Geographic range Number of referred patients Responses Spearman Responses Spearman (n) correlation p-value * (n) correlation p-value * 44 45 46 45 45 43 43 39 40 42 45 42 45 37 20. such as 80 per cent and more. hospital stay. which are less tangible. hospital administrators and clinicians should pay careful attention to communication tools. 8.No.174 20.

1983). Recommendations We cannot have an accurate understanding of how our services are perceived by others without asking them. Not competition between specialists. 1993). 93 No. who refer only a few patients to the clinical department. 38-44. Working in separate medical realities may diminish understanding for the concerns of others (Kvamme et al. proposing a strong positive self-image in terms of services they provide. expectations and satisfaction. but good working relations across all boundaries is required. This may be subject to rather infrequent contact. comparative analysis allowed us to conclude that the majority of quality problems are perceived in a similar manner by referring physicians and clinicians. (2003). If the distance between referring specialists and hospitals is great then patient commendations decline.. Surveying referral physician perspectives is an essential method for gathering information on health care service perception. the frequency of patient commendation was found to be associated with the geographic range. Regular measurement and reporting to hospital staff members and the executive board is mandatory for a quality improvement process. estimated by clinicians. Vol. 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. care levels and care sectors (Javalgi et al. 1. Although we found statistically significant disagreements. We note that the frequency of patient commendation. utilizing survey results. which is separated into inpatient and outpatient care sectors with spending caps (Altenstetter. was significantly higher. clinicians tend to rate quality higher than referring physicians. A second step. which makes it difficult for referring physicians to give a valid rating. pp. However. 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. Referring physicians expect management to be shared with their cooperating medical partners. in general. “Insights from health care in Germany”. Although the validity of this latter item remains doubtful. References Altenstetter. C. . Health care provider images and satisfaction with those providers vary among consumers. One may speculate that physicians.. is equally important. are much more interested in reading and understanding medical reports than physicians who refer a greater number of patients. American Journal of Public Health. This situation is particularly important in the German health care system. The long-term strategic challenge lies in building creative and sustainable referral networks that promote professional partnership among physicians. physicians and the public (Scammon and Kennard. 2001). Before customer satisfaction can be addressed. therefore. hospitals need to understand stakeholder needs. 2003).IJHCQA 21.1 84 care between services but also the physicians who refer patients to higher-level health care institutions. An assumable cause may lie in a few but important referrals from the viewpoint of the referring physician.

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

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

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

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

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

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

H9. 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. Expectations have a negative effect on negative emotions. Patient involvement has a positive effect on expectations. Patient involvement has a positive effect on patient satisfaction. satisfaction and other predictors such as expectations and emotions. H8. These variables and measures were adopted: 92 Figure 1. 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. Methodology Sample We used a convenience sample composed of individuals attending targeted healthcare centres during approximately one month in each. Expectations have a positive effect on positive emotions. We presume that service involvement motivates patients to initiate a more positive service-interaction. The research model and the expected effects are represented in Figure 1. Research model .1 H5.IJHCQA 21. Patient involvement has a negative effect on negative emotions H10. H6. Patient involvement has a positive effect on positive emotions. Consequently. We obtained 317 valid responses from patients in six healthcare centres.

Service expectations quality scale. Westbrook and Oliver.. 2004. Examples include (E3) “Staff would have good appearance”. 1990. (P18) “I feel safe in my relationship with the auxiliary staff”. (P16) “I feel safe in my relationship with my doctor”. “Generally I am satisfied with the services of support”. (P26) “My doctor understands my specific needs” Satisfaction measure. 1992) to measure expectations and perceptions. “Generally I am satisfied with the level of services performed”. 1992.g. In order to obtain the users’ emotional reactions to the services provided. (E5) “They would fulfil their promised service at the time they promise to do so”. We considered the existing measures’ diversity in the literature. 1991) but not particularly in healthcare services. 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 scale asked patients how they considered services that were provided. we adapted Izard’s (1977) “Differential Emotions Scale” – DESII – used and validated in consumer studies (e. This scale consists of five items and includes: “Generally I am satisfied with my doctor”. Following recommendations in the literature (e. We included positive and negative emotions scales but we excluded the “surprise” item owing to its ambiguity. We used a five-point Likert scale ranging from “completely disagree” (1) to “completely agree” (5). 1988) for the particular healthcare sector contexts. Using the same 28 items. (E21) “My doctor would have a good professional preparation”. This instrument includes 28 items for the expectations scale and 28 items for the perceptions scale. The influence of service quality 93 . Kilbourne et al. We asked respondents to predict the degree of anticipated satisfaction (“what would you expect from this service”: “to feel satisfied with this medical consultation”. (P17) “I feel safe in my relationship with nurses”.. (P8) “They provide services at the promised time”. Expectations.Service quality. Service perceptions quality scale. 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). Following Oliver’s (1981. Patients were asked. “Generally I am satisfied with this healthcare centre”. Carman. we used an adapted SERVQUAL scale (Parasuraman et al. Vandamme and Leunis. 1997) proposal. Emotions. (E24) “The doctor would give me personal attention”.g. before consultation. “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). Babakus and Mangold. taking into account a series of hospital service characteristics. 1987.. 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. Examples include: (P4) “Materials and documents are clear and visually appealing”. what they thought – on the basis of their experience – what could be expected from services provided in a healthcare unit. Westbrook. we used a satisfaction expectation measure focusing on the service to be provided. “Generally I am satisfied with the nurses”. (E15) “My doctor instils me with confidence” (E19) “Nurses would be always courteous with me”. Consumer satisfaction is the main dependent variable in our study.

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

comprehending simultaneously in the same factor the Assurance regarding their professional competency and empathy towards the patients.84 to 0. The influence of service quality 95 .in the gap between user perceptions and respective expectations. W So. it groups two items from the physical elements. (2) Physician’s assurance. are disaggregated in two groups corresponding to distinct occupational groups: physicians. 1). Although with fewer items. we intended to identify service quality scale structure through Principal Component Analysis (PCA). Considering the construct’s multidimensional nature..01 per cent of total variance. Cronbach alpha varied from 0. grouped by valence (positive and negative emotions within the emotional experience). 1992. The Empathy and Assurance dimensions. 2007. By analysing the saturation matrix after Varimax rotation (Table I). With factor loadings ranging from 0. so alpha could be lower in scales with fewer items.64. we fused Reliability and Response Capacity.69. The global service quality scale presented a Cronbach alpha of 0. Babakus and Mangold. we checked subscale validity and consistency. Alpha coefficient is dependent not only on the magnitude of correlations among items but also on the number of items in the scale. the Physical Elements dimension was kept. Nunnaly (1978) indicated 0. we used the SPSS “compute variable” function to calculate 28 new variables representing the result of the numerical expression (perception – expectation) for each item. The scales showed a good internal consistency. Regarding the theoretical model. Parasuraman et al.77 to 0. Considering that the scale comprehends differing and opposite valences. we extracted four components that explained 67. With factor loadings ranging from 0.72 to 0.68.60 are also used in the literature (e. nurses and auxiliary staff. we eliminated 11 items owing to cross-loading. 1992.97 for Reliability. Vandamme and Leunis. (3) Employee’s assurance. it integrates all items concerning medical performance. From this point of view. it integrates all items from the Reliability factor plus two more from the Response Capacity factor in the original scale.95. it integrates items from the Assurance factor concerning Nurses and Auxiliary staff. The extracted factors are interpretable and allow us to identify four service quality dimensions: (1) Reliability.g. In order to identify variables concerning service quality. Measure of emotions in service experience The DESII scale showed high internal consistency for all 30 items (a ¼ 0:91).76. Using Kaiser’s criterion (“Eigenvalue” ... (4) Tangibles. Wright. The scale presented a high internal consistency (a ¼ 0:97). 1991).7 to be an acceptable reliability coefficient but lower values as 0. Aspy et al. 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. 2002. 2002). With factor loadings ranging from 0.67 for the Physical Elements scale (which also has fewer items) to 0. 2004. both concerning specifically the relation with the service provider.

23 0.21 0.22 0.76 and 0. Negative emotions Our PCA on the seven DESII negative valence subscales revealed four interpretable components (Varimax rotation with Kaiser criterion) explaining cumulatively 78.35 0.87 respectively) and 0.75 0.68 0.32 0.18 0.12 0.23 0.28 0.33 0.88 per cent of total variance.73 0.3 0.1 Statement number code QS5 Text Reliability 0.28 0.3 0.13 0. Service quality’s factor structure: rotated component matrix (Varimax) They fulfil their promised service at the time they promise to do so QS8 They provide me the services at the promised time QS10 They give accurate information as to when services will be provided QS7 They perform the service right the first time QS6 When I have a problem.69 67.IJHCQA 21.82 0.27 0.28 per .64 0.25 0.37 0.73 0.15 0.77 0.12 0.21 0.93 Components Physician’s Employees’ assurance assurance 0.33 0.69 0.22 0.66 0. The internal consistency analysis showed a Cronbach alpha of 0.35 14.17 0.73 0.27 0.14 0.09 0. 1977 study.01 0. Cronbach alpha for these subscales was 0.76 0.88 0.21 0.26 0.24 0.31 0.34 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 79.19 0.90 for “Enjoyment” (in Izard’s.08 0.33 0.27 0.11 0.25 0.23 0.15 0.73 0.95 0.3 0.82 0.22 0.84 0.76 0.17 0.72 0.23 0.84 for the total scale.22 0.7 0.21 0.37 0.37 0.22 23.56 Tangibles 0.27 0.67 96 Table I.72 10.15 0.06 18.83 for “Interest” and 0.77 0.

27 0.27 0.85 0.25 0.18 0.39 0. Satisfaction measure In order to verify the measure’s one-dimensional character we developed a PCA with five composing items.88.16 0.14 0.18 0. Negative emotion’s factor structure: rotated component matrix (Varimax) .20 0.79 0.21 0. Factors extracted allowed us to identify four negative emotions: “disgust”.88 Table II.21 0.19 0. Satisfaction expectation scale Three items composing this measure revealed a high Cronbach alpha of 0.92 0. df ¼ 51. p .30 0.57 The influence of service quality 97 Items Downhearted Sad Discouraged Feeling of distaste Disgusted Feeling of revulsion Contemptuous Scared Fearful Afraid Sheepish Bashful Shy Guilty % Of explained variance (with rotation) % Of explained variance (with rotation) Factor internal consistency (Cronbach alpha) Factor internal consistency all items (Cronbach alpha) Disgust 0.74 0.27 0. “shame”.96 for the subscales and 0.22 0.60 78.66 17. All the remaining factors were maintained. imposing two co-variances has shown to improve the fit indices (x2 ¼ 106:89. the hypothesized model was evaluated. The measurement model was estimated without mistakes or warnings (from the program built in control processes) and presented good fit indices. Seven items had to be discarded in the rotated matrix owing to unacceptable cross-loading (Table II). TLI ¼ 0:99. By applying the Kaiser criterion we extracted a single factor that accounted for 71.84 0.37 0.001.07 0.86 0. 0.23 Fear 0.12 0.08 0.12 0. good internal consistency with alpha values ranging from 0.33 0.28 0. However.90.34 31.13 0.11 0.89 0.86 0. Components Shame Distress 0.81 0.09 0. “distress” and “fear”.03 0.24 0.40 0.08 0.24 0.19 0.23 0.25 15. we started with the measurement model factorial structure analysis as well as its adjustment to data.27 0.85 0. Structural model Following Anderson and Gerbing’s (1988) recommendations regarding Structural Equation Modelling. the second item in Guilty).87 to 0.96 0.77 0.16 -0. The subscales we found presented. in order to validate the latent variables. IFI ¼ 0:99.29 0.19 13.90 0.10 0.92 for the total scale.84 per cent of total variance with a Cronbach alpha of 0. Factor “Shame” absorbs one factor item that had disappeared (namely.24 0.22 0. Our results indicated that items composing “Aversion” and “Despise” factorise into a single factor.16 0.83 0.37 0.73 0.cent of total variance. In a second phase. thus confirming our global satisfaction scale’s one-dimensionality hypothesis.84 0.87 0.72 0.

Results showed that the structural model has good fit (x2 ¼ 134:46. 0.IJHCQA 21. df ¼ 54. All estimated parameters were significant.001.1 98 CFI ¼ 0:99 and RMSEA ¼ 0:052). IFI 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. p . The predictors we considered had a direct effect on patient satisfaction. Estimated structural model . TLI ¼ 0:99. CFI ¼ 0:98 and RMSEA ¼ 0:061). indicating that latent variables were actually depicting different constructs. The estimated structural model corroborated our hypotheses. Figure 2. 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. The perceived service quality. As the measurement model revealed good fit.

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

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Design/method/approach – A questionnaire was administered to 750 and 34 per cent responded. Service levels.The current issue and full text archive of this journal is available at www. preferring the company over others. . social needs for belongingness and affection and individual needs International Journal of Health Care Quality Assurance Vol.1 The relative importance of service dimensions in a healthcare setting Rooma Roshnee Ramsaran-Fowdar Faculty of Law and Management. Zeithaml and Bitner (2000) described how customers express such intentions in positive ways: . 104-124 q Emerald Group Publishing Limited 0952-6862 DOI 10. or . The “reliability and fair and equitable treatment” factor was found to be the most important healthcare service quality dimension. increasing their volume of purchases. Reduit. Therefore. University of Mauritius. 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.htm IJHCQA 21. 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. . clothing and safety. 21 No. praising the firm. 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.emeraldinsight. On the other hand. 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.1108/09526860810841192 . Keywords Health services. 2008 pp. Findings – A new service quality instrument called PRIVHEALTHQUAL emerged from the study. based on factor and reliability analysis. customer dissatisfaction may lead to unfavourable behavioral intentions such as negative word-of-mouth. Retaining customers may be more profitable than attracting new ones. doing less business or switching to alternative service providers. Mauritius Abstract Purpose – The paper aims to focus on an augmented SERVQUAL instrument that was used to measure private patients’ service expectations and perceptions. Human needs are states of felt deprivation such as physical needs for food. agreeing to pay a price premium. 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. Private hospitals.

Office aesthetics.. Brown et al. patients are likely to look for cues or “signals” that are redolent of treatment quality they are likely to receive (or do receive) from a provider. 1993b). additional research is necessary to gauge its applicability to healthcare services. Importance of service dimensions 105 . 1994). 1988). Given healthcare’s credence. (4) assurance. staff appearance. 1993a. Exactly what are consumers’ needs and wants in a healthcare context? By and large. Zeithaml et al. 1990). (2) reliability. Within each dimension there are several items (22 in total) measured on a seven-point scale from strongly agree to strongly disagree. there is a need to test if SERVQUAL is a comprehensive patient evaluation of healthcare service quality measure or if additional dimensions are needed.. Specifically. Spreng and Singh.. relationship between patient and doctors and the punctuality of appointment among others may be medical care quality indicators. Between these two expectation levels lies “tolerance zones” that represent a performance range consumers consider acceptable. One of these criticisms is SERVQUAL’s inappropriateness as a generic measure for all service settings.. 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. Although SERVQUAL proved to be a robust service quality measure.. 1993. (1988) used a single expectation standard. 1993. 1992. In their popular measuring service quality framework. 1989. 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). desired expectations as a comparison against which service performance is assessed. There is research that service quality is contingent upon service type (Babakus and Mangold. 2000). Recently. 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. Parasuraman et al. it has been subject to criticisms conceptually and methodologically (Babakus and Mangold.. The most widely accepted measurement scale for service quality is SERVQUAL (Parasuraman et al. researchers proposed that multi-expectation standard approaches may be more appropriate for service quality models (Boulding et al. and (5) empathy. research on consumers’ multi-expectations. 1989). Parasuraman et al. These service quality surrogate indicators can be used by patients to assess service provider efficaciousness. Since SERVQUAL was generated outside healthcare and has limited examination in the healthcare literature. 1993. However. This model proposes that service expectations can be separated into an adequate standard and a desired standard (Zeithaml et al.for knowledge and self-expression. 1990. 1993). (3) responsiveness. which consists of five essential service quality dimensions: (1) tangibles. Cronin and Taylor. Teas. 1993. Wants are the form taken by human needs as they are shaped by culture and individual personality. Carman.

Singapore and other developed countries where average life expectancy is above 75 years and infant mortality rates is below seven. Consequently. private medical services were identified as a suitable study setting to explore professional service quality and its evaluation from the clients’ perspectives. The Mauritius healthcare system The Republic of Mauritius has a total area of 720 square miles and a population of 1. The total number of beds in government institutions was 3.000.000 live births. MSS and MSA is in the exploratory stage.716 at the end of 2001. representing one doctor for every 1. the government allows public doctors to practise privately as part of its staff retention strategy. The private sector has 588 beds of which 283 are single rooms (Ministry of Health and Quality of Life.8 per cent in France and 13 per cent in the USA (Ministry of Health and Quality of Life. Consequently. Healthcare service performance is also relatively low in Mauritius compared to other countries because of staffing differences. in comparison to developing countries. poor remuneration. for instance. 8 per cent in New Zealand. 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 . Compared to other African countries. inability to take initiatives and poor leadership.3 per cent in Singapore. 9. 2002). there is a serious demoralisation problem among hospital employees resulting from cumbersome workload. 2003). Mauritius spends about 2.107 doctors in Mauritius. Furthermore. 2001. Nevertheless. 5. 8.IJHCQA 21. that is. All impede patient service delivery in the public sector.000 population in Mauritius is significantly below that found in countries with better levels of health. patients have to wait in long queues in the public hospitals. 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. Presently. Similarly. many nurses have migrated. there were 1.2 beds per 1. Indeed. 2002). Although Mauritius is doing well. Given the physician shortage. The number of doctors registered has declined over the years since these professionals prefer to work overseas where they are better remunerated. One reason for this difference in health status may be the relative level of investment in the health services in different countries. which absorbs 32 per cent of the country’s total health expenditure.089 inhabitants. low working life quality. At the end of 2001. Mauritian medical care is freely provided by the state and there is also a well-established private sector. People at the bottom of the socioeconomic ladder obviously cannot access paid services. The private sector.2 million residents (Central Statistics Office. 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 1.9 per cent in Belgium. new measures are needed to improve its performance to reach the levels achieved by places such as New Zealand. The public sector employs over 690 doctors (including about 245 specialists) and around 2.9 per cent in Seychelles. employs over 400 doctors and provides primary and secondary services in 14 private clinics.700 nurses. one bed for 315 inhabitants or 3.8 per cent of its Gross Domestic Product on health compared to 3. Private general practitioners (GPs) were selected because they deal with patients on a long-term basis. the number of doctors and nurses employed per 100. Mauritius has made remarkable progress addressing citizens’ healthcare needs.1 tolerance zones. Often.

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

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

and (3) a specific company’s perceived service. 2000). The tolerance measures were also less susceptible to response errors compared to single expectation measures. A performance below the tolerance zone (or below the adequate service level) will engender customer frustration and dissatisfaction and decrease customer loyalty (competitive disadvantage). the tolerance zone provides detailed and probably more accurate managerially diagnostic information and thus better strategy decisions (Teas and DeCarlo. incorporates this expanded expectation conceptualisation. As mentioned earlier. (Berry and Parasuraman. (1994) modified SERVQUAL’s structure to capture the MSS and MSA gaps. (2) service level adequacy. The latest SERVQUAL modification. desired and predicted expectations along with perceived performance. This service quality framework combines adequate. Parasuraman et al. 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. 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. For each SERVQUAL attribute. The three-column format (Table I) involved obtaining separate desired. 1991). Hence. A performance level above the tolerance zone (or above the desired service level) will surprise and create customer delight and strengthen their loyalty (customer franchise). The 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. 2004). most customers are realistic and understand that company staff cannot always deliver the preferred service level. Convergent validity is the extent to which the scale correlates positively with other measures of the same construct. However. On the other hand. termed adequate service. Parasuraman et al. or the minimum level of service customers are willing to accept without dissatisfaction. adequate and perceived service ratings using Importance of service dimensions 109 . (1994) found that tolerance zone measures had convergent and predictive validity. 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. customers also have an expectation threshold. the tolerance zone is a service range within which customers do not pay explicit attention to performance. If the correlation between two measures is high then the initial measure is said to have predictive validity. therefore. 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. Separating these two expectation levels is a “tolerance zone” that represents a service performance range a customer would consider satisfactory. Moreover. customers will be satisfied if performance falls within their tolerance zone (competitive disadvantage). three values (on a nine-point scale) are measured: (1) customers’ desired service level. Additionally.conceptualisations with findings from a multi-sector focus-group study to develop an integrative customers’ service expectation model. In other words.

110 IJHCQA 21. 1 2 3 4 5 6 7 8 9 1 Modern-looking equipment Table I.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 .

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

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

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

GP accessibility by phone. Clear display of GP’s qualifications. GP’s medical qualifications.g. GP’s readiness to respond to the patient’s questions and worries. Convenient clinic location. Professional appearance/dress of the support staff. Prescription of affordable medicines. GP accessibility at odd hours in case of emergencies. waiting room. Physician reputation. Courteous and friendly doctor. Willingness to help patients. Professional appearance/dress of the GP. Physician compliance with hygienic and other precautions. Ability of support staff to inspire trust and confidence in patient. Uniform fees and other charges for all patients. GP’s familiarity with latest advances in medical field/products. tables and amenities). Highly experienced GP. Prompt service without an appointment. Careful diagnosis of the patient’s problems. . Honesty and integrity of physician. Maintaining accurate and neat records of the patient’s medical history. GP’s emphasis on patient education. Convenient hours of operation. Knowledgeable and skilled support staff. Courteous and friendly support staff. Ability of GP to inspire trust and confidence in patient. GP making patient feel good emotionally and psychologically. Modern medical equipment.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. Punctuality of appointment. GP having patients’ best interest at heart. Visually attractive and comfortable physical facilities (e. GP’s willingness to listen carefully to patients. Reliability in handling the patient’s problems.IJHCQA 21. chairs. Knowledgeable and skilled GP. GP’s emphasis on prevention of health problems.

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

1989). Factor rotation maximises the loadings’ variance on each factor thus minimising factor complexity (Tabachnick and Fidell. Comparing individual factor Eigenvalues revealed that results were relatively equivalent.40 was considered. Based on the total variance explained.8 per cent.IJHCQA 21. In the initial stage of factor extraction. MSS scores explained the item loadings in a better and sound conceptual way. the total variation explained. Both MSS and MSA scores from 47 service quality items were factor analysed using Parasuraman et al. 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. We can. therefore. . was chosen for our factor analysis second stage. 1992. the MSS format was found to be superior. Only factors with Eigenvalues greater than one were retained and a decision rule of factor loadings in excess of 0. MSS scores explained 19. A comparison of two possible formats is needed to determine which should be used to decide the factor structure for further analysis. Nevertheless. with maximum likelihood method. 116 . There could be a nonlinear relationship between them that is not captured by R 2. Therefore. Table IV summarises two factor analysis results derived from MSS and MSA scores based on: . MSS convergent and predictive validity were superior compared to the MSA format (Table IV) by the higher R 2. Factor structure reliability was tested for internal consistency after items were grouped. Overall service quality ratings were used as the dependent variable. Cronbach alphas.3 per cent of the variation in overall service quality and MSA scores 9. eigenvalues. 1992. and .’s (1994) recommendation. Moreover. the factors derived from the MSA construct were slightly superior to the MSS score format. Cronin and Taylor. empirically supporting the superior predictive power of this scale compared to the difference-score measures (Babakus and Mangold. The same conclusion was reached when comparing the Cronbach alphas. confirm the service quality scale’s convergent and predictive validity. The resulting respondent profile was deemed to be encompassing and fairly well distributed. Results are illustrated in Table III. while MSS (sum of MSS means of 44 service statements retained from MSS construct divided by 44). 1994). it does not mean that these constructs are unrelated to overall service quality. Table II provides a summary of the respondents’ demographics. Findings and discussion Table III shows that the perceptions-only scale had higher R 2 value than the other two measures. a regression analysis was performed to assess the questionnaire’s convergent and predictive properties. According to Table III. Raw data were initially organised into MSS and MSA.1 considered adequate for the study. Three different regressions were done. Although MSS and MSA scores produced fairly low R 2 values. McDougall and Levesque. The Varimax rotation technique. To test instrument scale validity. principal component analysis was used to extract the maximum variance from our data. Data analysis We examined dimensionality using factor analysis.

4 3.000 Above Rs 50.001-50. 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. etc.0 11.2 3.1 3.001-20.001-20.1 6. Respondents’ demographic profile .000 Rs 30.0 8.9 Importance of service dimensions 117 Table II.8 72.4 49.) Self-employed Others Highest level of education completed CPE (cert.3 36.000 Rs 10.1 5.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.000 Rs 10.9 14.1 34.8 1.000 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 % 49.3 14.2 51.9 20.0 0.2 15.0 44 56 40.000 Rs 40.8 32.9 25.6 3.001-40. doctors. lawyers.0 17.7 24.5 7.4 12.1 0.8 8.8 50.2 44.1 16.1 61.2 3.

which largely explain the total variance: “Core Medical Services/Professionalism/Skill/Competence” and “Information Dissemination”.72 Table IV.97 0.2 1.95 0.6 3.IJHCQA 21. Moreover.1 4.72 No.81 2 0.91 0. which demonstrates that SERVQUAL is not a service quality generic measure for all industries.193 0.9 4 Cronbach Alpha 0.000 0.098 Adjusted R 2 0. We also show a need to examine current tools that measure service standards in the professional services domain.2 4 7.000 MSS format 63.9 0. Consequently.189 0.’s (1988) SERVQUAL dimensions. our study provides evidence that expectations drive service quality diagnostic evaluations by consumers and. there were two additional dimensions with high Eigenvalues and Cronbach alphas. we named our new service quality instrument PRIVHEALTHQUAL. of items 19 5 15 MSA format 65.340 0. an understanding of both adequate and desired expectations is necessary to avoid service shortfalls and achieve better resource allocations. “Fairness and treatment equity” was also associated to the “reliability” dimension.76 4 5 2 2 4.8 0.7% Total variance explained Dimensions Assurance/empathy Core medical services/professionalism/ skill/competence Responsiveness Responsiveness/tangibility Tangibility/image Image/fair and equitable treatment Reliability/fair and equitable treatment Reliability Equipment and records Information dissemination No.094 F 102. Proportion of variance in overall service quality (dependent variable) Perceptions-only (overall) MSS (overall) MSA (overall) R2 0. which were obtained using factor and reliability analyses on data from private healthcare settings. From our comparisons it can be said that an augmented and modified SERVQUAL instrument can be used in a private healthcare context.5 0.092 47.2 6.000 0. Comparison between MSS and MSA score formats .94 0.8 1.6 Cronbach Alpha 0. of items 13 8 9 4 Eigenvalues 6. One way to test core outcome ` dimension importance (vis-a-vis other service quality dimensions) is to examine its Independent variable used Table III. Clearly.294 21. Our study adds to the large body of service quality research. 0.4% Eigenvalues 9. therefore.4 3.545 df 1 1 1 Sig.75 0. Although some dimensions were relatively equivalent.87 0.337 0. managers should not continue to ignore consumer expectations.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.

SERVQUAL Dimensions versus service quality dimensions generated from factor and reliability analyses correlation with a global measure of service quality and satisfaction. Table VI lists the results. .SERVQUAL dimensions 1. 4. 7. 2 Reliability – ability to perform the expected service dependably and accurately 3. individualised attention provided to customers 5. The square of the correlation gives the proportion of criterion variance that is accounted for by its linear relationship with the predictor. The Pearson product-moment correlation coefficient (r) indicates the degree that quantitative variables are linearly related in a sample. Table V. caring. 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. 4. Tangibility – physical facilities. accurately. equipment and appearance of personnel Service quality dimensions in private healthcare (PRIVHEALTHQUAL) 1. Empathy – caring. effectiveness and benefit to the patient. Tangibility/image – physical facilities. Responsiveness – willingness to help customers and provide prompt service 3. technical expertise. Here. knowledge. image and appearance of GP Reliability/fair and equitable treatment – ability to perform the service dependably. The significance test of r evaluates whether there is a linear relationship between two variables in the population. 6. we shall use the PRIVHEALTHQUAL scale derived from the MSS scores. 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. 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.

our research adds to the large body of previous research on service quality. and physician’s willingness to refer patients to a specialist if necessary”. a new dimension “Fair and Equitable Treatment”.097 0. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. In fact.175 * 0.247 * 0.210 * 0. . “Reliability” includes “careful diagnosis of the patients’ problems”. (two-tailed) n Pearson correlation Sig. “assurance/empathy” and “equipment and records” dimensions.098 0. Correlations between service quality dimensions. 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. followed by the “core outcome”.001 255 0. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig.01 level (two-tailed) From Table VI. (two-tailed) n What is your evaluation of the overall service quality you receive from your GP? 0.113 255 120 MEDEREL MEDERES MEDEASS MEDECORE MEDEEQUI Table VI. However.005 255 0. Thus. we conclude that core outcome is not the most important dimension in health care service quality.119 255 0.100 0.122 255 0.001 255 0. Berry and Parasuraman (1991).’s (2002) and Hellier et al. overall service quality evaluation and satisfaction MEDEINFO Note: * Correlation is significant at the 0. we suggest that seven service quality dimensions are applicable to private healthcare.000 255 0. is not supported – consistent with many studies including Zeithaml et al. 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. This new dimension included items such as “uniform fees and other charges for all patients”. Hypothesis H1 given earlier.1 MEDETAN Pearson correlation Sig.’s (2003) studies. ‘GP’s medical qualifications’.213 * 0. therefore. This reflected patients’ views that everyone should be treated alike by their GP.IJHCQA 21. Consequently. consistent with Sureshchandar et al. (1990). (two-tailed) n Pearson correlation Sig. the dimension “Reliability/Fair and Equitable Treatment” is the most important.

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

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ac. “The behavioural consequences of service quality”. (1990). The Free Press. 21 Or visit our web site for further details: www. V. pp. . “The nature and determinants of customer expectations of service”. Parasuraman.A.1 124 To purchase reprints of this article please e-mail: reprints@emeraldinsight. Vol. 31-46.L. and Parasuraman. and Berry. 1-12. Zeithaml. Corresponding author Rooma Roshnee Ramsaran-Fowdar can be contacted at: rooma@uom. New York.emeraldinsight. A. 1. Journal of Marketing. V. (1993).. Journal of the Academy of Marketing Science. L. and Parasuraman. A. 60. Further reading Zeithaml.A. L. NY. Berry. Delivering Quality Service: Balancing Customer Perceptions and Expectations. L. pp. Berry.L..L. V. (1996). A.IJHCQA 21.

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

where cancer will be an important part of the agenda. and local contributions to mental health and psychosocial support are easily marginalised or undermined.IJHCQA 21. focusing on the topic of health and migration. healers. Division for International Protection Services at the Office of the United Nations High Commissioner of Europe Future oncology healthcare strategy on the agenda of the Portuguese EU council presidency Keywords Healthcare strategy.” “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 have a clear focus on social interventions and supports. including severe trauma-induced disorders. Dr Bruce Eshaya-Chauvin. Quality healthcare. health workers. as well as access to psychological first aid for those in acute distress.” said Ms Manisha Thomas. The guidelines include attention to protection and care of people with severe mental disorders. NGOs can play a major role in this regard. acting Coordinator of the International Council of Voluntary Agencies. Treating survivors with dignity and enabling them to participate in and organize emergency support is essential. They focus on strengthening social networks and building on existing ways community members deal with distress in their lives. The “Round Table on Health Strategies in the European Union” is one of the most important initiatives launched by the EU Portuguese Presidency within the context of the EU strategy on health policy. Coordination of mental health and psychosocial support is difficult in large emergencies involving numerous agencies. Head of the Health and Care Department at the International Federation of Red Cross and Red Crescent Societies. and women’s groups to promote psychosocial well-being. ESMO . Affected populations can be overwhelmed by outsiders. They emphasize the importance of building on local resources such as teachers. remarked: “Achieving improved psychosocial support for populations affected by crises requires coordinated action among all government and non-government and humanitarian actors. 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. Deputy Director. For further information: www.who. 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. These guidelines give sensible advice on how to achieve that.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.

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

” The data tools included are: CHKS’ admitted patient care data set. For further information: www. target and evaluate quality improvement initiatives. The combination of performance data. and bespoke patient experience questionnaires developed to national standards by the Picker Institute. . correlate activity performance data with patient health and patient experience. business manager at the Picker Institute. The new service.IJHCQA 21. 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’”. Quality improvement measures UK hospitals can now combine their clinical data with both patient-reported health outcomes and a measurement of patient experience. Hospitals will be able to measure the three sets of indicators. said: “This combination will provide a patient-focused picture of the quality and effectiveness of the service provided by a clinical specialty over time. outcome data and patient experience data gives UK hospitals the ability to: . and what patients say about their experience of receiving that care and treatment. and the Picker Institute.” 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. the charity which is a leading authority on capturing patient and staff feedback and using it to improve services. the EQ5D patient-reported outcome measure compared to a major new normative database. Clinicians will be able to see how their own activity compares to the health outcomes reported by patients. . said: “There is considerable interest within the health service in the potential of PROMs – patient-reported outcome measures. 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 UK Quality improvement: patient-reported outcomes and experiences now integrated with clinical data for the first time Keywords Patient feedback. is being developed jointly by CHKS. “Patient Driven Quality”. and judge them against national benchmarks. the leading independent provider of healthcare information.1 iv will guarantee a high value contribution to the global debate on cancer and health in Europe. over time. external relationship manager at CHKS. applied to particular clinical specialties. Kay Usher.medicalnewsblog. for the first time. Paul Robinson. Healthcare standards.

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

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

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

which was already available via a Healthcare Commission web site.nhs. GP practices and health organisations to improve urgent care services for patients. it highlights a clear need for better signposting as patients are often unable to determine .1 viii Patients have been given a choice of where they can go to be treated for non-emergency treatment since last year. One of the problems with the internet is that some of the information about health is top quality and some of it is rubbish. 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.” Ms Hewitt is also hoping the web site will push doctors into releasing information about the results of Signposting the way to better out of hours services for patients Keywords Healthcare information. Later in the year people needing hip and knee operations will be able to choose from any hospital. Health Secretary Patricia Hewitt said: “We know patients and the public are thirsty about getting information on health. And that will be extended to all specialities by April next year. .” For further information: www. including ratings and MRSA rates. The multi-media web site has sections giving advice on healthy lifestyles and also allows users to carry out an online health check. While the RCGP recognises that good quality urgent care exists in some areas. Primary Care Trusts (PCTs). The RCGP plan recognises the pivotal role of GPs and includes across-the-board recommendations for the Department of Health. 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 has detailed information on 40 of the most common diseases and also uses data compiled by the Healthcare Commission on hospital performance. fragmented. 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. 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. .with the internet age resisting progress is fruitless. 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. The web site includes death rate data from individual heart units. 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.IJHCQA 21. “What NHS Choices will do is give the public access to the best information about health. Service delivery. At the moment.

” “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. 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. PCTs must make efforts to engage and involve GPs in out of hours care: some PCTs have already managed to do this effectively.” The RCGP ten point action plan recommends that services are designed around the clinical needs of patients who should expect to receive a consistent and rigorous assessment of their needs and an appropriate and prompt response to that need – regardless of who is administering their care. and to kickstart action in improving urgent care services. (8) Emergency care practitioners to be trained to a defined national standard including an assessment of competence. Athough no longer contractually responsible for out of hours work. walk-in centres and minor injury units to foster integration and co-ordination of care between providers. GPs are still involved in OOH rotas and a large proportion of OOH is still provided by GP co-operatives. 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. (3) PCTs to develop Urgent Care Networks comprising GP practices. (2) All GP practices to have a system for responding to and dealing with urgent care during surgery hours. RCGP Chairman Professor Mayur Lakhani. (4) Quality standards including clinical outcomes to be monitored and enforce. (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 . 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. To address this. planning and support for urgent care and out of hours services. which will enable PCTs to monitor clinical outcomes. emphasising the necessity for high clinical standards. (5) Engagement with local GPs and recognition of their key role in leadership. a practising GP in Leicester. (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.the most appropriate service to access. and training opportunities in urgent care for GP Registrars. (7) The Department of Health to make urgent care a priority and set a clear national strategy. The action plan calls for: (1) Care to be configured around the needs of patients with better signposting for access.

“The majority of care is still provided by GPs. “Everyone has struggled with patient satisfaction and the surveys in general. hospitals can improve survey responses. “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. Any attempt to downgrade the role of GPs will lead to further diminution of quality and put pressure on other parts of the NHS. Professor Lakhani said: “A step change in policy is x Americas Outsourcing improves patient satisfaction Keywords Patient experience.IJHCQA 21. Chief Nursing Officer and . 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 2007.1 GP Registrars. but we see HCAHPS as an opportunity”. Clear signposting to appropriate care is essential. 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. 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. 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. As the proven experts in providing urgent care. We urge that PCTs be held to account for the quality of their out of hours services. Financial management. Being ill in the middle of night is frightening experience and patients need to be sure the NHS will be there for them.medicalnewstoday. not the lucky few. says Laura Fortin. said: “Patients are very confused and bewildered about which services may be available to them outside GP surgery appointments.” Ailsa Donnelly. Chair of the RCGP Patient Partnership Group. and this plan will go a long way towards demystifying the maze that currently exists. 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. 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.” For further information: www.

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

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

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

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

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

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

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